травми LowerLeg

Defence Research and Development Canada
Recherche et dveloppement pour la dfense Canada
Assessment of Lower Leg Injury from Land Mine Blast Phase 1

Test Results using a Frangible Surrogate Leg with Assorted Protective Footwear and Comparison with Cadaver Test Data
D.M. Bergeron, G.G. Coley, R.W. Fall Defence R&D Canada Suffield I.B. Anderson Canadian Forces Medical Group
Technical Report DRDC Suffield TR 2006-051 February 2006
Assessment of Lower Leg Injury from Land Mine Blast Phase 1

Test Results using a Frangible Surrogate Leg with Assorted Protective Footwear and Comparison with Cadaver Test Data
D.M. Bergeron, G.G. Coley, R.W. Fall Defence R&D Canada Suffield I.B. Anderson Canadian Forces Medical Group
Defence R&D Canada Suffield

Technical Report DRDC Suffield TR 2006-051 February 2006
Author D.M. Bergeron
Approved by Dr. Chris A. Weickert Director, Canadian Centre for Mine Action Technologies
Approved for release by Dr. Paul DAgostino Chair, Document Review Panel
Her Majesty the Queen as represented by the Minister of National Defence, 2006 Sa majest la reine, reprsente par le ministre de la Dfense nationale, 2006
Abstract
In 1999, the Canadian Centre for Mine Action Technologies (CCMAT) sponsored a series of tests involving the detonation of 25 anti-personnel blast mines against a frangible leg model. The model was fitted with various footwear and additional protective equipment. The aim of these tests was to assess whether this model could be used for routine tests of protective footwear against mine blast. The report describes the frangible leg and compares it to its human counterpart. It then presents an overview of the physics of mine blast and the devastating effects on the human leg. Details of the test setup and procedures are described so that the reader might better interpret the test results. These tests involved medical staff, including two surgeons that had operated on mine blast victims, to examine the frangible legs and determine probable medical outcomes. These results are compared to a database of mine blast injury against human cadavers to identify the strengths and limitations of the frangible leg model. It was found that this frangible leg model has potential to be a good testing tool, provided some modifications are implemented, and further testing be carried out to properly calibrate the response of the modified model against the database of mine injuries.
DRDC Suffield TR-2006-051
Rsum
En 1999, le Centre canadien des technologies de dminage (CCTD) commanditait une srie dessais impliquant la dtonation de 25 mines terrestres anti-personnelles contre des jambes synthtiques. Chaque jambe tait chausse dune botte rgulire ou antimine, parfois avec un quipement de protection supplmentaire. Le but de ces essais tait de dterminer si cette jambe synthtique peut devenir un outil courant pour valuer la performance de bottes anti-mines. Ce rapport dcrit la jambe synthtique et la compare son homologue humain. Le rapport prsente ensuite un survol de la physique des explosions de mines terrestres effet de souffle et leur effet dvastateur sur la jambe humaine. Les dtails concernant la prparation et la conduite des essais est dcrite pour que le lecteur puisse mieux interprter les rsultats ci-joint. Une fois les essais conclus, du personnel mdical, y compris deux chirurgiens ayant dj opr sur des pieds de mine, ont examin les jambes synthtiques afin de dterminer ce qui serait arriv un tre humain. Le rapport compare ces rsultats une base de donnes tablie lors dessais qui opposaient des cadavres humains contre des mines terrestres. Cette comparaison a permis dtablir que cette jambe synthtique peut devenir un bon outil pour ce genre dessais moyennant quun nombre damliorations y soient apportes et quune nouvelle srie dessais soit faite pour calibrer la rponse de la jambe amliore contre la base de donnes susmentionne.
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Executive summary
In April 1999, the United States Humanitarian Demining Program sponsored the Lower Extremity Assessment Program (LEAP). The purpose of LEAP was to assess the effect of a land mine explosion on the human foot as a function of protective footwear. These tests were particularly useful because human cadavers were used to provide detailed information about injuries to soft tissues and bones. However, only authorized institutions can perform such tests and biomedical expertise is required to fully realise the benefits. It also involves special handling considerations because dead human tissues pose a biohazard. Another consideration is that the age, sex and bodybuild of the subjects can vary widely, which might introduce a large variance in bone strength and body dimensions. Industry and test agencies find it difficult to use cadaver models for routine tests when developing mine-protected footwear. Recognising this fact, the Canadian Centre for Mine Action Technologies (CCMAT) sponsored twenty-five tests in September 1999 to assess the Australian Frangible Surrogate Leg (FSL) for its use as a tool for this niche market. Pending positive results, CCMAT proposed to develop suitable injury criteria for the FSL. The main objective of the CCMAT tests was to assess the feasibility of the FSL as a test model and develop mine blast injury criteria so it might be used in routine blast tests of protective footwear. The development of injury criteria would be achieved by comparing the results with those from the LEAP tests. To make this comparison, it was necessary to perform the CCMAT tests in the same way that the LEAP tests were performed, which involved reproducing as many test parameters as possible, such as the selection and placement of the mines, the soil type, the footwear, etc. In addition to the primary objective, the CCMAT tests also assessed the repeatability of the FSL as a diagnostic tool; acquired physical data using strain gauges and a load cell to determine their potential as instrumentation for the FSL; evaluated the relative protective performance of a small selection of footwear; and obtained structural response data for mines with an explosive mass between those of the M14 (29grams) and PMA-2 (100grams), which were used during LEAP. This test series partially achieved its primary objective: it demonstrated that the FSL has the main attributes required from a model for routine mine blast tests of protective footwear. The test results indicate that the FSL can reproduce the same result, within reason, when it is subjected to the same explosive stimulus. It is also capable of producing different results when the explosive stimulus or the level of protection is changed. The other part of the primary objectiveto correlate the response of the FSL to human injury from anti-personnel land minescould not be achieved because of differences in test conditions between the FSL and LEAP tests. The most important difference was that M14 mines could not be obtained in time. The PMA-3 mine used as a substitute is more powerful than the M14, which meant that one-to-one
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comparisons could not be made with confidence in the regime where protective footwear can make a difference. The flash x-ray images captured during these tests provide much insight into the injury mechanisms for mine blast trauma. These images show the existence of a hemispherical zone of high-pressure gas that imparts localized damage to those parts of the footwear in the immediate vicinity of the mine. There exists a small zone directly above the mine where the vertical push from the gas is particularly focussed, as evidenced by the deformation shape of the blast deflector embedded in the sole of the Wellco blast boot. When a blast boot is used in conjunction with an additional protective overboot, this zone of focussed momentum transfers significant loading through the lower deflector to the upper deflector. This has implications for the design of protective footwear. It suggests that the inclusion of any solid object in the sole of the boot must be done with care. The blast imparts momentum to such an object, which can become a projectile capable of penetrating the plantar region of the foot, as was the case for the steel shank in the sole of the standard combat boot of the Canadian Army. The flash x-ray images also demonstrate that the force of the impact can be so severe that the closer bones, particularly the calcaneus, are pulverized. Furthermore, it is clear that the damage to the leg starts distally and travels up, remaining relatively localized. When using a boot in isolation, even a mine-protected boot, the smallest mine destroyed the footwear. Adding further protective equipment affected the outcome of the tests. It appears that the additional protective footwear plays a sacrificial role to divert some of the force of the explosion while distancing the inner footwear from the zone of very high-pressure close to the mine. For the PMA-3, the overboot prevented total destruction of the inner footwear, but momentum transfer to the blast deflector of the overboot, particularly to the portion located directly above the mine, was large enough to deform the blast deflector located above in the sole of the inner boot. The arch of the boot was increased permanently. As the explosive content of the threat increased, the arch deformed further and tears began to appear in the upper and rear vamp of the inner boot. For the PMA-2 mine, the force transfer from the explosion was so strong that the foot of the FSL burst, ripping the boot open in the process. The increased standoff of the Spider Boot combined with displacement of the detonation point outside the footprint produced the best protection results during this test series. The structural integrity of the basic footwear was preserved for all tests against this protective equipment. However, the flash x-ray images clearly show that a significant potential for injury still exists. The gas pressure and soil ejecta apply a strong push on the Spider Boot, which locally crush the deflector shell and bend the top and hinge plates upward. Although this footwear prevented disintegration of the bones and soft tissues of the distal leg, further testing is required to assess the extent of injuries such as ankle dislocation and breaking of the long bones (tibia and fibula). The medical assessments confirmed that there does not exist an ideal scoring system for mine blast trauma. The MTS scale remains the best option, but it was difficult to apply to the FSL because of the difference in soft tissue response relative to human tissues. The FSL soft tissues do not reproduce the deep penetration of high-pressure
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gas into the leg and the skin is too weak, both of which introduce bias in the MTS scores. However, the response of the bones is repeatable and sensitive to the explosive mass and the level of protection. Rough comparison of the bone damage with the LEAP results revealed that the strength of the FSL calcaneus and talus must be reduced to improve the fidelity of the model relative to human injury. Excessive strength of these bones provided a pathway for load transmission further up the leg, causing damage to the long bones that was not seen in the cadaver tests. In summary, the FSL has good potential as a tool to test protective footwear against anti-personnel mine blast. However, there is a need to decrease the strength of the calcaneus and talus bones. Furthermore, it was not possible to compare the results from the present tests directly to the LEAP results because a different mine had to be used. It is therefore recommended that the FSL bones be modified, that M14 mines be acquired, and that a limited number of tests on the altered FSLs be done. These tests should concentrate on only two footwear combinations against the M14 mine to investigate the repeatability and fidelity of the FSL model against the LEAP database.
Bergeron DM; Anderson IB; Coley GG; Fall RW; (2006). Assessment of Lower Leg Injury from Land Mine Blast Phase 1: Test Results using a Frangible Surrogate Leg with Assorted Protective Footwear and Comparison with Cadaver Test Data. (DRDC Suffield TR 2006-051). Defence R&D Canada Suffield.
Sommaire
En avril 1999, les tats-Unis dAmrique commanditaient le Lower Extremity Assessment Program, (LEAP) sous la tutelle de leur programme daide au dminage humanitaire. Le but de LEAP tait de documenter ce quune explosion de mine terrestre fait au pied humain et de dvaluer lefficacit de diffrentes bottes antimines. Ce programme tait particulirement utile car il utilisait des cadavres humains. Cependant, lutilisation de spcimens humains requiert lapprobation de plusieurs autorits civiles et mdicales et nest la porte que de quelques institutions spcialises. De plus, lutilisation de cadavres exige des prcautions supplmentaires pour viter la transmission de maladies. Il y a aussi variation dun spcimen lautre d lge, le sexe et la constitution de chaque corps, ce qui peut biaiser les rsultats dessais. Lindustrie et les agences dessais ne peuvent donc recourir au modle cadavrique pour performer des essais de nature courante lors du dveloppement de bottes antimines. Reconnaissant ce problme, le Centre canadien des technologies de dminage (CCTD) commanditait 25 tirs contre des jambes synthtiques en septembre 1999. La jambe en question, appele Frangible Surrogate Leg (FSL), avait t dveloppe en Australie et offrait un bon potentiel pour lapplication propose. Dpendant des rsultats obtenus, le CCTD proposait de dvelopper des critres de blessure pour la FSL. Ceci serait fait en comparant les rsultats de la FSL ceux du programme LEAP. Afin dtre en position pour faire cette comparaison, il tait ncessaire que le programme du CCTD rpte le protocole dessai utilis pour LEAP, soit dutiliser les mmes mines, le mme sol, le mme placement de la mine, les mmes bottes, etc. Lvaluation de la FSL tait lobjectif principal du programme du CCTD. Cependant, il y avait aussi plusieurs objectifs secondaires. La capacit de la FSL reproduire le mme rsultat dun essai lautre quand soumise aux mmes conditions de tir, devait tre examine. Les spcimens taient instruments avec des jauges de contrainte et des capteurs de force pour en dterminer lutilit. Lefficacit dune petite slection de bottes anti-mines a t value. Finalement, des mines contenant un montant dexplosif entre celui de la M14 (29 grammes) et la PMA-2 (100 grammes), toutes deux utilises lors de LEAP, ont t employes afin dobtenir des mesures pour des menaces intermdiaires. Ce programme a atteint son objectif principal : il a dmontr que la FSL peut tre utilise comme instrument de routine pour valuer la performance de bottes antimines. Les rsultats dmontrent que la FSL produit des rsultats similaires, non pas identiques, lorsque soumise aux mmes conditions de tir. Encore plus important, la FSL produit des rsultats diffrents lorsque soumise des mines qui contiennent des masses diffrentes dexplosif. Les rsultats des tirs du CCTD ne peuvent tre utilises pour driver des critres de blessure. Cet objectif ne pouvait pas tre atteint car des mines M14 nont pu tre obtenues en temps pour ces essais. Le programme a t effectue avec des mines PMA-
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3 qui contiennent 34 grammes dexplosif, ce qui est plus que dans la M14. De plus, la gomtrie de ces deux mines diffre considrablement; dans la PMA-3, lexplosif est situe dans la partie suprieure de la mine, tandis que dans la M14, lexplosif est situe dans la partie infrieure. Ces deux mines produisent donc des conditions suffisamment diffrentes pour remettre en question la validit de critres de blessure qui seraient dvelopps partir des prsentes donnes. Les images rayons-x clair produites durant ces essais donnent des indices sur les mcanismes de blessure lors dune explosion de mine. Une zone hmisphrique centre sur la position initiale de la mine contient des gaz sous trs haute pression qui endommage la partie adjacente de la botte et du pied. Il existe aussi une zone, directement la verticale du centre de la mine, o la pousse des gaz est particulirement concentre, comme le dmontre la dformation des dflecteurs de souffle incorpors dans la semelle des bottes Wellco. Quand la mme botte Wellco est place au-dessus dune deuxime semelle identique, le moment cintique donn au dflecteur du bas est si grand dans cette zone que la dformation localise est aussi transmise au dflecteur du haut. Ce phnomne a des rpercussions importantes pour la conception de bottes dans le futur car le moment cintique transmis par la mine un objet massique dans la semelle doit tre arrt. Les images rayon-x dmontrent aussi que la force de limpact peut tre si grande que les os les plus proches sont pulvrises. Ceci concerne particulirement les calcanum et le talus. Finalement, les images rvlent que la destruction du pied se fait partir de la rgion plus distale et progresse vers le haut de la jambe, demeurant trs localise. Quand une botte (ce qui inclut les bottes soi-disant anti-mines) tait utilise par ellemme lors de nos essais, mme la plus petite des mines dtruisait la botte. Ce nest quavec laddition dune protection supplmentaire que les rsultats se sont amliores. Laccroissement de la distance entre le pied et la mine lorsquune protection supplmentaire est utilise joue un rle important. Pour la PMA-3, la distance supplmentaire a prvenu la destruction totale de la botte interne, bien que le dflecteur de cette dernire soit dform. Les dommages la botte interne augmentent proportionnellement avec la charge explosive, dabord en augmentant la dformation de la semelle, et puis en causant des fissures dans les quartiers. Une mine PMA-2 produit une telle force que le pied de la FSL a littralement explos, dchirant la botte du mme coup. La distance accrue de la botte Spider, combine avec le dplacement du point de dtonation de sous le pied, a produit les meilleurs rsultats durant ces essais. Lintgrit structurelle de la botte interne a t protge dans chacun des six tirs. Cependant, les rayons-x dmontrent que le potentiel de blessures existe nanmoins. La pression des gaz et limpacte du sol sur la chaussure crase le dessous de la plateforme et dforme la surface. Bien que la botte Spider ait limit la destruction des os et de la glatine de la FSL, de plus amples essais sont requis pour vritablement dterminer la porte des blessures telles la dislocation de la cheville et le bris du tibia et du pron. Les examens mdicaux ont confirm quil nexiste pas dchelle parfaite pour quantifier les blessures causes par une explosion de mine. Lchelle MTS dveloppe
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durant le programme LEAP demeure la meilleure option, mais elle sest avre difficile appliquer la FSL, principalement d la rponse peu fidle de la glatine au souffle. Cette dernire reproduit mal la pntration profonde des gaz le long des muscles et la peau synthtique nest pas assez forte, ce qui biaise les rsultats sur lchelle MTS. Cependant, la rponse des os est consistante dun tir lautre et diffrentes charges explosives produisent un changement apprciable dans la rponse des os. Une comparaison des dommages aux os avec les rsultats de LEAP rvle que le calcanum et le talus sont trop dur par rapport aux tissus humains; il y a donc trop de transfert de force au tibia et au pron. En rsum, la jambe FSL est potentiellement un bon outil pour valuer la performance de botte anti-mines, en autant que la duret du calcanum et du talus soit rduite un niveau similaire leurs homologues humains. De plus, il na pas t possible de comparer les rsultats de nos essais avec ceux de LEAP parce que des mines M14 ntaient pas disponibles. Il est donc recommand que dautres essais soient effectus avec une version amliore de la FSL et des mines M14. Ces essais devraient tre limits seulement deux combinaisons de bottes utilises lors du programme LEAP.
Bergeron DM; Anderson IB; Coley GG; Fall RW. (2006). Assessment of Lower Leg Injury from Land Mine Blast Phase 1: Test Results using a Frangible Surrogate Leg with Assorted Protective Footwear and Comparison with Cadaver Test Data. (DRDC Suffield TR 2006-051). R & D pour la dfense Canada Suffield.
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Table of contents
Abstract........................................................................................................................................ i Rsum ....................................................................................................................................... ii Executive summary ................................................................................................................... iii Sommaire................................................................................................................................... vi Table of contents ....................................................................................................................... ix List of figures ........................................................................................................................... xii List of tables ............................................................................................................................ xvi Acknowledgements ................................................................................................................ xvii 1. Introduction ................................................................................................................... 1 1.1 1.2 2. Scope and Objectives of the CFSL Program .................................................... 3 Organisation of this report................................................................................ 4
Structures of the Human Leg and the FSL .................................................................... 6 2.1 Clinical Anatomy of the Lower Limb .............................................................. 6 2.1.1 2.1.2 Organisation of the Anatomy .............................................................. 6 Lower Limb Anatomy from a Regional Perspective......................... 10 2.1.2.1 2.1.2.2 2.1.2.3 2.1.2.4 2.1.2.5 2.1.2.6 2.1.3 2.1.3.1 2.1.3.2 2.1.4 The Pelvis ...................................................................... 11 The Knee Joint ............................................................... 12 The Tibia and Fibula...................................................... 13 The Ankle Joint.............................................................. 15 The Foot......................................................................... 15 The Arches of the Foot .................................................. 17 Standing ......................................................................... 20 The Gait ......................................................................... 20
The Mechanics of Standing and Gait ................................................ 19
Circulation in the Lower Limb .......................................................... 21
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2.1.5 2.2 2.2.1 3.
Nerve Supply to the Lower Limb ...................................................... 24 Addition of a Load Cell in the Tibia ................................................. 31
The FSL a Very Simple Model Indeed........................................................ 28
Mine Blast Injury to the Lower Extremity .................................................................. 34 3.1 3.2 3.3 3.4 Basic Physics of Land Mine Blast.................................................................. 34 Pathology of Mine Blast Injury to the Lower Leg.......................................... 38 Medical Outcome of Mine Blast Injuries to the Human Leg ......................... 41 Medical Treatment of Mine Blast Injuries to Human Legs............................ 43
4.
Experimental Conditions and Diagnostics .................................................................. 47 4.1 4.2 Description of the Footwear ........................................................................... 47 Description of the Explosive Threats ............................................................. 52 4.2.1 4.2.2 4.3 4.3.1 4.3.2 4.4 4.4.1 4.4.2 4.4.3 4.4.4 4.5 4.5.1 4.5.2 Land mine Threats............................................................................. 52 Surrogate Charges ............................................................................. 54 Test Platform and Site Layout........................................................... 56 Instrumentation Support .................................................................... 57 Specimen Preparation........................................................................ 59 Platform Preparation.......................................................................... 60 Land mine and Specimen Placement................................................. 60 Post-Test Actions .............................................................................. 63 Post-Test Physical Assessments ........................................................ 64 Mine Trauma Scores ......................................................................... 66
Experimental Setup ........................................................................................ 55
Experimental Procedures................................................................................ 58
Medical Assessment Procedures .................................................................... 63
5.
Medical and Physical Results ...................................................................................... 67 5.1 5.2 Global Observations from the Video and Flash X-Ray Imagery ................... 67 Summary of Boot Damage ............................................................................. 74 5.2.1 5.2.2 5.2.3 5.2.4 Damage to Unprotected Footwear..................................................... 75 Damage to Combat Boot when Using an Overboot .......................... 75 Damage to Blast Boot when Using an Overboot............................... 76 Damage to Footwear when Using a Spider Boot .............................. 76
5.3
Medical Assessments of the FSL Specimens ................................................. 77 5.3.1 5.3.2 5.3.3 Damage to FSL for Unprotected Footwear ....................................... 78 Damage to FSL for Footwear Protected with an Overboot ............... 80 Damage to FSL for Footwear Protected with a Spider Boot.......... 80 Comparison Based on MTS Break Down ......................................... 82 Comparison Based on Refined Bone Damage Information .............. 86 Strain Gauge Results ......................................................................... 92 Load Cell Results .............................................................................. 97
5.4
Comparison of FSL Performance Against LEAP Results.............................. 80 5.4.1 5.4.2
5.5
Strain Gauge and Load Cell Records ............................................................. 92 5.5.1 5.5.2
6.
Conclusions and Recommendations.......................................................................... 104 6.1 6.2 6.3 6.4 Visualisation of the Mine Blast Trauma Process.......................................... 104 Footwear Damage Assessments ................................................................... 105 Medical Assessments of the FSL Specimens ............................................... 106 Recommendations for Future Work ............................................................. 107
References .............................................................................................................................. 109 Annex AInjury Assessment Scoring Systems .................................................................... 111 Annex B Detailed Boot Damage Assessments.................................................................... 117 Annex C Detailed Medical Assessments............................................................................. 173 Annex D Load Cell Force and Moment Records ................................................................ 229 Bibliography ........................................................................................................................... 239 List of symbols/abbreviations/acronyms/initialisms .............................................................. 242
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List of figures
Figure 1. Drawing of the foot showing its various componentsI. Anderson .......................... 7 Figure 2. Overview of the anatomy of a nerveI. Anderson .................................................... 8 Figure 3. Anatomical position showing anterior view of an upright postureI. Anderson ...... 9 Figure 4. Cross-sections of the leg showing different compartments; (a) Important muscles, arteries and nerves; (b) Compartments enclosed by fasciaI. Anderson......................... 12 Figure 5. Blood vessels about the hip jointI. Anderson........................................................ 13 Figure 6. The tibia and fibula bones of the lower legI. Anderson ........................................ 14 Figure 7. Talus bone; articular surfaces are coloured; there is very little surface area not covered with cartilage where nutrient blood vessels can enter this boneI. Anderson ... 17 Figure 8. The calcaneus bone (heel bone)I. Anderson ......................................................... 18 Figure 9. Diagram demonstrating the arches of the footI. Anderson ................................... 18 Figure 10. Lateral view of the human upright postureI. Anderson....................................... 19 Figure 11. The six phases that make up the normal stride gaitI. Anderson.......................... 21 Figure 12. Muscles and arteries of the thighI. Anderson...................................................... 22 Figure 13. Vessels and muscles of the knee join (posterior view)I. Anderson..................... 23 Figure 14. The nerve cellI. Anderson ................................................................................... 25 Figure 15. Organisation of nerves and motor unitI. Anderson ............................................. 26 Figure 16. Assembled and unassembled components of the FSL ............................................ 29 Figure 17. Polyamide glue is used to join the components at normal joint locations............... 30 Figure 18. Polymer materials simulating tendons over the ankle............................................. 30 Figure 19. FSL following pour of the gelatine around the bones ............................................. 31 Figure 20. Insertion of a load cell in the tibia.......................................................................... 32 Figure 21. High-speed film sequences showing the detonation of 100-gram charges in sand for flush buried (left) and 80mm overburden (right) burial conditions .................................. 35
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Figure 22. Height of the cloud of detonation products for a 100-gram charge at different depths of burial.................................................................................................................. 36 Figure 23. Estimated pressure drop for detonation products undergoing volumetric expansion37 Figure 24. Mechanism of injury depends on range from the explosion ................................... 38 Figure 25. Artists conception of mine blast injury .................................................................. 39 Figure 26. Diagram by Nachaev et al. that shows the distinct zones of land mine blast damage to the lower leg based on their experience in Afghanistan................................................ 40 Figure 27. Mk III combat boot of the Canadian Army............................................................. 49 Figure 28. Wellco blast protected combat boot or blast boot ............................................. 49 Figure 29. x-ray of the Wellco boot showing location of the blast deflector in the sole.......... 50 Figure 30. Wellco blast overboot designed to be worn on another boot .................................. 51 Figure 31. Spider Boot showing platform and legs extending outside the foot platform...... 51 Figure 32. PMA-3 land mine with cross-section showing internal fuse mechanism (Insert courtesy of Janes)............................................................................................................. 53 Figure 33. VS-50 land mine with diagram showing various components (Pictures courtesy of Janes) ............................................................................................................................... 53 Figure 34. PMA-2 land mine with cross-section showing fuse mechanism (Pictures courtesy of Janes) ........................................................................................................................... 54 Figure 35. Land mine surrogate charge containers used for developmental work ................... 55 Figure 36. Wood platform designed for x-rays and LEAP soil container ................................ 56 Figure 37. Reproduction of the steel soil container used in the LEAP program ...................... 57 Figure 38. Schematic showing the flash x-ray setup and relative location of the video/film equipment .......................................................................................................................... 58 Figure 39. Boot modification to the tongue and vamp for the CFSL program......................... 59 Figure 40. PMA-3 land mine was buried flush with the soil surface at centre of soil container61 Figure 41. Burial of the PMA-2 land mine with cardboard spacer........................................... 61 Figure 42. Vertical alignment of the FSL with the heel positioned over the land mine........... 62
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Figure 43. Sketch showing the location of the explosive under the Spider Boot and regular boot.................................................................................................................................... 63 Figure 44. Sequence of events during medical assessment of damage to FSL specimen ........ 65 Figure 45. Consecutive high-speed video frames captured 1ms apart showing the rapidity of the mine blast event; note the presence of footwear fragments just above the dark cloud 67 Figure 46. Flash x-rays (0 & 503ms) of a PMA-3 mine explosion under an unprotected combat boot....................................................................................................................... 69 Figure 47. Flash x-rays (0 & 503s) of a PMA-3 mine explosion under a blast boot without overboot............................................................................................................................. 70 Figure 48. Flash x-rays (0 & 755ms) of a PMA-3 mine explosion under a combat boot with overboot............................................................................................................................. 71 Figure 49. Flash x-rays (0 & 754ms) of a PMA-3 mine explosion under a blast boot with overboot............................................................................................................................. 72 Figure 50. Flash x-rays (0 & 1253s) of a PMA-2 mine explosion under a rear pod of the Spider Boot........................................................................................................................ 73 Figure 51. Flash x-rays (0 & 731s) of a PMA-2 mine explosion under a front pod of the Spider Boot........................................................................................................................ 73 Figure 52. Amputation level from the MTS score for unprotected footwear against small mines ................................................................................................................................. 83 Figure 53. Amputation level from the MTS score for footwear with an overboot against small mines ................................................................................................................................. 84 Figure 54. Average scores for bones of the lower leg unprotected basic footwear ............... 90 Figure 55. Average scores for bones of the lower leg footwear protected with overboot..... 91 Figure 56. Example of strain history for a large mine against protective footwear showing gauge failure...................................................................................................................... 93 Figure 57. Example of strain history for a small mine against protective footwear; bottom gauge shown on left and top gauge on right; note the similarity of the bottom and top traces, but different amplitudes ......................................................................................... 94 Figure 58. Effect of mine type on maximum amplitude of strain (first 5ms) for CB/OB footwear. The colour of the bars indicates individual shots.............................................. 95 Figure 59. Effect of footwear combination on maximum amplitude of strain (first 5ms) for two mines. The colour of the bars indicates different shots .............................................. 97
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Figure 60. Sample time record from the tibia load cell for an unprotected FSL .................... 100 Figure 61. Sample time record from the tibia load cell for an FSL with protective footwear 101 Figure 62. Peak RMS force and impulse (after 2ms) values show the effect of protection ... 102 Figure 63. Time of arrival and peak force are significantly smaller without protection ........ 103
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List of tables
Table 1. Description of nerve injuries by Sunderland Classification ....................................... 27 Table 2. Open wound classification by Gustilo........................................................................ 44 Table 3. Test matrix for the September 1999 CFSL test series ................................................ 48 Table 4. Number of tests performed for each combination of footwear and explosive............ 74 Table 5. Summary of the MTS scores assigned to each FSL; the data is ordered by protection type and then by increasing explosive mass...................................................................... 79 Table 6. Summary of the MTS scores obtained during LEAP [3] ........................................... 81 Table 7. Crude scoring system used to compare the level of bone damage between LEAP and FSL tests............................................................................................................................ 86 Table 8. Summary of damage to some of the bones of the FSL specimens ............................. 87 Table 9. Summary of damage to some of the bones during the LEAP study, deduced from reference [3] ...................................................................................................................... 88 Table 10. Abbreviated Injury Score ....................................................................................... 111 Table 11. International Committee of the Red Cross Score ................................................... 112 Table 12. NISSA Scoring System .......................................................................................... 113 Table 13. Mine Trauma Score developed for the LEAP program.......................................... 114
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Acknowledgements
A project needs the contributions from many individuals to be successful. Unfortunately, only a few names appear on a report and, too often, essential contributions from individuals working in the background are forgotten soon after the project is over. Here, the authors would like to list the personnel that contributed to this project, from start to finish, both to thank these people, but also to stress the importance of a team effort to achieve success in a project. We are indebted to (not in any particular order): Micheal Footner from DSTO, Australia, for installing the strain gauges on the FSL and instrumentation support during the tests; Jim Roseveare, Paul Schile, Dan Roseveare and Doug Roseveare of Amtech Aeronautical Limited, and Rob Matheson, from Suffield, for their hard work during preparation and while running the tests; Gurdev Boghal and John Staats from the Suffield Experimental Model Shop for manufacturing the soil container; Scott Trebble and Randy Lynde of Suffield for their high-speed photo instrumentation support and the painstaking hours spent digitalizing the x-rays; Darrell Boechler, Mike Hickey, from Suffield and Blair Mullin, from Amtech Aeronautical Limited, for running the electronic instrumentation; Dave Ulriksen and Sgt G. Handford, from Suffield, for medical support during the experiments; Garth Woolf, Jim Forbes and Lyle Catton, from Suffield, for preparing and handling the explosives; Bob Martin and Paul Mast, the Suffield FTOs, for looking after everyones safety; Dr Lenny Griffin, from Caltech, for providing flash x-ray estimates for these tests; Dr Jean Lapointe, from Laval University, for assisting during the medical assessment of the initial batch of FSL specimens; Tom Storrie and Steve Mowers, from Suffield, for their expert support and producing outstanding flash x-ray images; Ellory Sanderson, from the Aberdeen Test Center, USA, Dr Dale Bass and Jim Funk, from the University of Virginia, USA, for the loan of their tibia load cells; Dr Aris Makris, from Med-Eng Systems Inc., for providing free-of-charge the Spider Boots that were used in these tests;
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The Diagnostics Imaging Staff of the Medicine Hat Regional hospital for putting in long hours during evenings, after a long work day, to produce medical x-rays and CT scans of the specimens; Dr Alexander Krstic, from DSTO, Australia, for his guidance in preparing and using the FSL and in providing the 3D reconstructions from the CT scans through the University of Adelaide; Dr Robert Harris and Mr Steve Rountree, from the US Army Institute for Surgical Research for providing assistance in the preparation of each test and in the post-trial surgical analysis of the specimens; and Betty McIvor, Vicky Roberts and Shelley Ewing for their help during report preparation and reproduction. This list clearly shows that even a simple project such as this one requires a full team to succeed. Many thanks to all! We hope that we did not forget anyone. If we did, please accept our sincere apologies.
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1.
Introduction
A survey of 232 accidents that injured 295 victims [1] during demining operations was recently published by the United States Department of Defense as part of their Humanitarian Demining Program (HDP). The munitions involved in these accidents included anti-personnel (AP) mines, anti-tank (AT) mines, and other munitions such as grenades and mortars. An AP mine was involved in 79% of these accidents, accounting for 78% of all injured people and 81% of fatalities. The data includes AP mines of the fragmentation and blast types. The exact threat was unknown in 11% of the cases. Of those cases involving an AP mine, 83% of the accidents were with a blast mine as opposed to a fragmentation mine. It is interesting to note that although a blast mine was involved in the majority of the cases, only 7% of these accidents resulted in fatalities. AP fragmentation mines were much more lethal since 38% of those victims died, nearly six times more than for blast mines. This reflects the different nature of the fragmentation mine threat: a blast mine is designed to maim its victims, but fragmentation mines are designed to kill. Another interesting statistic extracted from Reference [1] relates to the activity that the victims of AP mines were performing at the time of accident. Out of the 13 categories of work listed in the survey, two categories account for 71% of all injuries: these are Excavation and Missed Mines (34% and 37%, respectively). It should be noted that Missed Mines is not an activity on its own: the term indicates human error or the failure of the equipment to detect a mine. The survey also reports that Missed Mines resulted in 3.5 times more leg injuries than Excavation accidents, which suggests that the victims were standing at the time of accident. These statistics provide a clear indication that protection of the lower leg from mine blast effects is a worthwhile goal to reach. Even prior to the publication of Reference [1], based on injury reports coming back from the field, the HDP had identified the need to improve the protection of the lower leg. However, to guide the design of suitable footwear, it was first necessary to better understand the injury mechanisms associated with a mine exploding under the human foot. This was one of the main objectives of the Lower Extremity Assessment Program (LEAP) [2, 3], which documented the effects of mine blast on the human lower extremity using cadaver models. The program involved both technical and medical staff, thereby linking mine blast physics with medical outcomes. Instrumentation such as high-speed photography and cineradiography was used to record the event as it took place. The medical staff had access to standard medical equipment and performed post-event autopsies to document the extent of physical and biological disruption to the legs. The LEAP tests used three blast mines (M14 with 29 grams Tetryl, PMA-2 with 100 grams TNT, and PMN with 240 grams TNT) that represent the full range of threat conditions. A small, but representative range of footwear was tested. An improvised sandal and the standard US Army Combat Boot (CB) were used as the references for unprotected footwear. Two mine-protected boots were used: the Wellco Blast Boot
(BB) and the BFR-40 boot. These boots have a blast deflector in the rear portion of their sole while the forward portion of the sole is unprotected. Finally, two boot supplements were used in conjunction with another footwear. These were the Wellco Over-Boot (OB) that consists of the BB sole with its blast deflector, but mounted on a Kevlar strapping system so that the OB can be worn over another boot; and the MedEng Systems Spider Boot (SB), which consists of a platform supported approximately 100mm above the ground by four legstwo that protrude in front and two that protrude to the rear of the platform. The SB is designed to move the point of detonation outside the footprint. The LEAP study was particularly useful because it provided detailed information about injuries to soft tissues and bones following exposure to a mine blast. At this point, it should be noted that tests involving human cadavers are conducted within a strict legal and ethical framework. Only authorized institutions can perform such tests and biomedical expertise is required to fully realise the benefits. It also involves special handling considerations because dead human tissues pose a biohazard. Another consideration is that the age, sex and body-build of the subjects can range widely. For example, the subjects used during LEAP ranged from 37 to 96 years of age and weighed from 44 to 93 kg (97 to 205 pounds). This introduced a large variance in bone strength and body dimensions. Other factors must also be considered when comparing the results from cadaver studies to injuries to live humans. These include the lack of tonal response of dead tissues as compared to live tissues, the lack of arterial pressure, and the lack of systemic response of the body following trauma to an extremity. These factors must be carefully weighed during the medical assessment. The high specialization and resources required make it very difficult for industry and test agencies to use cadaver models to conduct routine tests when supporting the development of mine-protected footwear. Recognising this fact, in 1999 the Canadian Centre for Mine Action Technologies (CCMAT) proposed to develop suitable injury criteria [4] for an existing surrogate of the human leg that could be used in mine blast tests. Surrogates to the human body have been used successfully for decades. A prime example is the Hybrid III anthropomorphic mannequin, which serves the automotive and aircraft crash safety industry. This human surrogate replicates the generic shape of the human body with particular attention given to the mass distribution. It is used in accident simulations where the body is subjected to sudden acceleration or deceleration. The response of the model is related to human injury via injury criteria. The Hybrid III even has an instrumented leg with an injury criterion that yields a probability of injury due to the deflection of floorboards during a car crash. Unfortunately, this particular criterion is not applicable to the case of an AP mine explosion under a foot because the loading rate from a mine explosion is 10 to 100 times faster, and has a much greater magnitude, than the loads produced during a car crash. Furthermore, the mine explosion exposes the foot to such high pressure that bones and soft tissue simply disintegrate, which results in a traumatic amputation. Car crash injuries on the other hand are primarily of a crushing nature.
Years of experience with Hybrid III type surrogates suggest that a surrogate leg model should be useful if its response can be connected to human injuries. In dealing with mine blast injuries, the development of suitable injury criteria should be made easier if the model selected can replicate, to some extent, the actual damage mechanisms occurring to a human leg. This might involve some level of frangibility for the materials in response to the very high pressure near the explosion. Researchers at CCMAT were aware of the development of a synthetic reproduction of the human leg by the Australian Defence Science and Technology Organization (DSTO). The Frangible Surrogate Leg (FSL) potentially offers several advantages for use in mine blast testing. Being synthetic, the biohazard and ethical considerations are avoided. The geometry and physical properties of the FSL can also be fixed and controlled within pre-established limits to avoid variations in bone strength and density from one test specimen to the next. These attributes make the FSL a good candidate for use by industry and test agencies. However, to be useful, there is a need to develop and validate injury criteria that link the FSL response to human injuries. There are significant limitations to surrogate technology. Biological structures are orders of magnitude more complex than the current level of realism achievable in a surrogate leg, even for a relatively sophisticated model such as the FSL. The implication is that such a model cannot be used to replicate detailed injuries to soft tissues from the muscular, nervous and vascular systems of the human limb. In other words, the surrogate remains a gross over-simplification of the human structures that it tries to mimic. Despite these limitations, the development of injury criteria for a surrogate such as the FSL remains a worthwhile venture because it should yield a useful tool to assess the probability of human injuries due to mine blast. It is under the above premises that CCMAT proposed to sponsor a series of tests with the FSL that replicated selected test conditions from LEAP. This program was called CCMAT FSL (CFSL) and involved 25 mine detonations against the FSL in September 1999. The tests were performed at the Defence R&D Canada Suffield (DRDC Suffield) facilities.
1.1 Scope and Objectives of the CFSL Program

The main objective of the CFSL program is to assess the feasibility of the FSL as a test model and develop mine blast injury criteria so it might be used in routine blast tests of protective footwear. To achieve this objective, it is necessary to generate a database of physical damages to the FSL and determine the correlation between the CFSL and LEAP test results. To make this comparison, it was necessary to perform the CFSL tests in the same way that the LEAP tests were performed. This involved reproducing as many test parameters as possible, such as the selection and placement of the mines, the soil type, the footwear, etc. In addition to the primary objective listed above, the CFSL tests had the following secondary objectives:
Assess the repeatability of the FSL as a diagnostic tool, subject to the inherent repeatability limits of the mine explosion itself; Acquire physical data using strain gauges and a load cell to determine their potential as instrumentation for the FSL; Evaluate the relative protective performance of a small selection of footwear; Obtain structural response data for mines with an explosive mass between those of the M14 (29 grams) and PMA-2 (100 grams), which were used during LEAP.
It is important to note that, as of September 1999, the FSL was still under development. Some earlier versions of the FSL had been subjected to explosive tests, including footwear tests against AP blast mines, but there had been no focus on calibrating the mechanical response of the FSL against mine injuries to actual human limbs. The results presented in this report are part of the evolution of the FSL. However, given that the FSL had reached a certain level of maturity in terms of the quality control of the geometry and materials, it is reasonable to interpret the trends as a function of footwear or explosive mass. The medical assessments contained herein are based mostly on the level of damage imparted to the bones of the FSL. Comparison of the LEAP and CFSL medical assessments of soft tissue damage was more difficult because of the low level of fidelity of the FSL soft tissue simulant as compared to an actual human limb. In spite of these limitations, professional physicians and surgeons that had experience in the treatment of mine casualties made the medical assessments. This provides significant confidence and credibility to the results of this study.
1.2 Organisation of this report

This report presents a synopsis of the main results from the twenty-five FSL tests performed in September 1999 along with a first order comparison of the trauma scores to those obtained with similar test conditions during LEAP. The report contains sufficient detail to give a rough understanding of the medical problem posed by AP blast mines and the limitations that any surrogate might have to accurately reproduce this level of detail. It also describes the control parameters used during the CFSL program so that the results can be interpreted within a proper context. Thus, this report is organised as follows:
Section 2 describes the anatomy of the human lower extremity, which consists of interdependent systems, e.g., skeletal, vascular, nervous and muscular. The description highlights the complexity of these systems to allow an appreciation of the simplicity of a surrogate like the FSL. The insertion of a load cell in the tibia of the FSL is also described. Section 3 describes the physics of a mine blast to illuminate the violence and short duration of this event. This section then proceeds to describe the injuries imparted to the lower limb during the explosion of a mine under a foot, which causes great
disruption to the bones and soft tissues, with a corresponding loss of functionality of the limb. Some of the factors that affect the medical outcome are indicated, followed by a coarse description of the steps required to perform a surgical procedure on the lower limb following mine blast trauma.
Section 4 focuses on the experimental detail of the CFSL program. Descriptions are given for the footwear, the mine and surrogate explosive threats, the geometry of the test set-up and the disposition of the diagnostic imaging equipment. The section also describes the experimental procedures and the medical assessment protocols, including a description of the Mine Trauma Score (MTS), used during the LEAP and CFSL programs. Section 5 starts with an overview of the mine blast trauma to the FSL as recorded from high-speed video and flash x-ray imaging. The footwear damage is then examined in detail to determine those factors that might influence the outcome of the test. The section then details key results from the twenty-five tests. The emphasis is put on the MTS scores that were determined by medical staff experienced with mine blast injuries. The MTS scores from the CFSL and LEAP programs are also compared, but this comparison must be interpreted with care because of differences in experimental conditions and the fact that the FSL was still under development. Finally, this section presents a summary of the strain and load cell data obtained during these tests. Section 6 presents our conclusions from the current CFSL work. A series of recommendations for follow-on work are made. The results from this test series indicated the need for structural modifications to the FSL due to excessive strength of the calcaneus and talus, which are critical bones for this application. It was also determined that follow-on tests would be justified only when M14 mines were obtained. Using the M14 would improve the comparison with the LEAP data. The results from these follow-on tests are the subject of a subsequent report. Annex A provides details of four wound classification systems and outlines the usefulness of each in determining tissue damage and amputation levels for lower mine injuries. Annexes B, C and D provide a compilation of key data from the CFSL tests. Respectively, these annexes present a description of the physical damages imparted to the footwear, summaries of the medical assessments for each test, and complete records from the load cell data.
2.
Structures of the Human Leg and the FSL

To better appreciate the complexity of the human leg, the relative simplicity of the FSL, and the implications to a living person of injury to the lower leg, a basic understanding of the structure and function of both kinds of legs is necessary. Consideration of mechanical and regional organization, coupled with significant details of circulatory and nervous systems, serve to illustrate the devastating impact of lower limb injury to a living patient. This section is not intended to be a comprehensive discussion of anatomyseveral good sources for just that are cited in the Bibliography. Details of the construction of the FSL, including the addition of a load cell in the midtibia in some specimens, allows for a realistic comparison of results obtained by the LEAP and CFSL test programs.
2.1 Clinical Anatomy of the Lower Limb

It is vitally important to consider anatomy as a functional study; each small part of the limb supports the function of another and so the whole leg is dependent on the proper function of all parts of the leg. As an example, injury to, and possible functional loss of, a portion of the footeven a small partcould interfere with weight bearing of the entire body. The knee and upper leg could lose balance and strength and, ultimately, significantly interfere with gait and work. The pelvis, in turn, is attached to the spine and thence to the entire body. The body is a persona soldier or workerwho depends upon a healthy working body in order to support a family and participate in society. Knowledge of the anatomy of the lower limb can be adapted to make a mechanical device which can then be used for testing the efficacy of protective equipment when subjected to the effects of AP land mines. It is obvious that a mechanical or computerized device, no matter how complex, cannot come close to mimicking the entire system. Some areas particularly challenge the modeller, who must consider not just the static anatomy of the limb, but also the way these structures interact to allow motion like standing and walking. Additionally, the circulatory and nervous systems respond to particular conditions, such as traumatic injury, vitally affecting mechanical functionan effect that no model can replicate yet.
2.1.1 Organisation of the Anatomy

The lower leg can be viewed as several interdependent regions. The torso, containing the main abdominal and thoracic organs, is supported by the spine and pelvis. These are, in turn, supported in the upright position by the two lower limbs. The pelvis meets with the thigh at the hip joint, or femoral head, and the thigh region is supported by the knee. The knee rests on the lower leg which consists of two bones the tibia and fibula. These bones articulate
through the ankle joint to the foot, which is further classified into hind foot, mid foot, and fore foot (see Figure 1). The bones, nerves, and major muscle groups of each region of the leg all have matching structures in the respective regions of the arm. The exact function varies as an adaptation to life in the upright bipedal position.
Figure 1. Drawing of the foot showing its various componentsI. Anderson
Because of the complexity of the human body structures, there are many ways to describe the anatomy of the lower limb. The previous description is based on the regional organisation of the structures, but the anatomy of the lower limb could also be described in terms of organs and tissues. The limb has skin, muscles, fat, nerves, vascular tissue (including veins, arteries, lymphatic tissue and capillary beds), bones and bone marrow. Extensive connective tissues form the ligaments that support the joints, connect major muscle groups and support the important anatomic structures of the leg. Each organ can be further described as a collection of structures that are progressively smaller, finer, and more specialized. Nerves (Figure 2), for example, are organised in large trunks that include the actual axons, the cells that transmit electrical messages. Nerves also contain large amounts of connective tissues that perform support functions and prevent injury. Blood vessels provide oxygen and nutrients while specialized, fat-containing myelin cells wrap the axons, thereby providing insulation to prevent interference from other nerves. Large bundles of nerve fibres go to the same location, but as the nerves pass distally down the leg, the bundles branch off to specific muscle groups and regions. Each branch then gives off individual nerves and axons to perform specific purposes. Nerve tissues pass information in both
directions, with some axons passing electrical information down to the limbs to direct specific function, while others pass information from sub-specialized sensation organelles up the body to connect with other nerves and the brain. Ultimately, at the cellular level, each tissue consists of cells that are highly specialized in their function.
Figure 2. Overview of the anatomy of a nerveI. Anderson
Another useful method to describe the anatomy of the lower limb is from a spatial and regional point of view. Figure 3 illustrates the convention used to describe the regions of the human body, which considers the body standing with all limbs straight and the arms rotated so that the thumbs are pointing outthe so-called anatomical position. Anything in front is called anterior, and anything behind is called posterior. Structures that are closer to the centre of the body are called proximal, while structures further away from the centre of mass are called distal. Similarly, superior refers to the upper body and inferior to the lower body. Any structure referred to being closer to the head area is cranial, while those closer to the buttock are caudal (referring to the tail). The lower limb is mostly tubular and is divided into compartments with specific functions. Each region of the leg includes one or more joints and supports more joints above. Each joint varies in the degree of freedom through which it can move. For example, the hip joint is a ball and socket joint and can move in many directions; the knee joint is a hinge joint and is
capable of very restricted movement in one plane onlyflexion and extension. Muscle groups within specific compartments control each of these
Figure 3. Anatomical position showing anterior view of an upright postureI. Anderson
movements. Muscles within each of these compartments may act for a short range over a single joint or over a long range over two or more joints. An example is found in the large posterior compartment of the lower leg:
The gastrocnemius muscle takes its origin in the distal femur above the knee joint and joins with the soleus muscle to insert on the calcaneus below the knee joint. The gastrocnemius thus acts over two joints; The soleus is also in the large posterior compartment, originating on the back of the tibia and fibula, and so acts over only one joint; Muscles originating on the lateral compartment of the leg form into long tendons and curve around the lateral part of the talus and calcaneus to insert into several bones of the foot, thereby preventing inversion of the foot or helping to evert the foot. The real function of these and other muscles is to steady the foot as the person walks and runs, so anchoring the foot in one position to allow the rest of the body to shift forward as a stride is taken.
The clinical significance of compartments is two-fold. There is frequently a specific vascular supply and nerve supply to the group of muscles. Each muscle compartment is surrounded and supported by a very strong resilient membrane called fascia that serves to support the muscles when they are exercising. When muscle groups are injured, as in a gunshot wound, fragment injury or mine blast, the tissue swells in response to the trauma. Because the fascia does not stretch, there is insufficient room for the swelling and pressure within the compartment increases. This can have serious consequences for the casualty. Even though blood pressure in arteries is relatively high (90-120mm Hg systolic), the pressure within veins coursing through these compartments is quite low 10-15mm Hg. Oxygen exchange occurs in tissue at around 2030mm Hg. Thus, a small increase in pressure will rapidly reduce venous blood flow and cause blood to back up in a cascade that worsens as arterial blood still enters under high pressure. Oxygen exchange with the muscle cells stops and the muscle cells will quickly die. Compartment syndromes are common and a frequent cause of severe disability. While a mine blast may rip open the fascia restraining a compartment, the fact that there are several compartments running up the entire leg (see Figure 4) means that there is a high risk of this problem in any significant trauma.
2.1.2 Lower Limb Anatomy from a Regional Perspective

Considering the anatomy of the lower limb on a regional basis allows for a better appreciation of the possible impact of a mine blast on both the immediate region and on the rest of the body. The following description starts with the pelvis and moves down the body through the structures of the lower limb.
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2.1.2.1
The Pelvis The pelvis is an important part of the lower extremity. It has two equally important components to consider: the visceral pelvis, which contains several organ systems including the rectum, bladder, urethra, female sex organs, and many of the male sex organs; and the bony pelvis, which consists of the two halves of the iliumthe pubis and the ischiumwhich are fused together to form the inominate bone and joined to a midline sacrum to produce a solid ring. The pelvis is susceptible to injuries from mine blast. Injuries to the visceral pelvic organs are fatal if not treated because of sepsis and haemorrhage. The external genitalia are also exposed to upward moving fragments. In reference to the lower limbs, the bony pelvis is fundamentally important because:
All of the blood vessels and nerves to the leg pass from the central torso through specific canals formed by the pelvis bones and the supporting ligaments, as depicted in Figure 5. The femoral nerve, artery and vein pass through the femoral canal formed between the pubic ramus and inguinal ligament and is very exposed anteriorly. For each leg, the sciatic nerve, which is the main nerve to the lower leg and foot, passes out the greater sciatic foramen formed by the supporting ligaments of the sacrum to the sciatic ischeal spine of the ischium. The obturator nerve and artery pass through the obturator foramen formed between the pubis and ischium. The obturator membrane and muscle partially close what would normally be a large opening. The obturator nerve is the main supply to the muscles in the medial part of the leg which draw the femur towards the midline; It is the main support of the leg and transfers the support of a single axis of the spine to the double axis of the legs. This support must be stable and capable of control in four directions to allow normal gait and standing.
The hip joint is a ball and socket joint that is highly mobile, but relatively stable from the point of view of dislocation. This is because of the strong pelvic bones, ligaments and large muscles mostly posterior to the joint. The ball of the joint is formed by the head of the femur, which receives its blood supply from the neck of the femur and less so from a ligament attaching the femoral head into the socket or acetabulum. The femoral head can easily loose its blood supply, be fractured or dislocated, which could result in collapse of the bone and arthritis. The muscles around the hip joint are enormously strong to help extend the hip joint as in normal gait and climbing actions.
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Figure 4. Cross-sections of the leg showing different compartments; (a) Important muscles, arteries and nerves; (b) Compartments enclosed by fasciaI. Anderson
2.1.2.2
The Knee Joint The knee is a complex joint that does more than act as a simple hinge joint. Because a person walks by swinging the entire body weight onto first one limb then the other, as one lower limb recovers, the entire body weight above the opposite knee joint places it under enormous stress. Ligaments must act to stabilize the knee to limit certain kinds of motion. For example, there are strong ligaments that prevent lateral bending of the joint. A strong posterior ligament prevents forward flexion when the knee is straightthe knee locks because of this ligament so less muscle mass is needed to maintain a standing position. The actual cartilage surface of the femur glides along the surface of the tibia as the knee flexes and extends. There are also two cartilaginous
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menisci that act as spacers in the joint and provide more congruent application of joint surfaces and sliding of the femur on the tibial plateau surface. Two complex ligaments, called the cruciate ligaments because they cross in the middle of the knee joints, limit forward and posterior displacement of the femur. The knee joint may bend a million times in one year with the normal activities of living. Thus, any imbalance or arthritis can have a profound effect on the mobility of the person.
Figure 5. Blood vessels about the hip jointI. Anderson
2.1.2.3
The Tibia and Fibula
The tibia and fibula, the two long bones of the lower leg, are joined by ligaments at both ends and by a very strong and resilient interosseous membrane, as shown in Figure 6. The tibia is the only weight bearing bone of this region since the fibula does not form part of the knee joint. The fibula is very important in the stability of the ankle joint however. The upper fibula is less important and may form a brace for the tibia and a support for muscles. The common peroneal nerve curves around the upper head of the fibula and is commonly injured with fractures of this area. The interosseous membrane is quite strong. The tearing of this membrane implies that a
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significant amount of force has been applied to the leg to cause the injury. One should then be suspicious for other
Figure 6. The tibia and fibula bones of the lower legI. Anderson
complications such as compartment syndromes. Anatomically, this region has two clinically relevant problems for injury:
The lower leg in this area is divided into four muscular compartments that can experience serious problems if posttraumatic swelling causes pressure to build up in any or all of them; The blood supply to the tibia is poor in comparison to other bones. Because of the size and distance from the torso, the blood vessels supply a lower blood flow to the tibia, and especially the distal tibia. A large force is required to fracture the distal tibia, and because of a lack of muscle support
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around that area, distal tibia fractures are frequently badly displaced, thereby increasing the amount of tissue injury and disruption of blood supply. The periosteum of the tibia is often partially stripped by the force of injury. Distal tibia fractures are frequently compound or open with the resultant risk of infection. The net result of this loss of blood supply is a high rate of complication for injuries in this region. Fractures are slow to heal, have a high rate of non-union, and of infection. Surgery is frequently needed to aid healing. If infected, this injury may need very sophisticated techniques to increase blood supply to the area, including hyperbaric oxygen and free muscle, bone and skin flaps. Many medical centres are not equipped to support such operations. 2.1.2.4 The Ankle Joint The ankle joint is a hinge joint formed by a mortise consisting of the distal tibia, which has the weight bearing surface and medial support, and the fibula, which is strongly bonded to the tibia with ligaments to provide the lateral support. The ankle joint articulates with the talus and has strong ligament support to maintain alignment. The ankle joint is highly mobile relative to the joints of the foot, particularly in dorsi and plantar flexion. Some amount of inversion and eversion are possible, although in weight bearing, this can create instability and injuryindicated by the high frequency of sprained ankles. The mortise of the joint prevents significant medial and lateral sliding. The close alignment of the talar and tibial joint surfaces is maintained as the joint undergoes dorsiflexion. When there is laxity in the joint through spreading of the fibula-tibia mortise, fracture, ligament laxity, and disabling arthritis can easily occur. A number of tendons, arteries and nerves pass around the ankle joint to reach the foot. The mobility of the joint mandates that these be able to move in response to ankle motion to prevent kinking. 2.1.2.5 The Foot The foot is a complex assembly of bones that supports the entire weight of the body. It must protect the remainder of the leg from impact when walking or running, it must be strong and resilient to withstand the direct impact of the environment with every step (footwear is a recent adaptation), and it must be able to warn the person of harmful stimuli when stepping on hard or sharp objects.
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The organisation of the foot incorporates an arch system that acts as a shock absorber and increases the mechanical advantage of the spring phase of gait. Stabilizing tendons and muscles enter the foot from the ankle and create the force necessary to walk or run. The foot is richly supplied with arteries and nerves. The bottom (or plantar) surface of the foot has a very thick layer of skin, yet it has a generous supply of nerve endings and sense organs. Without the resultant protective sensation, a condition called anaesthetic foot causes susceptibility to minor injuries that can cause small fractures and arthritis. Considerable fat and fibrous tissues support the thick under-surface skin to prevent unnecessary shearing and injury of this layer. Injuries to the under-surface of the foot can be serious if they become infected. Because the foot is often bare or enclosed in dirty footwear, contamination and infection is frequent, even in relatively minor wounds. Scar tissue can cause problems from pressure and pain. The foot is subdivided into the hind foot, mid foot, and fore foot. The hind foot includes the calcaneus and talus. The mid foot consists of the navicular, cuboid and three cuneiform bones, and the fore foot consists of the metatarsals and phalanges of the toes. This complexity includes fifty-seven articular surfaces and permits the foot to adapt to almost any surface texture, alignment, incline and speed. The talus is the most superior bone of the foot. It articulates the entire foot with respect to the tibia-fibula mortise. Below are the very solid calcaneus and navicular bones. The talus is at the apex of a triangle formed by these bones and the muscles and ligaments maintaining the longitudinal arch. Impact injuries of the calcaneus against rudder bars of aircraft (so common that talar fractures are called rudder bar fractures), or in falls or mine blasts, frequently fracture the neck of the talus. Because of the various leg and foot bones adjacent to it, approximately 60% of the talus surface area is covered by cartilage (Figure 7). Since the blood supply to the talus can only enter the bone where there is no cartilagemainly the neck and the posterior tuberclemany areas of the talus have a fragile blood supply. Any injury to the talus has a very high incidence of collapse and non-healing. Because of the large amount of cartilage and joint surface, and its fundamental role in supporting the weight of the body and in any gait, fractures of the talus are very disabling and require sophisticated surgical techniques including, bone grafting and fusing the foot and ankle.
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Figure 7. Talus bone; articular surfaces are coloured; there is very little surface area not covered with cartilage where nutrient blood vessels can enter this boneI. Anderson
The calcaneus also supports the weight of the body. It is immediately below, and projects behind, the talus as the heel bone. It acts as a lever to increase the mechanical advantage of the muscles in the posterior part of the lower leg, which form the Achilles tendon that acts to push the foot down and, more importantly, acts in the push-off phase of gait. It also takes the full impact of the strike phase of gait, and stabilizes and controls the foot as the remainder of the leg and torso rotates over it as the person walks forward. The calcaneus is the most commonly fractured bone of the mid or hind foot. Its shell of dense cortical bone surrounds a core of finely spiculated cancellous bone (Figure 8) that is easily fractured. 2.1.2.6 The Arches of the Foot The arch of the foot is present at birth. There are two arches: longitudinal, which is formed and maintained by alignment of the calcaneus, talus, navicular and fore foot bones; and transverse, which is formed by the heads of the metatarsals. The ligaments of the foot help keep these bones together. The longitudinal arch is maintained in the standing position, irrespective of loading, until very severe loads are applied (Figure 9). The muscles and ligaments of the foot do not actively form the arch. When standing, most of the loading is applied to the talus and then the calcaneus, navicular and first metatarsal and the great toe. The heads of the metatarsals for the transverse arch tend to flattened as loads are applied. The foot undergoes complex geometric loading with normal gait.
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Figure 8. The calcaneus bone (heel bone)I. Anderson
Figure 9. Diagram demonstrating the arches of the footI. Anderson
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2.1.3 The Mechanics of Standing and Gait

The alignment of the lower limb and the remainder of the upper torso is extremely energy efficient and requires a sophisticated balance of joints, ligaments and muscle groups. Figure 10 shows how the centre of gravity of the body passes behind the hip joint and in front of the knee. The weight of the torso is focused on the spine, which is transferred to a rigid pelvis. The weight is then transmitted equally to the femoral heads. Individually, each femoral head is forced into hyperextension by the weight of the body. This is resisted by the tension of the ligaments anterior to the joint, especially the ilio-femoral ligament. The hip joint can be kept in this extension with no muscular work for extended periods. Standing on two feet allows muscle relaxation except for brief actions of the hamstrings and iliopsoas muscle to provide balance.
Figure 10. Lateral view of the human upright postureI. Anderson
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2.1.3.1
Standing When standing on one foot, the pelvis tendency is to move the unsupported side down. This is counterbalanced by powerful hip and pelvis abductors, which stabilize the pelvis, draw it up and rotate it slightly forward. Interference with the hip abductors of the unsupported side would significantly interfere with normal gait. When the centre of weight of the knee is anterior to the centre of movement, the knee tends to remain fully extended and resists hyperextension of the collateral ligaments and posterior joint capsule. Standing on one knee further forces the knee into hyperextension that, when resisted by the ligaments, causes the femoral head to internally rotate slightly on the tibia to further tighten the collateral ligaments to lock the joint. An injury might damage the alignment of the knee joint, cause wear of the cartilages of the joint and laxity of the cruciate and collateral ligaments. The stability of the leg would then be compromised and much more muscle work would be required to maintain upright stature. While the static stance of standing does not require the active use of muscles of the plantar surface of the foot, it is easy to see that loss of, or weakness in, one group can unbalance a very elegant anatomical machine, resulting in disability from arthritis, pain and stress fracture.
2.1.3.2
The Gait Walking is normally divided in two phases: the stance phase when the foot or part of it rests on the ground, and the swing phase as the foot recovers forward for the next step. Normally about 60% of the pace is in the stance, 40% in the swing. Both feet are in contact with the ground for approximately 20% of the time. There are several classifications of foot movements in gait. Figure 11 shows how it can be divided into at least six stages:
Heel strike Foot flat Mid stance Heel off Push off Toe off As the heel strikes the ground and moves to the foot flat phase, the weight of the body transfers from the calcaneus to the navicularfifth metatarsal axis. As more weight is placed in mid stance, the weight is distributed to all metatarsal heads with more pressure on the first head. With the push off, increasing pressure is applied to the second metatarsal. With running, more pressure is applied to the first, second and third metatarsal heads.
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Figure 11. The six phases that make up the normal stride gaitI. Anderson
2.1.4 Circulation in the Lower Limb

Circulation consists of arterial inflow, venous outflow, and lymphatic flow. All are important for the healthy function of the lower limb. Arterial flow into the leg is characterized by limited numbers of vessels entering the limb at certain areas and by a net of collateral vessels crossing certain joints. Some of these are capable of adaptation in response to gradual obstruction such as arteriosclerosis. With chronic obstruction, the limb can develop extra blood vessels by increasing flow through smaller vessels that flow into the limb. Even so, there is a limit to how much this will save a limb from serious problems of ischemia. Unlike elderly patients with ateriosclerosis, though, a trauma patient usually has a normal pre-injury anatomy and no long-term adaptation has taken place. The compensatory flow comes from the obturator artery that supplies a limited area in the adductor group of muscles. This is very limited in its ability to supply the majority of the lower limb with blood. The main arterial inflow to the leg is from the femoral artery (Figure 12) just in front of the hip joint. This artery rapidly divides into a deep profunda artery that supplies many of the muscles of the upper leg and descends distally. In some cases, it provides a significant supply of blood to the collateral vessels around the knee, especially under conditions of gradual onset. The blood flow past the knee is via the popliteal artery (Figure 13) and is again a critical area where, in most cases, this is the only vessel supplying blood to the lower leg. It is somewhat exposed in the posterior part of the knee. The blood supply to the lower leg is via three arteries that divide off the popliteal just below the knee: the tibialis anterior goes to the anterior muscles
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of the leg, the tibialis posterior feeds the deep posterior compartment muscles, and the peroneal artery supplies the lateral muscles. Several smaller branches supply many of the other compartments.
Figure 12. Muscles and arteries of the thighI. Anderson
The foot has a rich collateral circulation consisting of several arteries that continue from the main vessels in the lower leg. As such, blood supply to the foot is rarely a problem unless there is long standing vascular disease (such as arteriosclerosis or diabetes), injury to the popliteal artery or several of its branches, or a significant displacement of the ankle joint and foot from fracture or dislocation. (This displacement kinks the vessels and blocks blood flow).
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Figure 13. Vessels and muscles of the knee join (posterior view)I. Anderson
The flow of oxygen-rich blood is critically limited to several other areas, which significantly threatens the viability of injured tissues. The arterial flow is limited to a single vessel across the hip and knee joints unless longstanding disease has promoted the development of collaterals. Limited flow has also been described in the distal tibia and talus bones where a fracture would further decrease the flow, and delay or prevent healing. This results in avascular necrosis where the bone loses its strength and collapses under the weight of the upper body. Tibial fractures are slow to heal and have a high incidence of infection. Increasing blood flow into an injured area is very difficult and may require very sophisticated surgical procedures such as free vascular-muscle grafts. Such surgical procedures are available only in a limited number of medical centres within the developed world.
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Often overlooked, but of no lesser importance, is the venous drainage of the limb. A rich net of veins draws blood from the foot up to the leg. Venous drainage up the leg is in two layers: superficial and deep. The superficial system collects blood from the skin and superficial tissues and follows two large veins: the long saphenous vein, which ascends the medial leg to the thigh, and the short saphenous vein, which ascends the lateral leg to the knee. Each of these veins has several branches that take blood from the superficial to the deep venous system. This is the more important system, which ascends between muscle groups to the popliteal vein at the knee. This is a critical vein. While there are collateral veins, these are insufficient to drain blood from the lower leg. Injury to this vein prevents blood, pumped continuously into the leg via the popliteal artery, from returning to the central circulation of the torso. The leg swells rapidly and ominously to produce high pressure and ends in gangrene. Once past the popliteal vein, venous drainage of the leg continues through the femoral vein, which follows the femoral artery into the pelvis. Venous injuries are common and disabling. The lower pressure in the veins does not mean that they have less flow. The veins of the legs are large and can contain a large portion of the circulating blood volume; they are therefore called capacitance vessels. Veins are under neural control and maintain tone in the wall to avoid pooling too much blood. Veins of the leg have one-way valves to prevent backflow of blood down the leg. The muscles of the legs contract to continuously compress the veins, thus maintaining blood return to the central core. Loss of function of these valves or insufficient venous drainage causes chronic swelling, skin breakdown, infection, and pain. As blood is pumped into the arterial system under high pressure to the thin walled capillaries (where oxygen is exchanged with tissues), some of the blood serum leaks out into the interstitial tissues between cells. This excess fluid is collected into small thin-walled vessels called lymphatic channels that, from a diffuse net, ascend the leg. These form larger channels and pass through lymph nodes of the thigh. Lymphatic channels can be blocked by excess surgical dissection in the groin, chronic infection and inflammation caused by parasites and not wearing footwear.
2.1.5 Nerve Supply to the Lower Limb

The nervous system is the most complex organ system in the body. A simple overview will be presented here. Nerve cells are small and extremely variable in their form and biochemistry, depending on their function. Typically, nerve cells of the limbs contain cell bodies that are located in the spinal cord, with extremely long extensions of the cell cytoplasm contained in cell membranes that form the actual nerve tissue to conduct electrical signals (see Figure 14). Each cytoplasmic extension is called an axon, most of which are covered in a fatty tissue (myelin) that does not conduct electricity. Axons may have small defects of myelin, called nodes of Ranvier, that speed up the electrical signals, which jump from node to node. Axons end in fine branches that are
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applied to other extensions of the cell body called dendrites. The junctions between two nerve cells are called synapses. When an electrical signal gets to the end of one axon, various chemicals (depending on the type of nerve) are released that diffuse rapidly across the microscopic space at the synapse, stimulating a chemical reaction on the opposing cell membrane that results in the generation of an electrical wave.
Figure 14. The nerve cellI. Anderson
A nerve signal occurs when the cell membrane of the axon receives an appropriate stimulus (physical touch, sound, light, chemical, temperature for sense organs). At the synapse, chemicals (neurotransmitters) are secreted by the presynaptic membrane and diffuse across to react with the postsynaptic membrane. The membrane leaks ions to cause the normally negative electric charge across the membrane (-90 millivolts inside) to become positive. At some threshold, the membrane reaction spreads and causes an electrical wave (called an action potential) to spread down the length of the elongated nerve cells. For motor nerves, the length of the nerve from the spinal cord to the targeted muscle group is stimulated. After the electrical signal has passed, energy-requiring reactions transfer ions back across the membrane to recreate the balance of chemicals. Axons and nerves are arranged in very complicated arrays and can be made more or less sensitive to stimulation by the effect of other nerves, hormones, and repeated action potentials (where the nerve is exhausted and cannot continue the ion exchanges necessary to create the electrical signal). A typical nerve consists of connective tissues and vascular tissues, called epineurium, that surround bundles of nerves. Nerve bundles are further supported by perineurium. Individual nerves run in the nerve bundles but may
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also be separated by more connective tissue, called endoneurium. The abundant connective tissue provides the vascular supply to the metabolically very active nervous tissue. This connective tissue is quite tough and provides strong physical support for the nerves, which are subject to considerable stress in moving limbs. Nerve supply to the lower limb is organised into sensory nerves that carry information from sense organs in the limb back toward the brain, and motor nerves that send electrical messages to the muscles to stimulate them. In most cases, large nerves carry both sensory and motor nerves. As the nerve goes distally, motor nerves branch off to the muscle groups and sensory nerves join the nerve from areas of skin innervated by the specific nerve. The cell body for the motor nerve is located in the spinal cord and travels the entire distance to the muscle fibres where the axons branch off to become end plates. The cell body, axon, end plate and all of the muscle fibres innervated by the axon are called a motor unit (see Figure 15).
Figure 15. Organisation of nerves and motor unitI. Anderson
Nerve supply to the lower limb arises from a plexus of nerves that exit the spinal foramens of the lumbar and sacral spine. There are two plexus of nerves: the lumbar plexus lies deep in the back and furnishes the femoral nerve that passes to the anterior thigh muscles with the femoral artery and vein; and the sacral plexus (the main plexus), which undergoes complicated branching and connections to produce the numerous nerves that serve the lower limb. Several nerves to the skin come off the plexus that provide sensation to the hip and thigh areas. The main nerve is the sciatic nerve. This large nerve includes two large nerves, the tibial and peroneal nerves, in a common fibrous sheath. In the
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thigh, it provides muscle control to the hamstring muscles at the posterior part of the leg. The sciatic nerve is the largest in the body (up to 2 cm wide) and is critical to maintaining proper leg function. It is well protected deep in the muscles of the thigh and hamstrings. When injury happens, it results in severe disability. The tibial nerve continues straight into the lower leg via the popliteal fossa (accompanying the popliteal artery and vein) and common peroneal nerve just above the knee joint. The common peroneal vein curves around the lateral part of the knee joint to the head of the fibula. It is in an exposed position as it curves around the fibula before dividing into the deep and superficial peroneal nerves. Fractures and compression on the head of the fibula can easily injure this nerve with disabling consequences. The tibial and peroneal nerves are extremely important for the foot and lower leg. The tibial nerve controls the posterior leg muscles and many of the muscles of the inferior part of the foot and toes. It also provides sensation to the sole of the foot. The peroneal nerve controls the muscles of the lateral and anterior compartments of the leg, the dorsal (extensor) muscles of the foot and sensation in this area. Nerves can be easily injured by blunt trauma, pressure-causing contusion, direct cutting, or other disruptions of the nerve or part of the nerve. The type of injury depends upon the part of the axon, fibre or bundle that has been injured and on whether there is continuity or full disruption of the fibre. Table 1 gives the Sutherland classification system used to describe these injuries.
Table 1. Description of nerve injuries by Sunderland Classification CLASSIFICATION
1 2 3 4
DESCRIPTION OF NERVE INJURY

Loss of axon conduction Transection of axon, intact endoneural sheath Transection of axon and endoneural sheath inside intact perineurium Transection of many axons with endoneural sheath and perineurium. Nerve trunk continuously maintained by epineural tissue Transection of entire nerve trunk.
Nerves are capable of repair but the axons must be in direct contact for the best chance to heal. The effect resulting from injury, and the time needed to recover from it, both depend on the location and extent of the injury. In type 1, or neuropraxia injuries, recovery is the rule although it may take some time. The more extensive the nerve injury, the longer it will take to heal. The more extensive the organisation of the axon, nerve bundle, nerve trunk, and connective tissue support, the longer recovery will take and the less likely that full recovery will occur. When the injury is severe, any recovery is unlikely.
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In ballistic injuries, recovery is easier when just a single nerve is involved. When several nerves are damaged, as when the entire limb is mangled, once again recovery is unlikely. When a single nerve does not completely recover full function, the patient can frequently manage reasonable activity with the assistance of special footwear, canes, crutches, or braces. Injuries to nerves must be considered in terms of the entire sense organ: nerve-reflex-motor end plate. Any interference with the function of this cycle will interfere with the function of the whole unit. Sensation is extremely important. Patients with sensation problems of the foot (from chronic western-type ailments) have a high complication rate including infection, minor and continuing fractures, loss of bone density, bone collapse and arthritis. Amputation is common and all of these patients are heavy users of the health care system. In the third world, where footwear is less common and heavy work on ones feet typical, minor nerve injuries can cause longterm disability and employment problems. Another common problem from abnormal nerve healing can be scarred nerves that create pain. This is often seen after amputation, where the cut end of a nerve repairs with scarring and becomes a painful pressure-sensitive neuroma. This can make the fitting of a proper prosthesis difficult. The patient may need another operation to find and remove the nerve ending. Such complications can be avoided by providing adequate soft tissue over cut nerve ends.
2.2 The FSL a Very Simple Model Indeed

In the mid-1990s, the Australian Government launched a program to develop a standardised and reproducible surrogate of the human body. These anthropomorphic devices, or parts thereof, would be used in battlefield ballistic and blast trauma studies. The Frangible Surrogate Leg (FSL) represents the lower limb component from this program. Prior to the CFSL program, the FSL was used in other landmine blast experiments, both relating to human trauma inside vehicles and to the effectiveness of anti-personnel landmine protective equipment. The FSL evolved throughout these various test series, and the FSL described herein is the fourth generation design, designated the Mark (or MK) IV FSL. The Mk IV FSL consists in four main subgroups: bones, tendons, soft tissues and skin. The bones are constructed from a proprietary blend of resin, hardener and x-ray contrast agent. The blend is injected into geometrically accurate moulds of the lower limb bones, reproduced from an actual human cadaver, and allowed to cure. This manufacturing process results in a uniform distribution of the blend across each bone, which differs from most actual bones which have a hollow core containing marrow or other soft materials. The concentration of x-ray agent was adjusted to give good Computer Tomography (CT) contrast at the machines clinical setting. The four bones of the leg (femur, patella, tibia and fibula) as well as the talus and calcaneus are produced separately. For ease of manufacturing, the remaining bones of the foot are moulded as two sub-assemblies consisting of the navicular, cuboid and
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cuneiforms for the mid foot, and of the metatarsals and phalanges for the fore foot. Figure 16 shows all the bones that make up the FSL skeleton. The bones are then put in an assembly fixture and connected using a high temperature, high flexibility polyamide glue (Figure 17). The polyamide glue simulates cartilage tissues and, upon setting, forms a strong bond between the bones. At the same time, it also prevents significant movement of the knee and ankle joints.
Figure 16. Assembled and unassembled components of the FSL
Tendons play an important role in the strength of the human leg, thus they were simulated with flat and tubular polymeric materials in the Mk IV FSL. The femur and tibia bones were attached with simulated tendons, and a complete knee-capsule was constructed out of RTV material. Tendons were also used to strengthen the ankle articulation (Figure 18). Once assembled, the leg skeleton was properly located within a fibreglass mould of the outer shape of the leg. The mould was constructed in halves with a tight seal so that melted pigskin gelatine (20%aq @ 10C) could be poured in to act as the muscle tissue simulant. Curing occurred overnight at 4C. This particular gelatine mixture has been used for more than five decades as the muscle tissue simulant of choice for the international ballistic wound community. Although not a high-fidelity simulant for the microstructures of muscles, the large amount of penetrating ballistics data for this simulant made it a good candidate for the task. Figure 19 shows the Mk IV FSL that results from the pour. The skin is added as the final step. In previous versions of the FSL, an aqueous gelatine- and oil-conditioned chamois was developed as a realistic skin simulant with reasonable tensile strength
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Figure 17. Polyamide glue is used to join the components at normal joint locations
Figure 18. Polymer materials simulating tendons over the ankle
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properties. For the Mk IV FSL, a gel-soaked nylon stocking was melted in the outer layer of the muscle simulant. Various instrumentation packages were investigated with the previous versions of the FSL. These included a mix of pressurized artery simulants, accelerometers and strain gauges. The basic Mk IV FSLs were produced with strain gauges only, to provide insight into the wave propagation speed in the FSL bone materials. The strain gauge might also capture the local bending and compression induced by the force of the explosion. Triple rosettes were placed at the mid-femur and the one-third tibia locations. Uniaxial strain gauges were installed on the proximal and distal tibia, 275mm apart. Compared to the human leg, the structure of the FSL is very simple, leg, raising the question of its usefulness in assessing injuries from a landmine blast. Yet, it is because of this very simplicity that quality control can be maintained to produce practically identical test specimens, which potentially makes the FSL a useful injury assessment tool.
Figure 19. FSL following pour of the gelatine around the bones
2.2.1 Addition of a Load Cell in the Tibia

Eight FSL specimens were ordered without the integral nylon skin in order to install a five- or six-axis load cell in the mid-tibia section. These load cells
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were the same ones that had been used in the LEAP program. Hence, the data collected in the two programsCFSL and LEAPcould be directly compared. The key steps of the procedure used to install the load cells are depicted in Figure 20. It should be noted that the same person installed the load cells in both the CFSL and LEAP programs.
Figure 20. Insertion of a load cell in the tibia
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After removing the plastic wrap and installing the FSL in one half of the mould to ensure stability, the location of the incisions was determined using a ruler and the strain gauges. The gelatine was then completely removed over a length of 175mm using a surgical scalpel. The material removed extended downward starting 6mm below the uniaxial strain gauge on the proximal tibia. During this operation, care was taken to not cut the strain gauge cables. When the tibia and fibula bones were completely exposed, a 75mm long tibia segment was cut, starting 48mm below the strain gauge on the proximal tibia. The cuts were made with an improvised surgical saw, first through the distal end of the tibia, and then through the proximal end. The order of the cuts mattered because the lower portion of the limb becomes unstable and prone to damage if the proximal end is cut first. After the short tibia segment was removed, end caps were placed loosely over the freshly cut tibia ends. These end caps were machined specifically for the task. On one side, a cup was fitted over the bone; the other side consisted of a cradle and a clamping ring to receive the load cell. A blank, with the same diameter and length as the load cell, was then installed to link the two end caps and 3mm holes were drilled to fit pairs of stabilisation wires to locate the end caps appropriately. Once the end caps and blank were firmly in place, the FSL specimen was carefully removed from the half-mould. The specimen was placed upside down in a stand and five-minute epoxy was mixed and poured into the cup to create a solid bond with the tibia bone. A syringe was most useful for this operation. A solid bond of the distal end cap was usually obtained within thirty minutes. The specimen was then turned upright and the epoxy operation was repeated for the proximal end cap. After curing, the ends of the stabilisation wires were clipped flush with the outer diameter of the cups. The specimen was returned to the half-mould, the blank was removed and the actual load cell installed. The load cell cables were run along the surface of the gelatine to exit on the upper portion of the specimen, next to the femoral end. The mould was then closed and sealed, and molten gelatine was poured into the mid-tibia region through an access port. The mould was rocked gently to remove excess air and obtain a uniform distribution of the gelatine throughout the space around the bones. Excess gelatine was poured into a small dam around the access hole to compensate for any shrinkage during cooling. The modified specimen was then returned to cold storage at approximately 4C to cure overnight. The next day, the specimen was extracted from the mould and excess gelatine was trimmed. Final preparation of the specimen will be explained in Chapter 4.
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3.
Mine Blast Injury to the Lower Extremity

Before equipment designed to protect the lower limb from land mine blast can be adequately assessed, the blast, and the resulting injuries, must be described. By design, a land mine explodes near a victim, causing a severe injury pattern involving burns, blast, fragments and contamination, all of which affect treatment and outcome. Pressure, temperature, flow velocity and distance all seem to play a role in causing injuries, which are devastating and complexparticularly to the lower legas is the required medical treatment. Russian experience during the Afghan war [5] provides details regarding the multi-system trauma that results from mine blast, since medical teams, operating in-theatre, dealt with large numbers of mine casualties and kept extensive records.
3.1 Basic Physics of Land Mine Blast

The worst and most injurious part of a landmine explosion is over in a few milliseconds. When the fuse of an AP land mine is triggered, it initiates a rapid chemical reaction chain that releases a large amount of energy. Within a few microseconds, the explosive is transformed into a mass of hot high-pressure gas, called detonation products, that starts doing thermodynamic work on its surroundings. Typical temperatures for detonation products are in the range of 3000 to 5000C; pressure is in the range of 100,000 to 200,000 bars. The hot gas pushes on the surrounding soil, compressing and displacing it away from the centre of the explosion. However, because a land mine is buried close to the ground surface, and because soil offers much more resistance to movement than air, the expansion of the hot gases quickly takes the path of least resistance and the energy and force of the explosion is directed upward. The soil capsoil particles directly above the land mineis ejected at great velocity. Elsewhere, soil compression reaches a limit, then the direction of soil flow changes and soil particles are ejected at a significant velocity during crater formation. This soil flow is referred to as soil ejecta and surrounds a core of vertically expanding gas. The expansion of the hot gas acts like a piston, accelerating the surrounding air and creating an air shock in the process. Objects near it will be subjected to the force of this explosion, which is greater within the expanding gas bubble. Researchers have measured the land mine explosion process [6,7] in terms of physical quantities like pressure and velocity so that an engineering model could be developed and used to design protective measures. Two frame sequences from high-speed films of the detonations of 100-gram explosive charges buried at different depths show the strong directionality of the event (Figure 21). The charge depth of burial clearly influences the nature of the process: the flush-buried charge results in a very bright event, while the cloud of detonation products is very dark for the 80mm depth of burial. The differences are even more apparent when considering other physical characteristics for these two events.
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The vertical expansion front of the detonation products was measured and plotted from the films (Figure 22). In each case, the maximum vertical velocity of the cloud occurs at an early stage and decreases with time. Initial vertical velocity was measured for each depth of burial by fitting a quadratic through the position data and taking the initial slope. For a flush-buried charge, the initial vertical velocity is about 2700m/s and remains strong for a long duration. The event is very bright because burning of the hot combustion products continues long after the initial detonation due to the strong rate of expansion of the front, which makes it possible for the hot, unburned products to mix with fresh oxygen and sustain the combustion process. The presence of jetting indicates that strong turbulent mixing takes place at the interface between the detonation products and the air.
Figure 21. High-speed film sequences showing the detonation of 100-gram charges in sand for flush buried (left) and 80mm overburden (right) burial conditions
The overburden (the soil on top of the mine) slows down the expansion rate of the detonation products considerablyto about 900m/s and 400m/s for overburdens of 30mm and 80mm, respectively. Analysis of the high-speed film frames clearly demonstrates that the nature of the event is also changed. The first frame for the 80mm depth of burial in Figure 21 shows that the detonation products push the soil overburden, which stretches into a semi-hemispherical shape. The soil cap quickly thins out and the detonation products burst through the top of the bubble, which marks the beginning of the visible expansion phase of the detonation products. The darkness of the cloud shows that the overburden has quenched the chemical reaction. This is attributed to the hot detonation products undergoing sufficient volumetric expansion while under soil cover for the temperature to drop below the ignition temperature required to continue the combustion process when fresh air is encountered.
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Within the present context of land mine injury to the human lower leg, it is useful to consider land mine blast output in terms of injury-causing quantities such as heat, pressure and velocity. The spatial and temporal distribution of these physical quantities depends on a wide range of parameters. The effect of soil overburden is essentially a geometrical parameter, as discussed above. Soil condition, another parameter, is determined from the aggregate distribution, compaction and moisture. While the explosive mass and type fix the amount of energy present in the initial bubble of hot detonation products, research has shown that soil conditions have a significant effect on how much of this energy will escape in the upward direction to wound the victim. Thus, when choosing a method to test or proof protective footwear, the choice of soil medium is believed to matter as much as the mass and type of explosive. The relationship between temperature, pressure and density is determined from the laws of physics. However, of these three quantities, pressure is the one that is most relevant to land mine blast injury to the lower leg. As mentioned above, the pressure within the explosive can reach values as large as 100,000 to 200,000 bars. However, pressure relief is extremely rapid as expansion of the detonation products occurs.
140 120 100 Cloud Height (cm) 80 60 40 20 0 -20 0 1 2 T im e (m s) 3 4 5

8 cm 3 cm 0 cm
Figure 22. Height of the cloud of detonation products for a 100-gram charge at different depths of burial
Furthermore, the expansion rate is such that it can be assumed that heat transfer is minimal and that the process can be considered adiabatic for demonstration purposes. Figure 23 shows a semi-logarithmic plot of pressure drop as a function of volumetric expansion of the detonation products. The ratio of specific heats for detonation products was assumed to be 1.35 and two initial values of pressure are considered.
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Pressure Drop due to Adiabatic Expansion

100000
10000
Pressure [Bar]
1000
100 10
0.1 0 0.2 0.4 0.6 0.8 1 Radius [m ] Po=100,000 Po=200,000
Figure 23. Estimated pressure drop for detonation products undergoing volumetric expansion
While the pressure drop is indeed dramatic, the pressure nevertheless remains extremely high within the distance that a foot normally occupies. For example, pressure at 100mm, which ranges from 6,000 to 12,000 bars, only drops to between 360 to 730 bars at 200mm. Most materials, particularly human tissues, cannot withstand such extreme pressures, even in this lower rangethey simply break down. This is also the case for several materials used in the construction of regular and protective footwear. The importance of standoff cannot be over-emphasized. Another quantity that plays an important role in the transfer of load to any footwear in the vicinity of the explosion is kinetic energy, as reflected by the product of density and velocity of the flow components, which include the detonation products and soil ejecta. For detonation products, the principles of fluid dynamics dictate that an object immersed in this transient flow is subject to a drag force. The magnitude of the drag force depends on density, flow direction and velocity of the detonation products, as well as the geometry of the object. As the flow is brought to rest, it creates a force that accelerates the object and propels it away from the centre of the explosion. The fundamental principles governing the impact of soil ejecta against the same object differ somewhat. Since soil ejecta consists of a multitude of small particles, each carrying its own momentum, the transfer of force to the object is governed by the law of mechanics for the conservation of momentum as individual particles impact the object in its path. Geometry of the object plays an important role in this process.
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By combining the main factors discussed above, i.e., pressure, temperature, gas flow velocity and soil particle momentum, the extreme environment surrounding the human lower leg during a mine explosion is evident. Again, standoff is critical.
3.2 Pathology of Mine Blast Injury to the Lower Leg

Mine blasts that occur near a person primarily cause thermal, blast and fragment injuries. Each contributes to the wound, but it is difficult to determine which mechanism dominates, although it appears that there is a dependence on distance from the explosion source. Figure 24 illustrates this concept.
Figure 24. Mechanism of injury depends on range from the explosion
Thermal injury is common with any close range explosion, but it is often overwhelmed and hidden by other injury mechanisms. For an AP mine blast, thermal injury is usually restricted to the very near region to the blast and its severity depends on the time of exposure [8]. The level of burn is also affected by the depth of burial of the mine, which determines the level of afterburn. In the worst case, the duration of the afterburn is of the order of 10-15ms, but the temperature can be of the order of 1000C, which is sufficient to cause thermal injury. However, due to the very close range to the explosion, thermal injury is often hidden by the blast injury. Several authors hypothesised about blast injury. From a macroscopic point of view, the very high pressure near the explosion source overwhelms the strength of human tissues, causing their disintegration. Coupland [9] hypothesised that the explosion under the foot causes its disintegration, destroying the lower attachment point of the long muscles of the lower leg and leading to stripping of the soft tissues away from the long bones. He also described a fanning out of the soft tissues during the explosion, allowing the ingress of fragments from the destroyed foot, environmental debris and hot gas between soft tissue facia in the direction radiating from the mine explosion. He based his description of mine blast trauma on clinical observations while treating victims is hospitals of the International Committee of the Red Cross (ICRC). From
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Couplands description, it is seen that the radius of gross tissue disruption due to blast is smaller than the radius of fragment injuries. The broad stages of a mine blast injury causing traumatic amputation are depicted (artists conception) in Figure 25.
Figure 25. Artists conception of mine blast injury
Fomin [10] was involved in the war in Afghanistan during the 1980s and treated a large number of soldiers that fell victim to mine blast. He also investigated mine blast trauma in further detail using amputated limbs and animal models. The Afghan war casualties provided a broad base of case studies from which the body response to mine blast trauma could be monitored. The basic pattern of injury to the lower extremity, depicted in Figure 26, includes a zone of complete tissue destruction (Zone Ia) where the brisant, or splitting effect, of the explosive dominates the process. The size of this zone is delimited by the distal location of bone damage, depends on the explosive content of the mine, and is roughly hemispherical in shape. This implies that the medical outcome is influenced by which part of the foot initiates the detonation: a heel detonation has a significantly different outcome than, say, a detonation under the big toe. Furthermore, the relatively fixed dependence of the size of this zone on explosive mass means that anthropometrics play a role in the outcome: bigger people are likely
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to suffer somewhat less damage than smaller people. Zone Ib is characterized primarily by the total destruction of soft tissues, while the more resilient bone tissues remain. The Russian model attributes the main cause of damage in Zone I to the expansion of gas.
Figure 26. Diagram by Nachaev et al. that shows the distinct zones of land mine blast damage to the lower leg based on their experience in Afghanistan
Within Zone II, the damage is attributed to the propagation of a shock wave through the tissues. From the physics of wave propagation, a wave front is defined as a discontinuity across which the physical state (pressure or stress, temperature, density, etc.) of the medium changes abruptly. The propagation of a wave in a medium depends on the bulk density of, and speed of sound through, that medium. The product of these two quantities defines the impedance of the medium. Different media generally have different impedances and this impedance determines how a wave transfers from one medium to another adjacent to it. If the two media have identical impedances, a wave transfers perfectly. However, in general, impedances differ and part of the wave energy is transmitted to the next medium while part of the energy is reflected at the interface. During the brief moment when the wave front passes through the media interface, the transmitted and reflected waves can impart a large tearing force to the interface. Translating this principle to human tissues, which are characterized by cell membranes and widely different impedances when comparing soft tissues to bone, wave transmission could generate forces at the cellular level that cause internal damage. The exact role of these waves remains the subject of much debate because it is difficult to observe them under mine blast conditions. Using this theory, though, when a mine explodes, a wave front transits through the mine case, then the soil, then the boot, and finally enters the foot materials. As it
40
propagates further up the leg, it adjusts its speed to the medium, and causes damage at the cellular level and between major structures of the leg. Of course, this is hard to prove because it is short-lived and immediately afterwards, the expansion of the highpressure gas destroys the tissues. However, the Russian team reported evidence of microscopic damage inside blood vessels and nerve structures that fit well with the wave propagation theory. It is very likely that these waves pre-condition the biological material prior to the strong push from expanding detonation products. There is also evidence of shock wave damage further up the leg causing microcirculation and dystrophic changes in the affected limb. Even further up the body, the shock wave is believed to cause contusion to internal organs. These effects can only be observed over time in patients that survive the primary accident. A combination of shock wave and jetting of the detonation products is also believed to cause the stripping of tissues from the periosteum of the tibia and fibula above the level of traumatic amputation. Detachment of tissues along the facial planes of muscles opens the way for the penetration of foreign objects such as gas, disintegrated biological tissues, pieces of footwear, dirt, etc. The compartments of the leg provide preferential pathways for ingress of such contaminants. Thus, it appears that clinical observations made by different surgical teams operating in different parts of the world converge towards the same basic description of mine blast trauma to the lower extremity. From a surgical perspective, a blast wound consists of tissue disruption (due to overloading), thermal injury and fragments. Many types of tissues are affected, including skin, fat, muscles, bone and tendons. Beyond the zone of complete tissue disruption, high-pressure gas drives foreign materials and contamination up the leg through fascial planes along paths that are easily self-dissected. All of these injury mechanisms result in unusual and severe injury patterns that pose an intimidating surgical problem.
3.3 Medical Outcome of Mine Blast Injuries to the Human Leg

It is very important to recognise that, although the mine explosion plays an important role in determining the extent of initial injury to the lower leg, it is the casualty management and the medical care available that will determine the long-term medical outcome for the patient. The gross disruption of tissues is just the first problem for mine victims. The injury will trigger a cascade of system responses as the body attempts to cope with the new situation. Vascular injuries are common since large vessels extend quite a distance into the limbs. The vessels are pressurized and, due to the nature of their fluid-containing tubes, can act as hydraulic conduits of pressure for some distance. Thus, injuries to these conduits affect the flow of blood both into and out of the injured zone and could threaten the life of the casualty. Arterial injuries can result in unexpected bleeding and shock, or render a limb ischemic and in need of amputation. Venous injuries can likewise threaten a limb with gangrene. Neurological structures suffer similar damage which, if excessive, can also affect the outcome for the patient.
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Mine victims go into medical shock caused by the initial traumatic amputation resulting in the loss of blood pressure, blood flow, and the delivery of oxygen to the various tissues of the body. As the body adjusts to this state, aerobic metabolism (production of energy using oxygen) slows down and anaerobic metabolism (production of energy in the absence of oxygen) takes over, which is very inefficient. The resulting oxygen debt accounts for the flat affect of casualties, altered pain perception, and generalized weakness. Shock is caused by the initial loss of blood as the traumatic amputation occurs; the limb has a certain volume of blood in it that will be lost, but more importantly, the very large, high pressure arteries and low pressure veins will be severed and continue to bleed. Blood vessels will go into spasm and can completely shut themselves off to stop the loss of blood, but there is a limit to this. The rich supply of collateral vessels around joints result in continued supply of blood to the injured tissues, and continued blood loss. Thus, together with the large raw surface of the amputated limb and open fractures, the risk of bleeding is significant. Major fractures, for example to the femur, could result in additional significant blood loss, even if distant to the primary injury. The overwhelming majority of anti-personnel mine blast victims die of shock from the initial and delayed loss of blood. The ongoing loss of blood and anaerobic metabolism reaches a point where regulatory mechanisms cease to function (with the loss of tone in the muscles of blood vessels compounding the shock and continued blood loss), failure of respiratory muscles and resulting respiratory failure, and worsening hypoxia, cardiac ischemia and cerebral ischemia (with less respiratory drive). This results in a vicious circle of hypoxia, respiratory failure, cardiac ischemia and cerebral ischemia that finally causes the heart to stop beating, ultimately killing the patient. Should patients survive the initial shock caused by the injury, they must contend with the inherent dirty nature of the process. Since most land mines are buried in soil, the blast forces large numbers of microorganisms into the wound. As gas is pumped up in the fascial planes, bacteria is also carried up and mixed into tissues. Bacteria will reproduce in the fat, blood and tissues deprived of vascular flow, causing infection and sepsis. Thus, mine blast victims are at extreme risk of gangrene, tetanus and mixed infections, which can be extremely challenging to treat. Infection is especially common during wartime and in third world situations, since delays in evacuation are normal due to distance, lack of means of transportation and lack of security. This increases the risk of sepsis, and experience with ICRC hospitals has shown that casualties often arrive with advanced stages of infection and gangrene. Unfortunately, uninformed or misdirected attempts at emergency treatment can make matters worse. A typical example is improper use of a tourniquet: when placed above the wound, it renders tissues distal to the tourniquet anoxic and may precipitate the conditions for gas gangrene, necessitating higher amputations.
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3.4 Medical Treatment of Mine Blast Injuries to Human Legs

From the time that a mine blast victim is injured, certain medical principles should be applied in order to maximize the chances of recovery and reintegration of the victim. The principles of surgery for patients in shock, possibly septic, with complex wounds that possibly cover several body systems, are the same irrespective of the nature of the surgical problem. Initial care should be given as soon after wounding as is consistent with the security and safety of the rescuers. In many instances, this means that a mine free route must be established to the victim. The casualty needs to be taken to a secure area and rescue attempts must focus on maintaining an airway, ensuring that the patient is breathing adequately, and to stop obvious sources of blood loss. Extremities that are massively injured may not be bleeding, either because of injury or spasm of the major blood vessels to the limb, or heat injury and contusion of small blood vessels of the tissues. The casualty may be in severe shock with a low blood pressure that results in little bleeding. It should be noted that bleeding can usually be controlled by a pressure dressing around the injured part of the leg just firm enough to control bleeding but not tight enough to stop the flow of blood entirely to the extremity. The application of a tourniquet should be avoided unless bleeding to death is the only alternative. In many instances, tourniquets have been placed too high and their use will almost always mandate an amputation at that level, which is usually higher than could have been achieved if a tourniquet was not used. The net result is to increase the disability of the casualty. The next focus should be on evacuating the casualty to a proper medical facility while some attention is made to start intravenous catheters in an attempt to treat shock. This is an area of controversy and there is some evidence that over zealous intravenous fluids to the point of normalizing blood pressure will increase blood loss by restarting bleeding wounds. Evacuation should not be delayed to start intravenous fluids. Once in a medical facility, the same principles apply to ensure adequate control of the airway and breathing and to resuscitate the patient from shock with adequate intravenous fluids. An aggressive search is made for undiagnosed injuries and perforations from fragments. Specifically the patient must be rolled on the back and the legs spread and a very careful search made of the gluteal and perineal areas. A rectal exam is mandatory and the presence of blood must force a search for rectal, perineal, or abdominal injury. Image diagnostics of the limbs are needed to look for fractures, metallic fragments, foreign material and gas. If there is concern for a blast injury, a chest x-ray is warranted. Unfortunately many of these casualties appear in third world medical centres that lack many of the sophisticated diagnostic equipment of modern trauma centres. Penetrating injuries do not need these diagnostic aids in most cases. The presence of a perforation needs to be explained and may need exploration. Antibiotics specific to the wound and suspected microorganisms are given as soon as possible. With a grossly contaminated wounds, antibiotics are aimed at gram positive bacteria, gram negative bacteria, and soil borne bacteria (this includes high dose penicillin). Active and/or passive immunization against tetanus is obligatory.
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Open wounds are classified according to a system originally described by Gustilo [11,12] (see Table 2). The risk of infection is reflected in the obvious escalating degree of injury and one can easily see that anti-personnel mine injuries are some of the most serious fractures related injuries seen in trauma. The risk of infection increases with delayed surgery, failure to use antibiotics or the correct antibiotics, the development of resistant bacteria, extensive soft tissue damage, positive cultures at the end of surgical procedures, and wound closure in the presence of Clostridium perfringens bacteria in the wound.
Table 2. Open wound classification by Gustilo CLASSIFICATION

Gustilo 1 Gustilo 2
DESCRIPTION
Open fracture with open skin wound less than 10mm long and clean Open fracture with laceration longer than 10mm without extensive soft tissue damage, flaps, or avulsions. Either an open segmental fracture, open fractures with extensive soft tissue damage or a traumatic amputation; these are further classified as: Adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration, or flaps, or high energy trauma irrespective of the size of the wound. Extensive soft tissue injury loss with periosteal stripping and bone exposure usually associated with massive contamination. Open fracture associated with arterial injury requiring repair.
Gustilo 3
Gustilo 3a
Gustilo 3b
Gustilo 3c
Patients are operated on as soon as they are stable or they are resuscitated [13,14,15]. Badly mangled and devascularized limbs must be amputated. The surgeon will ultimately tailor the operation to his or her training, the activity of the casualty, and the resources of the facility. Ideally, treatment will consist of the following steps:
Try to move the casualty to surgery as soon as is safely done preferably within six hours; Thoroughly debride devascularized muscle, skin, fascia, subcutaneous tissue, fat, bone, and all foreign material; Extend the wounds to identify all areas of devitalized tissue; Perform fasciotomy of all areas subject to blast and fragment wound. These wounds will continue to swell with the administration of intravenous fluids and could result in further devascularization and worsening sepsis;
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Leave the wound open with a bulky absorptive dressing that does not constrict blood supply to the limb; Consider a second look operation in 48-72 hours depending upon the casualtys condition; Continue antibiotics for at least 72 hours or until 24 hours after closure; Perform closure, best carried out in 4 to 5 days either as delayed primary closure or as flaps (rotational, advancement, or free).
Patients need to be evaluated on a daily basis. One is reassured if the patient has no elevated temperature, no tachycardia, less pain, and regains appetite. Fever, tachycardia, pain, and loss of appetite are signs of ongoing sepsis and the wound should be re-explored. As a final procedure, rehabilitation of the patient should start. Each casualty has a family and society to rejoin. Mines frequently strike against the breadwinner of the family and the aim must be to provide rehabilitation to allow them to regain the means to support their family. This is just as important as surgical reconstruction inadequate rehabilitation makes surgical therapy pointless. Great care should also be paid to the level of amputation. Even with prosthesis, there is a considerable functional difference between transfemoral and transtibial amputees. Through-knee amputations are seldom undertaken as they present very great difficulties for prosthetic production and fitting. It has been shown that transfemoral amputees are considerably less mobile, make less use of their prostheses, and have greater metabolic requirements in order to mobilize than transtibial subjects. With prostheses, the energy expenditure in a young amputee is 25% over baseline for a transtibial amputation, 40% for bilateral transtibial amputations, 65% for a transfemoral amputation, and 150% for bilateral transfemoral amputations. In victims who do not receive a prosthesis, the energy requirements are increased 32% over the normal baseline of walking for a transtibial amputation victim with a three-point gait. Failure to consider the increased energy requirements for amputees explains why patients discontinue walking despite the availability of prosthetic care. Therefore, from a surgical perspective every attempt should be made to preserve the knee joint if possible. Preservation of the limb or an amputation that spares the knee joint carries many physiological advantages. Young people with transtibial amputations can, with minimal increase in energy expenditure, have near normal function in certain daily living activities. In many ways, comparison of functional outcomes in this situation is dependent on local factors beyond the mere extent of the injury. Medical supplies and the availability of open reduction and internal fixation resources for the hind foot fractures and prosthetic provision for the amputees will determine the treatment options in thirdworld countries. While no specific reference exists regarding the likely outcome of these severe, closed, mid foot, and/or hind foot fractures, it is reasonable to conclude that the overall function is likely to be poor. A stiff, painless ankle and foot may act as
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a biologic prosthesis, but if there were to be severe pain, then possibly an ankle and/or subtalar arthrodesis would be indicated. Open reduction and internal fixation of these hind foot fractures are rarely available in the third-world setting.
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4.
Experimental Conditions and Diagnostics

The range of test conditions and diagnostics used during this first test series of the CFSL program are described and listed chronologically in Table 3. Conditions were chosen so that data from the CFSL and LEAP programs could be compared. The following five aspects of the test set-up and protocols are detailed:

The footwear fitted on the FSL specimen and additional protective equipment; The explosive threat charges used for the tests; The general layout of the test site and associated instrumentation support; The overall steps from specimen preparation to minutes after the explosive event; and The medical procedures used after each test to assess medical outcomes.
4.1 Description of the Footwear

The footwear for these tests was selected both to provide variety and to obtain combinations of footwear and land mine blast protection systems that had been tested in the LEAP program. In each case, the FSL was fitted with one of two boot types: either the Canadian Army Mk III combat boot or the Wellco blast protected combat boot. The standard Canadian Army Mk III combat boot (NSN 8430-21-872-4319), shown in Figure 27, was selected because of availability and the fact that it is similar to a standard work boot often used in humanitarian demining. The Mk III is the government-issued boot worn by Canadian Armed Forces for operations that do not necessitate specialized footwear. It is a high-cut boot with a lace-up front and comfortflex notch, plain toe vamp and quarters, fully bellowed tongue, leather-lined vamp and quarters, a backstrap, a leather insole, a styrene toe box, and direct moulded rubber outsole and heel. All boots tested were brand new and of North American size 11 (to fit the FSL). The Wellco blast-protected combat boot (Figure 28), or blast boot, was tested in the LEAP program and is used by both the Canadian and US armies. This boot is similar to the US Army combat boot with the addition of blast- protective components. These include a composite Kevlar Aramid insole and a V-shaped blast deflector that is moulded into a vented (cleat style) vulcanized rubber sole. The blast deflector is constructed from a steel outer shell filled with aluminium honeycomb, designed to deflect some of the blast flow and to attenuate the strength of the shock transmitted
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Table 3. Test matrix for the September 1999 CFSL test series SHOT ID
M99256A M99257A M99257B M99257C M99257D M99258A M99259A M99259B M99259C M99260A M99260B M99260C M99260D M99263A M99263B M99263C M99263D M99263E M99264A M99264B M99264C M99264D M99264E M99265A M99265B
THREAT
VS-50 PMA-3 PMA-2 PMA-2 PMA-2 PMA-3 PMA-3 PMA-3 PMA-2 PMA-3 PMA-3 PMA-2 PMA-2 PMA-2 PMA-3 PMA-3 PMA-2 PMA-2 C4-50 C4-50 PMA-2 VS-50 VS-50 PMA-3 PMA-3
POSITION
Heel Heel Heel Heel Heel Heel Heel Rear pod Rear pod Heel Front pod Front pod Front pod Rear pod Heel Heel Heel Heel Heel Heel Heel Heel Heel Heel Heel
(2)
BONE TYPE
Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard No No No No No
LOAD CELL
BOOT TYPE (1)

Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Blast (Wellco) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco)
PROTECTION (1)
Overboot Overboot Overboot Overboot Overboot Overboot Overboot Spider Boot Spider Boot Overboot Spider Boot Spider Boot Spider Boot Spider Boot Overboot Overboot None Overboot Overboot Overboot None Overboot Overboot None None
Yes Yes No No Yes No No No No Yes No No No Yes Yes No No No Yes Yes
Notes: (1) See Section 4.1 for descriptions of footwear used for these tests. (2) See section 4.2 for descriptions of charge placement.
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Figure 27. Mk III combat boot of the Canadian Army
Figure 28. Wellco blast protected combat boot or blast boot
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through the sole to the underside of the foot. The top portion of the blast deflector is flat. Figure 29 is an x-ray that shows the position of the blast deflector through the heel and instep areas. In a few cases, the FSL was fitted with only a boot and subjected to a land mine blast. This yielded data for an unprotected or minimally protected foot. For the remaining shots, additional protection was added to the FSL and boot combination. Two types of protective equipment were used: the Wellco overboot and the Spider Boot.
Blast deflector insert within the sole
Figure 29. x-ray of the Wellco boot showing location of the blast deflector in the sole
The Wellco overboot is shown in Figure 30. The vamp consists of Kevlar Aramid medial and lateral sidewalls that are sown together at the back with a backstrap. The toe is also made of Kevlar Aramid. The sidewalls are designed to fold over the boot and are attached together with two retaining straps and quick-connect clips. The sole design is identical to that of the Wellco blast boot. The Spider Boot, shown in Figure 31, is worn with any regular footwear. It is designed to distance the foot from the explosion. The rigid platform is shaped roughly like a blast deflector and is constructed of materials that offer some level of fragmentation resistance. Two forward and two rearward protruding legs hold the platform above the ground. Each leg is offset laterally about the central vertical plane passing through the foot. The legs and platform configuration raise the operators foot approximately 150mm off the ground. Rubber pods at the base of each leg are intended to accommodate ground irregularities.
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Figure 30. Wellco blast overboot designed to be worn on another boot
Figure 31. Spider Boot showing platform and legs extending outside the foot platform
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The design of the Spider Boot favours the detonation of a mine ahead or behind, and slightly outside, of the footprint. This design is intended to increase the vertical standoff from the blastimportant because even a small increase in the separation between the foot and the blast can greatly reduce the damage or injury through decay of blast overpressure. Additionally, the design displaces the blast from under the footprint, which is believed to substantially reduce the loading due to the vertical venting flow of the products of detonation.
4.2 Description of the Explosive Threats

The explosive threats for these tests were selected for compatibility with those used during the LEAP program. By consultation, it was determined that a large AP land mine such as the PMN, with 240 grams of TNT explosive, would not be useful since it would be an overmatch for most of the CFSL shots that were planned and would not yield useful information. It was, therefore, decided that the most powerful land mine that would be used in this program would be the PMA-2, which contains 100 grams of TNT explosive. The PMA-2 had been used in the LEAP program and was available for the CFSL program. The smallest land mine used during LEAP was the M14, which contains 29 grams of Tetryl explosive. Unfortunately, this land mine was not available during the present test series. However, the PMA-3, with 33 grams of Tetryl was available and was used. In addition, the VS-50, a land mine containing 43 grams of RDX, was used because its mass was between those of the PMA-3 and PMA-2. Finally, an explosive charge consisting of a plastic container filled with 50 grams of Composition C4 (essentially RDX) was used because this explosive is widely available. This last threat was tested as a surrogate to actual land mines, which are difficult to purchase because the Ottawa Treaty bans the use, production, and sale of AP landmines.
4.2.1 Land mine Threats

The PMA-3 land mine, shown in Figure 32, has a main body that is made of two large plastic parts shaped such that the upper part is a rocker plate free to tip in any direction within the lower body. The two parts are held together solely by a large rubber cap that fits completely over the upper part and down the side of the lower part of the body. The upper body contains the main charge of Tetryl explosive within a small circular enclosure located on the geometrical centre of this land mine. The UPMAH-3 fuse fits in a threaded insert located in the dead centre of the bottom of the land mine. It is plastic and there is a rubber O-ring between the fuse and the main body. The fuse contains a small steel needle potted in a friction-sensitive compound that is just below a detonator. The fuse is activated by the shearing action generated when the upper part of the mine body is tilted relative to the lower part.
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Figure 32. PMA-3 land mine with cross-section showing internal fuse mechanism (Insert courtesy of Janes)
The VS-50 land mine (Figure 33), contains a blast-resistant mechanism to counter explosive clearance and neutralisation systems. The body, which is constructed of plastic, consists of three main sections. The upper and middle sections form a pneumatic fuse mechanism consisting of two sealed cavities linked by a venting hole. The lower cavity contains a pivoting shutter that retains a spring-loaded striker. An inflatable bladder provides resistance to
Figure 33. VS-50 land mine with diagram showing various components (Pictures courtesy of Janes)
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prevent rotation of the shutter. Applying a downward force on the upper rubber cap pressurises the upper cavity, causing an air bleed to the lower cavity through the venting hole, pivoting the shutter and releasing the striker. The lower section contains the main explosive charge with a central detonator that is placed in the land mine for arming. The cylindrical casing of the main body of the PMA-2 land mine (Figure 34) is moulded from plastic. It is filled with cast TNT explosive, which constitutes the major portion of the main charge. There is a central fuse well on the upper surface of this land mine. A small pellet of RDX is located near the lower centre of the main charge to act as a booster. The UPMAH-2 fuse consists of three main components: the fuse body, made of hard plastic or Bakelite, which is shaped to receive the plastic six-pronged plunger on its upper end; the pointed lower end of the plunger, which sits above a pellet of friction-sensitive compound that, itself, sits above a small detonator; and the detonator assembly, which is bonded to the underside of the main fuse body. The only metal contained in this fuse is the thin aluminium shell of the detonator. As seen in Figure 34, the orientation of the long axis of the UPMAH-2 fuse is normally in the vertical direction.
Figure 34. PMA-2 land mine with cross-section showing fuse mechanism (Pictures courtesy of Janes)
4.2.2 Surrogate Charges

The difficulty with obtaining and transporting AP land mines, which are becoming banned weapons, makes it necessary to use surrogate explosives for testing purposes. Consequently, the CFSL program included two tests with surrogate charges. Charge containers in the shape of stub cylinders with a 35% height-to-diameter ratio were used. The containers (Figure 35), which
54
ensure consistency in geometry from one charge to the next, are moulded from Adriprene rubber. They are designed to accept a lid with a boss and a through-hole sized to receive a small detonator. The lids have a 2mm deep recess into which two discs of Detasheet, 19mm in diameter, are installed to act as a booster. Without this booster, a small detonator does not reliably detonate the main charge of C4. The location of the initiation point for the detonation is an important consideration since previous work [7] demonstrated that the strength of the blast field depends on this factor. When the detonation was initiated at the bottom of the charge, it generated a stronger blast, as measured by the side-on pressure field directly above the charge. It is speculated that this difference is due to the direction of travel of the initial detonation wave.
Figure 35. Land mine surrogate charge containers used for developmental work
4.3 Experimental Setup

The overall experimental setup was designed to produce a dataset that could be compared to the data from the LEAP program. Therefore, the site layout and selection of the instrumentation was done in cooperation with staff that had been involved with the LEAP program. It was determined that the main effort should be focussed on reproducing the land mine blast output. This involved keeping some of the geometrical parameters and the soil conditions as close as possible to those used in LEAP.
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4.3.1 Test Platform and Site Layout

A 2.4m x 2.4m wood platform (Figure 36) was constructed for the CFSL program. The platform was made to accommodate flash x-ray photography as well as a soil container identical to the one used during the LEAP program. The soil container (Figure 37) was constructed of 12mm thick mild steel. It was 460mm wide, 610mm long, and 460mm deep. The container rested in, but was not fastened to, an opening in the platform floor. The platform was fitted with overhead supports that tethered the strings used to maintain the FSL specimen in a vertical position. There were also two openings in the platform floor to hold two x-ray film cassettes. A white backdrop, located a short distance (approximately 3m) behind the platform, was used to increase the contrast between the FSL and the background for high-speed photography.
Figure 36. Wood platform designed for x-rays and LEAP soil container
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Figure 37. Reproduction of the steel soil container used in the LEAP program
Particular attention was given to the selection of the sand for the CFSL program, thus a sample of the sand used in the LEAP program was sent to DRDC Suffield prior to the tests. A simple sieve analysis determined that the LEAP sample was very clean and consisted primarily of medium sand with an average grain size between 500 and 800 micron. A local play sand was purchased and sieve analysis showed that, although it was also medium sand, its average grain diameter was larger by approximately 100 to 200 microns. The sand types used in both the LEAP and CFSL trials were very dry, with moisture contents well below 1%. It was known from other tests at DRDC Suffield that moisture plays an important role in the amount of energy delivered to a target above a land mine explosion. In fact, it is believed to be the leading soil factor that influences the vertical energy release from a mine effects point of view. Thus, it was estimated that the difference in average grain size between the LEAP and CFSL sand was less critical than good control over moisture, so the local play sand was used.
4.3.2 Instrumentation Support

As explained in Chapter 2, the FSL was instrumented with strain gauges and, in some cases, with an additional multi-axis load cell. These load cells were used previously in the LEAP program. Cables connecting these transducers to an off-site high-speed digital data acquisition system were directed upward from the top of the FSL to the topside of the overhead beam. The beam provided the main cables with sufficient shielding from blast, soil ejecta and fragments. The overall explosive event was recorded visually using highspeed video and high-speed film. The video and cine-photography equipment was located approximately 30m from Ground Zero (GZ). The framing rate for
57
the video was 1000 images per second, while the cine-camera recorded images at a rate of 3000 frames per second. A second high-speed cine-camera was used early during the test series, but its use was discontinued because it did not provide information that was deemed sufficiently useful. Figure 38 shows the setup for the flash x-ray equipment. Two heads were placed to record images at 90 degrees from each other. Originally, it had been planned to point the foot of the FSL directly at the photographic equipment to provide two oblique views. However, it was soon determined that the large obliquity between the x-ray head produced poor quality images that would be difficult to interpret, and even more difficult to compare to the x-ray images from LEAP, which were all from a lateral viewpoint. Thus, during the tests, the leg was rotated by 45 degrees to face the Channel 1 x-ray head, thereby resulting in a single lateral view per shot. The head-on images were also recorded with the understanding that the results would be difficult to analyse. Staff involved with the LEAP program provided timing estimates for the flash x-rays.
Figure 38. Schematic showing the flash x-ray setup and relative location of the video/film equipment
4.4 Experimental Procedures

This section provides details about the procedures needed to prepare the FSL specimen, the platform, the instrumentation, the soil, the placement of the explosive
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charge, placement of the FSL specimen, and the steps taken immediately after detonation.
4.4.1 Specimen Preparation

Because of the organic nature of ballistic gelatine, the FSL specimens were wrapped in plastic film (Saran Wrap) to prevent moisture loss (which changes the mechanical properties of the gelatine). Furthermore, the FSL were kept in refrigerated storage at approximately 4C. One to two hours prior to a shot, the designated FSL specimen, whether it contained a load cell or not, was taken from refrigerated storage to an indoor preparation facility. There, the plastic film was removed, the internal temperature of the gelatine was measured, an extra layer of nylon covering was added over the FSL and the basic footweareither a combat boot or a blast bootwas fitted to the specimen. The construction of the FSL ankle joint does not allow motion, as an actual foot does, which makes it very difficult to fit the boot on the FSL. In order to prevent damage to the FSL ankle, a slice was made through the tongue and 20-30mm into the vamp of each boot, as shown in Figure 39. This allowed the boot to be spread open for insertion over the foot without applying excessive force to the foot and ankle. A generous application of lubricant (automotive grease) was also spread on the foot and inside the boot to
Figure 39. Boot modification to the tongue and vamp for the CFSL program
facilitate the process. It might be argued that this modification to the boots may have affected the outcome of the tests, however the authors assert that
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any effect was minimal. Even without the cut, the tongue design is very wide (to allow the human foot to slide in the boot) and needs to be folded upon itself after the boot is fitted in order to tighten the laces enough to retain the boot on the foot of he wearer. During most tests, the fact that the boot would remain attached to the leg or stump lends credence to the assertion that the cut did not affect the outcome of the tests.
4.4.2 Platform Preparation

Preparation of the platform before bringing out the FSL specimen included filling the soil container with new sand and carrying out all instrumentation checks. Filling the soil container involved removing any old sand to a disposal site and simply pouring new dry sand from 20kg bags. No attempt was made to pack the sand. Previous experience had shown that a loose pour of the sand results in consistent soil density from shot to shot. The sand was levelled using a straight edge and excess sand was removed. Finally, the platform was cleaned for general work site safety. All instrumentation external to the FSL were checked for functionality and prepared for the shot. This included loading the film cassettes for the flash xray system and loading film in the high-speed camera(s). The high-speed video was set and armed. Finally, the fire control system was checked and put in the safe mode, ready for placement of the explosive charge and the positioning of the FSL over the land mine. Once these steps were completed, all non-essential personnel left the site and the FSL specimen was taken out to the platform for placement. Typically, the FSL was taken out to ground zero approximately thirty minutes before shot time.
4.4.3 Land mine and Specimen Placement

As with the LEAP program, the explosive charges were placed in the middle of the steel container, buried flush with the sand (Figure 40). Alignment of the charge with the centre was done visually using reference crosshairs made from a pair of taut strings. The accuracy of this method was judged to be within a few millimetres. It was found that the addition of a very thin layer (approximately 1 to 2 mm) of sand over the charge was very beneficial in reducing the flash from the blast, thereby improving the photographic and video records. The VS-50 mines and the 50g C4 surrogate charges were buried in exactly the same manner as the PMA-3. Burial of the PMA-2 land mine differed from that for the other explosive threats. As shown in Figure 41, the fuse of this land mine protrudes well above the top surface of the mine body. Thus, this land mine is normally buried so that the plunger protrudes fully above the ground, which places the top of the mine body about 20mm below ground surface. In order to account for the tactical placement of this land mine, a cardboard spacer was used to ensure that the appropriate spacing between the PMA-2 land mine and the
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Figure 40. PMA-3 land mine was buried flush with the soil surface at centre of soil container
Figure 41. Burial of the PMA-2 land mine with cardboard spacer
heel of the boot was obtained. The top of the cardboard tube was set flush with the ground surface.
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To position the FSL specimen over the land mine (Figure 42), the centre of the heel of the boot was aligned on the crosshairs, without the explosive charge being present. While one person held the FSL in the vertical position, another person put tension on four strings that ran from the top of the FSL to overhead attachment points. The FSL was held in the vertical position by these strings, with the full weight of the FSL resting on the explosive charge. When the FSL stood up satisfactorily, the data cables for the FSL strain gauges, and the load cell (if installed), were connected and function checks were carried out. Before each shot, strain gauge signal quality was verified using a specially built shunt-calibration circuit. Next, the FSL was tilted to move the foot sufficiently to one side so that the explosive charge could be positioned and buried. The FSL was then carefully located over the charge, final 35mm pictures were taken, the site was vacated and the charge was finally armed for the shot. Placement of the explosive charge was different for the Spider Boot. Because of its design, the charges were placed under the centre of the front of rear pod on the medial side of the leg. In doing so, this protective equipment was used as intended (see Section 4.1), and as the situation is most likely to occur. Figure 43 shows the relative position of the explosive charges for each of the configurations investigated during the CFSL program.
Figure 42. Vertical alignment of the FSL with the heel positioned over the land mine
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Figure 43. Sketch showing the location of the explosive under the Spider Boot and regular boot
4.4.4 Post-Test Actions

Immediately following each test, the specimen was photographed and observations about the superficial damage to the leg were noted. The specimen was then removed from the test platform and any footwear remaining attached to the specimen was removed and placed in reinforced plastic bags for inspection at a later time. The specimen was then returned to refrigerated storage pending medical assessment. If a load cell was present, the leg was dissected in a pre-arranged manner to remove the load cell and replace it with a spacer. This step was required because only two load cells were available for the test program. The area surrounding ground zero was combed for pieces of boot, overboot and FSL fragments. However, unlike the LEAP trials, the CFSL shots were conducted outdoors, without any confinement of fragments. As a result, numerous fragments were never found and, with the exception of the most obvious fragments, it could not be confirmed after the first shot that any small fragments found had originated from the latest shot. In any case, with real mine injuries, body components that have been explosively amputated from the leg are discarded and do not affect the resulting level of amputation during medical treatment.
4.5 Medical Assessment Procedures

At the end of each days trials, the specimens were taken to the Medicine Hat Regional Hospital where they underwent standard medical x-ray and Computerized Axial
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Tomographic Imaging (CT scan). The specimens were then returned to cold storage and transported back to the research facility the following day. A radiologist inspected the x-rays and reported on each specimen. The density of the CT scan data was adjusted between 2mm to 7mm cuts according to the level of local damage. In regions that were not injured and with a simple construction, e.g. the femur, slices were taken every 7mm. Regions without damage but with more complexity, e.g. the knee, were scanned every 3 to 5mm. In highly damaged regions, the scan rate was further increased to overlapping 3 x 2mm slices. The data was printed on film for immediate inspection and stored on digital medium for off-site processing at the Adelaide University hospital, Australia, where 3D sagittal reconstruction was carried out. The 3D results were displayed as rotating images on a regular PC, which was very useful to non-medical personnel. Unfortunately, the 3D reconstructions were not available to the medical staff while they were performing the post-test assessments.
4.5.1 Post-Test Physical Assessments

The specimens were examined and dissected by an experienced emergency physician, an experienced orthopaedic surgeon, and an experienced general surgeon. All were blinded as to protective equipment and type of mine. The medical assessments were performed in three batches due to time and schedule constraints. All three examiners evaluated the first batch that consisted of thirteen legs. One surgeon examined the next two legs and the other surgeon examined the remaining ten legs. Both surgeons reviewed a draft report with the full data compilation. The procedure used to inspect each specimen is depicted in Figure 44. A specimen was taken from cold storage to an improvised autopsy table. The x-rays and CT images were compared with the appearance of the specimen immediately before dissection and used to correlate the injury pattern found on dissection with that seen on the images. The medical staff then inspected the specimen visually making note of:

Completeness of specimen and if any portion was clearly missing; Perforations of the witness layer (nylon mesh); and Evidence of contamination (presence of sand, gravel, or textile adhering to the gelatine).
The specimen was then examined in detail. The intrinsic stability of the joints was tested and obvious laxity noted. Starting distally, the model was then destructively dissected. The witness layer was removed, starting at the foot and progressing to the ankle, distal leg, knee, and femoral areas. Splits and defects in the gelatine were noted and the gelatine stripped from the surrogate bones, which were then manipulated to confirm their integrity. Fractures in the bones were noted together if these coincided with abnormalities on diagnostic imaging. When bone and gelatine was shattered, the tissue was
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Figure 44. Sequence of events during medical assessment of damage to FSL specimen
reassembled as closely to the original structure as was feasible in order to estimate missing tissue. Joints were carefully examined to determine stability. The presence of load cells in the distal tibia was noted and a careful assessment of the type of fracturing in this area noted. A simple fracture at the lower end of the load cell fixation was discounted as artefact. A
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comminuted fracture of the tibia that extended up to the load cell was considered a legitimate abnormality. The proximal tibia, proximal tibia-fibula joint, knee, and femur were examined. Without clear evidence of injury after applying significant force to these structures, complete dissection was not carried out. Using the sum total of injuries for each specimen, each specimen was assigned a score against the Abbreviated Injury Score (AIS), the International committee of the Red Cross (ICRC) wound score, the NISSA score, and the Mine Trauma Score (MTS).
4.5.2 Mine Trauma Scores

Many scoring systems have been used to describe land mine blast injuries but the LEAP program found that none ideally described and rated injuries sustained by cadaver limbs. The AIS, ICRC, NISSA, and MTS scoring systems were all used to assess FSL specimens. This was done to allow not only a comparison of results between LEAP and CFSL programs, but also to provide useful comparative information for those who work with actual blast victims. (See Annex A for the criteria used by each system.) The intent of a lower extremity injury scoring system is to quantify the severity of the trauma and to generate a numerical score to guide the decision to amputate or salvage the limb. Most of these scoring systems were designed for injury mechanisms other than the explosion of a blast mine below the lower extremity. The exceptions are the ICRC and MTS scores, which were designed to deal with AP mines. Although all the systems were used in early tests, it was quickly apparent that a modified MTS Scoring System was the most useful and suitable for rating blast mine injuries to lower limbs.
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5.
Medical and Physical Results

This section presents the results obtained during the Phase 1 CFSL test program. The global event, as observed from the video and flash x-ray records, is discussed first to demonstrate the speed with which mine blast trauma is inflicted on the victim. The flash x-ray pictures are particularly valuable since they capture the state of affairs during the event, while damage is actually being done to the FSL. Next, a description of the final physical state of the footwear after the event provides an impression about the damage potential associated with each mine type. Medical diagnostics are then presented and discusseddata which are extremely helpful when assessing the usefulness of the FSL as a test device. The MTS scores from the FSL are then compared to those from LEAP to assess the accuracy of the FSL. Finally, a synopsis and analysis of the data captured with the strain gauges and tibia load cells is presented.
5.1 Global Observations from the Video and Flash X-Ray Imagery
High-speed video images captured at 1ms intervals (Figure 45) demonstrate how quickly mine blast trauma occurs. It is not possible to determine the exact time of detonation from these images; it can only be said that detonation occurred sometime between the first and second frames. It is nevertheless seen that within 1ms from detonation, significant expansion of the detonation products, seen here as a dark cloud, has taken place. It is also seen that the expansion of the detonation products is not
Figure 45. Consecutive high-speed video frames captured 1ms apart showing the rapidity of the mine blast event; note the presence of footwear fragments just above the dark cloud
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symmetrical about the heel of the footwear, which is likely due to small imperfections in the placement of the mine under the heel. A misalignment error of 2mm or 3mm is sufficient to generate such asymmetry. Over time, the size of the dark cloud grew to fill the full frame size shown here. The lens had to be zoomed out to capture what happens later. Analysis of the high-speed video over a much longer period (one second) shows that the FSL is imparted significant vertical momentum during the event. In most cases, the vertical velocity was sufficient for the leg to reach the height of the horizontal crossbeam, hitting it on some occasions. Footwear fragments are seen just above the upper limit of the detonation products within 1ms from detonation. The longer time observations also revealed that part of the footwear could become detached from the leg and fly away. For the larger mines and for unprotected legs, pieces of the FSL were seen to escape from the cloud of detonation products. The detonation products are optically opaque, which prevents the visual observation of the damage being inflicted to the lower end of the FSL specimen; yet, this is where most of the action takes place. Fortunately, flash x-rays can see through the products of detonation and capture images while mine blast trauma is occurring. The orientation of the two x-ray heads resulted in a front and a side view of the leg for each shot. Unfortunately, the interpretation of the front view proved difficult and essentially did not produce any useful information. The side view, however, revealed a lot about what was happening during the mine event. The contrast of the x-ray images presented in Figures 46 to 51 has been enhanced to better show what happens to the FSL bones and the metal inserts within the boots and protective systems. In each case, the image on the left represents the initial position of the FSL and footwear at firing time. The images on the right were taken at different times after detonation as indicated in the caption. In Figure 46, an FSL in an unprotected combat boot was exposed to a small PMA-3 mine. This event caused a complete traumatic amputation of the foot. The flash x-ray demonstrates that the damage to the foot occurs early during the event. At 503s, the envelope of the boot has been breached, the heel portion of the boot sole has disappeared and the calcaneus has been pulverized. Parts of the pulverized boot and calcaneus materials are seen to flow aft in the form of a jet above the nearhemispherical gas bubble. The talus and distal tibia have been damaged and a crack is propagating upward in the tibia. The mid foot is pushed upward with the steel shank insert of the boot still visible as it compresses and penetrates the soft gelatine material. It can be surmised how this push is causing bone dislocation in the mid foot and in the toes. Another important feature from the x-ray is that the zone of damage is localized around the distal portion of the lower extremity. While the lower portion of the boot and the foot are highly deformed, the upper portion of the boot and mid-tibia have barely moved at that early time.
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Figure 46. Flash x-rays (0 & 503ms) of a PMA-3 mine explosion under an unprotected combat boot
Figure 47 shows an FSL in a Blast Boot exposed to a PMA-3 mine. The blast boot has a metal deflector incorporated in the aft portion of the sole but the same distal disintegration occurs. The push from the hemispherical gas bubble is apparent once more. At 503s, destruction of the rubber sole has started and the envelope of the boot has been breached near the heel. Extensive damage to the calcaneus, talus and distal tibia is seen, with part of the calcaneus having been pulverized and bone material flowing in the aft direction. Crack propagation up the tibia is easily seen by the large gap that has already occurred. The sole of the boot is deformed into an arc under the push of the high-pressure gas and has compressed the gelatine in the longitudinal arch of the foot and caused deformation of the mid foot. Dislocation of the bones of the mid foot can be seen. The upper portion of the boot has not moved significantly, which confirms the highly localized zone of damage associated with mine blast trauma at this early stage of the process. The damage to the blast deflector requires further discussion. The FSL specimens were located such that the mine was roughly centred below the tibia, a location that is slightly ahead of the vertical line from the crosshairs overlay on the x-ray in this case. The local deformation of the metal deflector at that location reveals that there is a particularly strong push from the detonation products in that region. This is consistent
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with free field observations of mine blast that show the existence of a central core of gas surrounded by an expanding annulus of soil. In other experiments, it has been observed that the push of the gas in the core results in the application of very high pressure on any object located immediately above the mine. The evidence seen in this x-ray supports the hypothesis that there exists a zone of very high pressure immediately above the mine, which can impart significant damage to the footwear and boot.
Figure 47. Flash x-rays (0 & 503s) of a PMA-3 mine explosion under a blast boot without overboot
Figure 48 shows the FSL in a Combat Boot and protective Overboot subjected to the blast of a PMA-3 mine. Recall that the overboot provides a metal blast deflector and additional standoff from the mine (Section 4.1). At 755s after detonation, the hemispherical zone created by the expansion of the high-pressure gas is visible. The additional protection clearly influences the course of events, preventing the disintegration of the inner boot. However, the damage to the overboot and blast deflector is as extensive as when the blast boot was used alone. Focussing of the gas immediately above the mine is apparent, with momentum being transferred to the metal deflector pushing on the inner boot. The rubber sole of the inner boot is compressed and deformed while the steel shank inside the combat boot has compressed the gelatine and is pushing on the bones of the mid foot. Dislocation of the bone of the mid foot can be seen. The additional standoff and protection prevents the pulverization of the calcaneus, but it can be seen that this bone and the talus have rotated counter clockwise because of the gas pushing on the sole of the inner boot.
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Figure 48. Flash x-rays (0 & 755ms) of a PMA-3 mine explosion under a combat boot with overboot
Figure 49 shows an FSL in a Blast Boot and Protective Overboot when subjected to the explosion from a PMA-3 mine. This particular footwear configuration puts two metal deflectors between the mine and the foot. The disintegration of the sole of the overboot is similar to that observed in the previous cases, along with the localized deformation of the lower blast deflector. The lower blast deflector has impacted the sole of the inner boot and transferred much of its localized momentum to the blast deflector of the inner boot. This is apparent from the localized deformation pattern of the blast deflector of the inner boot. However, it is important to note that the lesser compression of the blast deflector of the inner boot suggests that some of the momentum has been dissipated when the honeycomb attenuator in the lower footwear was crushed. The x-ray also shows that the addition of the overboot successfully prevented the disintegration of the rubber sole of the inner boot, but the rubber nevertheless underwent strong compression. The bones of the foot did not crush, although counter clockwise rotation of the calcaneus and talus bones can be seen. The blast deflector in the inner boot is pushing on the middle and rear portions of the foot, compressing the gelatine and initiating a slight dislocation of the bones of the mid foot. The structural integrity of the tibia seems to be preserved at this early stage of the event as the deformation is still concentrated in the distal portion of the lower extremity. There is minimal displacement of the upper portion of the footwear, as seen from the location of the metal eyelets.
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Figure 49. Flash x-rays (0 & 754ms) of a PMA-3 mine explosion under a blast boot with overboot
So far, the flash x-ray images demonstrate the presence of a zone of concentrated upward force immediately above the mine. This suggests that one mechanism to better protect the foot is to displace the point of detonation outside the projection of the foot. This is the basic premise behind the design of the Spider Boot. Figures 50 and 51 show what happens to the FSL specimens when a PMA-2 mine is detonated under a rear and a front pod, respectively. Note that the orientation of the x-ray film had to be turned 90 in order to capture the front of the Spider Boot and the tibia, which is reflected by the smaller scale of the pictures in Figure 51. Figure 50 shows the Blast Boot/Spider Boot/PMA-2 combination. The deflector shell of the Spider Boot is hollow and the foot sits quite high above the ground and ahead of the zone of strongest vertical gas flow. At 1253s after detonation, the gas flow has vented to the atmosphere and soil ejecta is impacting on the underside of the rear portion of the protective footwear. The momentum imparted to the shell caused a complete collapse of the rear region while a significant portion of the rear half of the deflector shell is undergoing compression. The top plate of the deflector shell is curved; it pushes on the rearmost part of the blast boot. There is no apparent deformation of the blast deflector within the sole of the blast boot, but the latter is rotated counter clockwise, indicating deformation of the sole of the blast boot. There appears to be minimum movement of the remainder of the foot and front portion of the footwear at the time the x-ray was captured.
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Figure 50. Flash x-rays (0 & 1253s) of a PMA-2 mine explosion under a rear pod of the Spider Boot
Figure 51 shows the Combat Boot/Spider Boot/PMA-2 combination. The deflection of the front part of the Spider Boot 731s after detonation can be clearly seen. This early in the event, no significant movement of the rear part of the foot and tibia has yet taken place. The front part of the Spider Boot deflector shell collapsed and pushes up against the front part of the boot located on the platform. The strong curvature of the front platform suggests a high likelihood for dislocation of the toes. In this case,
Figure 51. Flash x-rays (0 & 731s) of a PMA-2 mine explosion under a front pod of the Spider Boot
oversized footwear was used so that the relatively rigid foot of the FSL could be inserted. As seen from the x-ray, this probably mitigated the level of bone dislocation that was observed during the post-test medical examinations of the FSL specimens subjected to these particular test conditions.
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5.2 Summary of Boot Damage

The flash x-ray images provide much insight into the mechanisms that lead to mine blast trauma. Clearly, significant deformation of the footwear and a major portion of the damage to the distal end of the lower extremity are both done early in the event. But the end states of each can only be assessed from a post-test examination of the final condition of the FSL specimens and of the final state of the inner boots and components like the metallic deflectors and shanks. A summary of damage assessments is presented here. For labelled photographs showing boot parts and for detailed results of boot damage, see Annex B, Detailed Boot Damage Assessments. . This test series involved two different basic footwear: the Canadian Army Combat Boot (CB) and the Wellco Blast Boot (BB). These were used either on their own or with two types of additional protective footwear: the Wellco OverBoot (OB) and the Med-Eng Systems Spider Boot (SB). Furthermore, because of the SB design, the mines were placed either under a front or a rear pod as per the design intentions and real use of the footwear. As a result, there were eight combinations of basic footwear and protective footwear that could be subjected to four different mine types. This yields thirty-two different test conditions, but only twenty-five tests could be conducted, which required careful selection. Table 8 lists the number of tests performed for each test condition. It is seen that the majority of tests involved the PMA-3 or PMA-2 mines and that only a single test was done for most test conditions. This means that statistical variations that occur from test to test, despite keeping the test conditions constant, cannot be evaluated from the present dataset.
Table 4. Number of tests performed for each combination of footwear and explosive FOOTWEAR
CB CB/OB CB/SB (front) CB/SB (rear) BB BB/OB BB/SB (front) BB/SB (rear)
PMA-3
1 4 1 1 1 2
VS-50
2 1
C4-50
2
PMA-2
1 2 1 1 1 2 1 1
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5.2.1 Damage to Unprotected Footwear

Four tests were performed against unprotected footwear, each involving a different boot and mine combination. In each case, there was catastrophic failure of the basic footwear, but the larger PMA-2 mine produced more extensive damage than the PMA-3. The sturdier construction of the BB also resulted in slightly less damage to that footwear, as compared to the CB, for a given mine. For the PMA-3 mine, the heel portion of the CB and BB were completely destroyed. The forward portion from the mid-foot onward survived. For the BB, the blast deflector plate was deformed and bent upward, but the components remained attached to the forward portion of the sole. The rear portion of the upper was completely torn off for both boots. The CB suffered considerably more damage to the upper than the BB, being completely shredded up to the toe portion of the boot. The steel shank was also bent. The effect of the larger quantity of explosive in the PMA-2 is apparent. Both the CB and BB were completely destroyed. Again, the forward portion of the sole remained as a single piece, but the extent of damage to the heel area was greater than for the PMA-3 mine. The upper was shredded for both boots all the way to the toe area. The steel shank of the CB and blast deflector of the BB were bent.
5.2.2 Damage to Combat Boot when Using an Overboot

The CB/OB combination is the only one that was exposed to all mine types during this test series, which makes it ideal to witness the progression of damage level with increasing explosive mass. The addition of the OB increases the standoff of the basic footwear from the mine and acts as a sacrificial component. In each case, the explosion destroyed the heel of the OB, but in general, the OB was successful in achieving its main purpose, i.e., to better protect the inner footwear. Against the PMA-3 mine, the external appearance of the CB did not show signs of blast damage. However, upon closer inspection, the steel shank was bent on two of the four tests with this particular footwear combination against this mine. Tears in the insole were the only clues left from the large dynamic deflection of the shank during the event, as was captured on the x-ray images; these tears were consistent with the shank being pushed up through the insole. One test used an old CB that had seen better days. This particular boot showed a few cracks along the upper and the steel shank was completely loose under the insole. It is suspected that the shank had become loose due to normal wear and tear, not because of the blast exposure. When the mine threat level was increased to the VS-50, the external damage to the CB was visible, consisting of small tears in the upper. The rubber sole of the boot appeared intact with the exception of a small increase of the arch curvature. The steel shank was bent and the insole had two longitudinal tears
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along the edges of the shank, which was detached from the upper part the rubber sole. Against the C4-50 charges, the damage to the CB increased further. Portions of the upper were detached from the rubber sole and tears in the upper were more prominent. The steel shank ripped through the insole, but remained attached at its front end. The largest mine, the PMA-2, produced the most damage to the CB footwear. Significant external damage was visible. The rubber sole of the boot was bent into an exaggerated arch, but was otherwise complete and intact. There was significant detachment of the upper from the rubber sole and large vertical tears were present in the upper. Post-test pictures and the early flash x-ray images suggest that foot material (bones and gelatine) were extruded through these tears. The steel shank had ripped through the insole and was completely separated at the rear of the boot.
5.2.3 Damage to Blast Boot when Using an Overboot

This particular combination of footwear was exposed to three mine types. Against the PMA-3 mine, there were visible external damage to the BB, which consisted of detachment of the upper from the outer sole. Damage to the interior of the boot was minor. The sole was opened to inspect the blast deflector, which showed significant permanent deformation and partial crushing of the honeycomb blast attenuator. The upper section of the blast deflector was also bent. The VS-50 mine, with its increased explosive mass, produced more damage to the inner BB footwear. There was negligible damage to the rubber sole, but the residual curvature was increased. Minor tearing of the upper was visible. Inside the boot, there were a few small cracks of the Kevlar insole and it is suspected that the internal blast deflector was bent, although the sole of the boot was not opened for inspection. This bending would be consistent with the observations for the smaller mines. The damage to the inner BB footwear was very significant when the footwear combination was exposed to the blast of a PMA-2 mine. The rear portion of the rubber sole was destroyed, resulting in extensive crushing of the blast deflector with some components being extracted from the sole. The upper became separated from the outer sole over most of the rear of the boot. Large horizontal and vertical tears were visible on the sides and the rear of the upper. As mentioned previously, it is suspected that bone and gelatine were extruded from the inner boot during the explosion due to the large footwear deflection observed on the x-ray images.
5.2.4 Damage to Footwear when Using a Spider Boot

The CB and BB used with the SB appeared completely undamaged by the explosion. This is the case for both the PMA-3 and PMA-2 mines and
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whether the explosion occurred under a front or rear leg. This suggests that the increased standoff combined with the displacement of the detonation point is an effective protection mechanism against mine blast. It is useful at this point to summarize the damage to the SB. For a front detonation, the PMA-3 broke off both front legs. It also produced cracks and local delamination in the forward portion of the deflector shell. The binding system and the top plate appeared to be undamaged. The detonation of a PMA-2 mine under a front leg produced significantly more damage to the deflector shell. There was complete delamination of the front portion of the shell and cracks propagated back to the centre of the shell. This greater extent of damage is consistent with the larger explosive content of this mine relative to the PMA-3. Detonation of the PMA-3 under a rear leg produced damage localized to the rear of the deflector shell. There were minor cracks, erosion and minor delamination, but these were limited to the rearmost portion of the deflector shell. Some upward bending of the upper plate was noted at the very rear. Both rear legs broke off. When the mine threat was increased to the PMA-2, the extent of damage increased significantly. As expected, both rear legs were shattered. There was extensive delamination and cracking of the rear portion of the deflector shell with erosion and missing material. The rear part of the top plate was permanently bent upward by up to 10mm. Yet, there were no signs of major damage to the binding system.
5.3 Medical Assessments of the FSL Specimens

Section 5.2 showed that the extent of damage inflicted on footwear increased with charge size, while the addition of protective measures for a given charge size reduced the extent of damage transmitted to the inner boot. In this section, the damage to the FSL specimens, the main diagnostic tool for these tests, will be summarised. A detailed account of the damage to each FSL, as determined by the medical examiners, is given in Annex B, Detailed Medical Assessments. As outlined in section 4.5, the post-test FSL examinations started with a review of available diagnostic imaging. In most cases there was good correlation between the x-rays and CT images and the dissection that followed. However, in some cases, a simple fracture of the plastic bones was not seen on the CT images in the axial or sagittal views, but when the bone was exposed during dissection and then stressed, the defect became readily apparent. It was apparent that, after creation of the crack, the two broken ends returned exactly to their pre-test position because of the supporting ballistic gelatine. Without displacement or separation of the fragments of plastic, there was no difference in radio-density of the structures to indicate that a defect was present. This is especially problematic in axial views since these represent cross sectional slices across the long axis of the bones. Each slice will, at any one point in the image, represent an average of the structures at
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that point over the entire 3 mm thick slice. This is called volume averaging. In living tissue, fractures that are not displaced are generally still visible since fracturing is associated with bleeding and soft tissue swelling. Some bleeding will separate the fragments of fractured bone and show up as an area of different density compared with the dense bone. Following the dissections, the pseudo-injuries were rated in accordance with four trauma scores. Given the simplified nature of the FSL model relative to a human leg, it was found that there is no ideal or universally accepted scoring system for identifying and classifying mine blast injuries. (See Annex A for details on scoring systems.) The AIS score does not have sufficient spread; an AIS of 2 is a relatively minor injury but one rarely saw an AIS of 4 since this would imply an above knee amputation. The ICRC system classifies blast injuries poorly since it was originally developed for projectile type injuries; it is descriptive for several wound patterns, however. The NISSA score was very difficult to use because it was impossible to assign proper scores for nerve and vascular damage when these structures are not modelled in the FSL. These observations about the suitability of existing trauma scores confirmed the findings of the US medical team that worked on LEAP. These trauma scores will therefore not be used in future tests of this type. Only the MTS score will be used for the remainder of this report. The MTS scoring system was suitable for use with the FSL despite the simplicity of the model. Injuries to nerves and the vascular system could only be inferred from the experience of the medical staff based on the level of destruction that had been inflicted on the FSL specimens. Table 5 lists the MTS scores assigned to each test. Recall that the medical examiners were blind to the footwear and threat types used for each specimen. (See Annex A-4 for MTS rating definitions.) As with the footwear assessments, the extent of damage to the FSL depended on charge size and protective footwear. MTS scores varied from 0 (no damage) to 3 (requiring below-knee/above-knee amputation), but do not provide details about how the injury was imparted to the FSL specimens. It is therefore useful to summarise the physical damage to the FSL. This is first done from a more global point of view as a function of protective footwear.
5.3.1 Damage to FSL for Unprotected Footwear

All cases involving a PMA-3 or PMA-2 detonation under an unprotected CB or BB resulted in a traumatic amputation above the ankle level, as reflected by MTS scores ranging from 2B to 3. Here, a traumatic amputation means that all or most of the footwear and foot was completely separated from the remainder of the leg. Pictures in Annex B show the state of each specimen as it was found immediately after the test.
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Table 5. Summary of the MTS scores assigned to each FSL; the data is ordered by protection type and then by increasing explosive mass SHOT ID
M99265A M99265B M99264C M99263D M99257A M99259A M99260A M99263C M99258A M99263B M99256A M99264A M99264B M99264D M99264E M99257B M99257C M99257D M99263E M99260B M99260D M99260C M99259B M99259C M99263A
FOOTWEAR
Combat Boot Blast Boot Combat Boot Blast Boot Combat Boot Combat Boot Combat Boot Combat Boot Blast Boot Blast Boot Combat Boot Combat Boot BB Combat Boot Combat Boot Combat Boot Combat Boot Blast Boot Blast Boot Combat Boot Combat Boot Blast Boot Combat Boot Combat Boot Blast Boot
PROTECTION
None None None None Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Spider Boot Spider Boot Spider Boot Spider Boot Spider Boot Spider Boot
EXPLOSIVE
PMA-3 PMA-3 PMA-2 PMA-2 PMA-3 PMA-3 PMA-3 PMA-3 PMA-3 PMA-3 VS-50 VS-50 VS-50 C4-50 C4-50 PMA-2 PMA-2 PMA-2 PMA-2 PMA-3(F) PMA-2(F) PMA-2(F) PMA-3(R) PMA-2(R) PMA-2(R)
MTS
2B 2B 2B 2B 2B 1B 2B 1B 2A 1B 2B 2B 2B 3 3 2B 3 3 3 1 1B 1A 0 1 1A
The letter F or R in brackets after the explosive type describes the location of the charge for tests against the Spider Boot.
79
In all cases, the calcaneus was ejected from the boot and was not recovered. The two tests against the PMA-2 stripped most of the distal soft tissue and caused clean breaks of the tibia and fibula approximately 360mm below the knee. In each case, there was a clean separation of the boot from the leg. For one test, a medial section of the distal tibia remained attached by a ligament, but it was stripped of all soft tissue. The front part of the foot was found still inside the front part of the boot.
5.3.2 Damage to FSL for Footwear Protected with an Overboot

The addition of an OB influenced the outcome of the tests. For the PMA-3 mine, the OB reduced the level of damage to the inner boot, preventing the traumatic amputation in all cases. Three out of six scores indicated salvageable limbs while the remainder indicated below-knee amputations. Despite the improved protection, the smallest mine used in these tests nevertheless produced sufficient damage to the FSL for the examiners to suggest clinical amputation. When the VS-50a larger charge sizewas used, the MTS scores were all 2B, consistently requiring clinical amputation. Increasing the charge mass to 50 grams of C4 produced more physical damage to the FSL, resulting in the ejection of parts of the foot from the boot during the event, and consistent MTS scores of 3. Finally, three out of the four tests with the PMA-2 mine resulted in traumatic amputation of the FSL. The MTS scores for these tests ranged from 2B to 3. The systematic increase of the physical damage to the FSL correlates well with the MTS scores given by the medical examiners.
5.3.3 Damage to FSL for Footwear Protected with a Spider Boot

The increased standoff of the SB protective footwear strongly influenced the outcome of the tests. In all cases, the detonation of a mine under a front or rear pod damaged the SB, but mitigated the damage to the inner footwear and the FSL. The MTS score range for these tests is 0 to 1B indicating that the SB would prevent the need for clinical amputation. However, the skin was violated in three out of six tests, which indicates that the mine blast produced significant deformation of the footwear, as witnessed by the flash x-ray images. Clearly, the MTS scores do not describe the details of each injury. The next section examines this further.
5.4 Comparison of FSL Performance Against LEAP Results

By comparing the above MTS scores to those obtained during the LEAP study, it might be possible to assess how well the FSL model simulates mine blast trauma to the lower extremity. Table 6 lists the MTS scores obtained during LEAP, as extracted from reference [3]. LEAP used three mines (M14, PMA-2 and PMN) and four basic types of footwear (US Army combat boot, Wellco blast boot, BFR blast boot and an improvised sandal). The protective footwear was the same as in the current study
80
Table 6. Summary of the MTS scores obtained during LEAP [3] SHOT ID
PS1 PS2 PS4 PS6 01 PS5 19 20 26 02 27 PS3 04 05 07 12 PS7 03 06 08 10 13 09 15 16 17
FOOTWEAR
Combat Boot Combat Boot Combat Boot Combat Boot Combat Boot Blast Boot BFR Boot BFR Boot Sandal Combat Boot Sandal Combat Boot Combat Boot Combat Boot Combat Boot Combat Boot Blast Boot Blast Boot Blast Boot Blast Boot Blast Boot Combat Boot Blast Boot Blast Boot Blast Boot Blast Boot
PROTECTION
None None None None None None None None None None None Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot
EXPLOSIVE
M14 M14 M14 M14 M14 M14 M14 M14 M14 PMN PMN M14 M14 M14 M14 M14 M14 M14 M14 M14 M14 PMA-2 PMA-2 PMA-2 PMA-2 PMA-2
MTS
3 3 3 3 4 2B 3 2B 2B 3 4 2 1A 2A 2A 1A 1 2A 2 2A 1 2B 2B 3 3 2B
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18 24 11 14 25 28 30 22 29 31 23
Blast Boot BFR Boot Combat Boot Blast Boot Blast Boot Blast Boot Blast Boot BFR Boot Blast Boot Blast Boot BFR Boot
Overboot Overboot Overboot Overboot Overboot Overboot Overboot Overboot Spider Boot Spider Boot Spider Boot
PMA-2 PMA-2 PMN PMN PMN PMN PMN PMN PMA-2 (C) PMN (F) PMN (R)
2B 2B 2B 2B 2B 3 2B 2A 2A 1 2A
The letter C, F or R in brackets after the explosive type describes the location of the charge for tests against the Spider Boot.
(none, Wellco overboot and Spider Boot). Because of the differences in mine and footwear types, a one-to-one comparison can only be done for the BB/OB combination against the PMA-2 mine, which is a very limited dataset. However, the FSL and LEAP data could be compared on the basis of coarse outcomes as a function of mine class (small, medium and large) and protective footwear. The MTS score does not lend itself to a direct linear evaluation; it can be argued that a 2 (closed injury requiring amputation) could be less severe than a 1B (open contaminated injury that might be salvageable). In the following analysis, the MTS score was therefore broken down into its main components, i.e., a number to describe the amputation level (0 to 4), and a letter qualifier relating to wound contamination (A, open contained; B, open contaminated; and N, added for cases where no skin breach occurred). MTS scores 3 and 4 are B wounds (open contaminated) by definition. By breaking down the scale, it might be easier to demonstrate the importance of the soft tissue damage in the unprotected injury [3] and the shift in importance to bone injury when the foot is protected.
5.4.1 Comparison Based on MTS Break Down

Only a few of the LEAP shots could be compared to the FSL shots. Those involving unprotected footwear against the M14 and the PMA-3 are used first. The shots involving footwear protected with an overboot against the M14, PMA-3 and PMA-2 mines are then considered. The LEAP study performed eleven tests against unprotected footwear; nine of these were against the M14 mine. Only two tests from the current test series
82
can be compared to the LEAP data; both tests against the PMA-3 mine. It is important to consider the differences in blast output produced by the M14 and PMA-3 mines, which contain 29 and 34 grams, respectively, of the same Tetryl explosive. In the PMA-3, the explosive is located in the upper tilt plate, which places it in near contact with the sole of the boot. In the M14, the main charge is located at the bottom of the mine, placing it approximately 25mm below the sole of the boot. Hence, because the PMA-3 contains more explosive and this explosive is closer to the sole of the boot, the PMA-3 produces a stronger blast output than the M14. When used against unprotected footwear, these two small mines always produced a B score, i.e., open contaminated soft tissue wounds. However, the MTS score does not describe the extent of soft tissue damage; this must be obtained separately from the detailed medical assessments. The MTS score component for the amputation level is shown in Figure 52. The CFSL always produced an MTS score of 2, i.e., below-knee amputation, while the LEAP study produced a score of 2 only one-third of the time; the majority of the LEAP tests produced a score of 3 or 4. The LEAP study determined that, for unprotected footwear, soft tissue damage was the predominant factor that determined the level of amputation. This demonstrates one limitation of using gelatine as the soft tissue simulant: gelatine is homogeneous and does not reproduce the self-dissecting planes that run lengthwise along the interfaces between the various compartments of the leg. Consequently, the FSL does not mimic soft tissue injuries seen in human wounds.
7 6 Number of Occurrences 5 4 3 2 1 0 0 1 2 MTS Level of Amputation
LEAP/M14 FSL/PMA-3
Figure 52. Amputation level from the MTS score for unprotected footwear against small mines
83
Tests involving footwear protected with an overboot provided a larger basis for comparison. There were ten LEAP shots against the M14 and seven shots against the PMA-2. These can be compared to six CFSL shots against the PMA-3 and four shots against the PMA-2. The MTS break down for both the level of amputation and the extent of soft tissue contamination is shown in Figure 53. Presented in this manner, the MTS data displays that there are
7 6 Number of Occurrences 5 4 3 2 1 0 0 1 2 MTS Level of Amputation
LEAP/M14 FSL/PMA-3 LEAP/PMA-2 FSL/PMA-2
8 7 Number of Occurrences 6 5 4 3 2 1 0 N A MTS Level of Soft Tissue Contam ination

LEAP/ M14 FSL/ PMA-3 LEAP/ PMA-2 FSL/ PMA- 2
Figure 53. Amputation level from the MTS score for footwear with an overboot against small mines
84
definite differences between the FSL and cadaver models. First of all, the predicted level of amputation is quite different. For small mines, it was deemed that six out of the ten LEAP shots would require clinical amputation. The FSL model predicted that three out of six shots would require clinical amputation. Given that the PMA-3 is a more powerful mine than the M14, this is contradictory to expectation, and the FSL should have produced a greater percentage of 2 scores. Thus, the FSL under-predicts the level of amputation for small mines. This trend is reversed for the larger PMA-2 mine. The LEAP study produced a score of 2 for five of the seven shots, and a score of 3 for the remaining two shots. The FSL results are opposite, with a score of 2 in one of the four cases, and a score of 3 for the remaining three shots. The FSL model therefore over-predicts the level of amputation for the PMA-2. When considering the component of the MTS score relating to soft tissue contamination, it is seen that all results for the PMA-2 produced a B score. This is expected given the magnitude of the load produced by this larger mine. The shots involving the smaller mines against footwear protected with an overboot produced less damage and yielded a broader range of MTS scores. Therefore, these shots were more useful to assess differences in response of the CFSL against the LEAP data. It should be added that this is the injury regime where a tool like the FSL can be most useful. Here, protection can make a difference and it is important that the assessment tool be capable of capturing small differences in performance. During the LEAP study, the M14 did not break the skin in four of the ten shots when an overboot was used. For the remaining shots, the wounds were scored as A, never as B. The corresponding tests with the FSL against the PMA-3 always damaged the skin. Only one of the six shots produced an A score, while the remaining shots were all scored as B. Clearly, the FSL overpredicts the level of skin damage. The FSL nylon skin not being as tough as human skin, a fact that was known prior to starting the CFSL test program. Because an early decision was made that the program would concentrate on bone damage and the extent of gelatine stripping, the weaker nylon skin was chosen for cost reasons. In fact, earlier versions of the FSL had been fitted with a chamois skin that had better mechanical properties than the nylon covering. The prominence of B scores for the FSL model was due to the skin breaking outside the footwear. This is significant for the intended purpose of the FSL model because it introduces a bias when the injuries are scored using the MTS scoring system. This phenomenon can be traced back to the response of the FSL bones to impact loads from mine blast. A more detailed consideration of the level of damage to selected bones will provide further insight.
85
5.4.2 Comparison Based on Refined Bone Damage Information

During the LEAP study, the mines were located under the heel, vertically below the long axis of the tibia. This position was deemed to represent a worse case in terms of medical outcome. As a result, the potential for physical damage was greater for the bones of the hind foot and mid foot, then to the ankle and distal ends of the tibia and fibula bones. It has also been noted that bone damage was gradual, varying from simple fractures to compound fractures to severe comminution. In the worst cases, the bones were pulverized into such small pieces that it could no longer be recognized. In general, the level of damage increased with the magnitude of the impact applied to the foot, i.e., with increasing mine size and decreasing protection. For the purposes of the present analysis, it was necessary to define a scoring system that reflected the level of damage to individual bones. A four level system was selected, with qualifiers as defined in Table 7. A simple linear numerical scale, from 0 to 3, was also selected so that the level of bone damage to the lower extremity could be compared. This system is very crude, but was designed to capture gross differences in performance for the FSL.
Table 7. Crude scoring system used to compare the level of bone damage between LEAP and FSL tests DESCRIPTOR
I S C
SCORE
0 1 2
LEVEL OF DAMAGE
Bone is intact, no physical damage is reported Simple fracture of the bone, could include up to 2 fractures Compound (> 2 breaks) or comminuted fracture of the bone is reported Highly comminuted fracture with missing bone material
This scoring of the level of damage to the bones was based strictly on the written medical assessments contained in this report and the LEAP volume II [3] report. (Note: the latter did not include the medical assessments for the first seven LEAP tests that had been performed in a preliminary test series.) The scores obtained from this analysis are given in Tables 8 and 9 for the FSL and LEAP models, respectively. Although five bones were considered in this analysis, the two bones closest to the explosive (the calcaneus and talus) were particularly relevant. Damage to the pilon area, at the interface between the talus and the long bones, was also considered separately from other damage to the tibia and fibula bones. This was deemed to be important because if the damage to the pilon is too severe, an amputation might be needed. Damage to the bones of the mid foot was excluded because damage to the calcaneus, talus and pilon was sufficient to
86
Table 8. Summary of damage to some of the bones of the FSL specimens CALCANEUS AVERAGE SCORE
10.0 M99265B M99264C M99263D M99257A M99259A M99260A M99263C M99258A M99263B M99256A M99264A M99264B M99264D M99264E M99257B M99257C M99257D M99263E M99260B M99260D M99260C M99259B BB CB BB CB/OB CB/OB CB/OB CB/OB BB/OB BB/OB CB/OB CB/OB BB/OB CB/OB CB/OB CB/OB CB/OB BB/OB BB/OB CB/SB CB/SB BB/SB CB/SB PMA-3 PMA-2 PMA-2 PMA-3 PMA-3 PMA-3 PMA-3 PMA-3 PMA-3 VS-50 VS-50 VS-50 C4-50 C4-50 PMA-2 PMA-2 PMA-2 PMA-2 PMA-3(F) PMA-2(F) PMA-2(F) PMA-3(R) M M M I S I S S S I S S C M M M M M I I I I M M M S I C S C C S C C C C M M M M I I I I M M C S S C C C I C S C C S M M C M I I I I S S S S S S S C C C C C C C C C C S S C S I S S S S C C C C C C C C C C C C C C I S S I 11 11 10.5 10 4 5 7 6.5 7 9 7 7 8 9 10 10.0 10 13 13 12.5 12 12 1 3 2.5 2 0 A A B B N B B B B 8.0 B A B B B B B B B B B B B
SHOT ID
M99265A
FOOTWEAR
CB
EXPLOSIVE
PMA-3
SOFT TISSUES
B
FIBULA
BONE SCORE
TALUS
PILON
TIBIA
87
M99259C M99263A
CB/SB BB/SB
PMA-2(R) PMA-2(R)
I I
S I
I I
S I
S S
3 2.0 1
N A
Note: The MTS soft tissue damage descriptors are also reported here for completeness. The bone score is for the five bones. The average score is for the same protective footwear against a given mine.
demonstrate the principal difference in response of the FSL relative to a human cadaver. Damage to the tibia and fibula, excluding the pilon area, includes the fractures further up these bones. Injury to the long bones reflects how effective the shattering of the lower bones and shows how effective the shattering of the lower bones is in preventing force transfer higher up the leg. Finally, although the lower bones were not injured when the Spider Boot was used, the suspicion was raised that the offset between the footprint and the mine location may have imparted bending moments to the long bonesa very different mode of injury. Assessment of long bone damage would be extremely useful in this case.
Table 9. Summary of damage to some of the bones during the LEAP study, deduced from reference [3] CALCANEUS AVERAGE SCORE
9.0 20 26 02 27 04 05 07 12 03 06 08 10 BFR Sandal CB Sandal CB/OB CB/OB CB/OB CB/OB BB/OB BB/OB BB/OB BB/OB M14 M14 PMN PMN M14 M14 M14 M14 M14 M14 M14 M14 C M M M C C C C C C C C S M M M I C C I S S C C C C M M I S S I C S C I S I S S I S S I I I I I C I S S C I S I C I S I 8 8 11 11.0 11 4 6 7 2 5.13 7 4 7 4 A N A N B A A A A B B B
SHOT ID
01 19
FOOTWEAR
CB BFR
EXPLOSIVE
M14 M14
M M
S M
C C
S C
S C
8 12
88
SOFT TISSUES
B B
FIBULA
BONE SCORE
TALUS
PILON
TIBIA
13 09 15 16 17 18 24 11 14 25 28 30 22 29 31 23
CB/OB BB/OB BB/OB BB/OB BB/OB BB/OB BFR/OB CB/OB BB/OB BB/OB BB/OB BB/OB BFR/OB BB/OB BB/OB BFR/OB
PMA-2 PMA-2 PMA-2 PMA-2 PMA-2 PMA-2 PMA-2 PMN PMN PMN PMN PMN PMN PMA-2 (C) PMN (F) PMN (R)
M M M M C M M M C M M M M C I C
M S C C C C C C C I C C C C I S
M C C C I C C C C C C C C C C S
S/C I C C S S C C C S C S S S S C
S/C S S/C C S S C S C C C C C S C C
12 7 7.5 11 6 9 11 10 10 8 9.83 11 10 10 8 5 8 9.07
B B B B B B B B B B B B A A A A
Note: The MTS soft tissue damage descriptors are also reported here for completeness. The bone score is for the five bones. The average score is for the same protective footwear against a given mine.
It should be noted that the introduction of a load cell in the mid-tibia produces a stress riser that might cause artificial breaks of this bone and the adjacent fibula. The breaks were nevertheless reported in the analysis in the absence of evidence to the contrary. When considering the bone damage data and scores, this fact should be kept in mind. The bone scores for the calcaneus, talus and pilon were averaged for the same combinations of footwear versus a given mine type (and mine location for the Spider Boot) as in the previous section. Generally, it is seen that the average scores increase with mine size and with decreasing protection. This is consistent for both models, which increases the confidence in this scoring method. For the FSL model, it is seen that the average score increased systematically with increasing mine size. This is a positive feature required for a device like the FSL. It indicates that the FSL has good potential as a performance-testing tool.
89
The results for unprotected footwear are displayed in Figure 54. It is seen that for the calcaneus, talus and pilon, the FSL model predicted slightly more severe bone damage than was observed against cadavers. The scores were approximately the same for the long bones. The increase in damage lower down reflects the violence of this particular event since the majority of the calcaneus and talus bones were missing from the specimen after the test. The pilon was also missing in half of the CFSL shots, but was always present in a damaged state during LEAP. This might indicate that there is a difference in the way the distal ends of the long bones break, but the difference in average bone scores is not sufficiently large to say that there is a definite difference in behaviour.
Average Bone Score
0 Calcaneus Talus Pilon

LEAP/M14 FSL/PMA-3
Tibia
Fibula
Figure 54. Average scores for bones of the lower leg unprotected basic footwear
As was the case previously, the shots involving the protective overboot provide a better basis to compare the performance of the FSL model with the LEAP data. Figure 55 compares the average bone scores for the smaller and larger mines, respectively. It is readily apparent that the scores are significantly lower for the smaller mines than for the PMA-2 mine, as expected. The scores for the smaller mines are particularly useful because the bones were damaged, but there was never any loss of material through open footwear. These results exposed important differences between the FSL and cadaver models. There is a large difference for the calcaneus, which indicates
90
3
Average Bone Score

LEAP/M14 FSL/PMA-3
Tibia
Fibula
3 Average Bone Score

LEAP/PMA-2 FSL/PMA-2
Tibia
Fibula
Figure 55. Average scores for bones of the lower leg footwear protected with overboot
that this bone is much too strong in the FSL. In fact, this particular bone always suffered a high level of damage during LEAP, while it was intact onethird of the time during the CFSL tests and only suffered a low degree of damage in the remaining tests against the PMA-3. The results for the talus are comparable for LEAP and CFSL, but there was more damage to the FSL bones further up the leg, particularly to the fibula. The manufacturer of the FSL confirmed later that both the calcaneus and talus bones were too strong
91
by a factor of up to three, suggesting that the calcaneus plays a sacrificial role in protecting the structures of the leg located above. Its strength allows it to transmit more load further up the leg through the talus, which explains the larger extent of damage to the pilon, tibia and fibula. A similar trend can be observed for the PMA-2 mine. The larger explosive content of this mine meant that the calcaneus was destroyed and missing every time for the FSL and six of the seven times for LEAP. This explains the similarity of the calcaneus results for this mine; the scores were simply saturated. There is more difference in the average score for the talus. This bone was missing every time for the FSL, but most of this bone remained attached to the cadaver limbs; it was missing only once out of seven tests. For the LEAP data, the sacrificial role of the calcaneus is reflected in the decreasing average scores as one moves proximally up the leg. Thus, the score for the talus is larger than for the pilon, which is larger than the score for the tibia and fibula bones. The trend is similar for the FSL, but is it seen that the pilon suffered considerably more damage than during LEAP; it was missing in three of the four tests.
5.5 Strain Gauge and Load Cell Records

A summary of the data recorded from the electronic instrumentation of the FSL, i.e., the strain gauges and, when it was used, the mid-tibia load cell follows. For more detailed results, see Annex D.
5.5.1 Strain Gauge Results

The strain gauges were successful at generating signals. Figures 56 and 57 show typical examples of the post-processed data. The detonation spike was filtered out digitally without affecting the overall nature of the main signal. Figure 56 shows the strain history for the gauge located near the bottom of the tibia when the FSL was exposed to the blast of a PMA-2 mine. The total signal was recorded for 128ms, as seen from the upper trace. The second trace shows the portion of the same signal after the application of a median filter (41 points) from 0 to 100ms. Zero time corresponds to the time of mine detonation. It is apparent that the strain gauge or the supporting structure was damaged during this test. The third (lower) trace narrows in on the first 5ms of the event, showing that the gauge was damaged 1.09ms into the event. Potentially useful information was recorded prior to that time, but the gauge did not provide any information about the longer-term behaviour of the tibia because it was destroyed in the process. The results from this test demonstrate that sensitive instrumentation and the supporting structure need to survive the event to realise its full potential. Figure 57 shows similar strain information for the uniaxial gauges located at the bottom and top of the tibia, when the FSL was exposed to the blast of a VS-50 mine. The load from this mine was less severe than for the PMA-2. In
92
this case, the supporting bone structure and both gauges survived the event, allowing continuous recording of signals, which display two distinct zones of behaviour. The early portion from 0 to approximately 10ms is characterized by a high frequency oscillation, of the
Figure 56. Example of strain history for a large mine against protective footwear showing gauge failure
order of 1000 to 4000Hz, which is highly dampened. The remainder of the signal, from 10 to 100ms, is characterized by slower oscillations that decrease from approximately 70Hz down to 25Hz over the time of the recording. The
93
magnitude of the strain for the top location is about twice as large as for the bottom location, but the two signals are in phase, indicating that a lower mode of vibration was excited.
Figure 57. Example of strain history for a small mine against protective footwear; bottom gauge shown on left and top gauge on right; note the similarity of the bottom and top traces, but different amplitudes
At this point, it is useful to take a moment to reflect on the strain gauge arrangement that was used for the FSL specimens during the present test series and the information that they provide. The FSL tibia and femur were instrumented with uniaxial or rosettes of strain gauges at four locations. At each location, the gauges were bonded to the surface on the medial (inside) side of the bone. This arrangement provides a measurement of local strain only. When used in conjunction with the stress-strain relationship for the materials to which the strain gauge is bonded, such a gauge is useful to determine how close the local strain comes to failure. However, if information is sought about the cross-sectional force and bending, strain must be measured in specific ways at several locations around the cross-section of interest. Furthermore, geometrical and material information about the crosssection must be well defined to allow the calculation of the resulting compressive forces and bending moments. In the case of the tibia, the bone cross-section is neither uniform nor symmetric, and the cross-sectional area varies continuously along the length of the tibia. Thus, with the current arrangement of strain gauges, it is not possible to resolve the forces and
94
bending moments about any cross-section of the tibia. The only useful information is the local surface response of the material, which consists of superposed compression and bending strains. The gauge also tells how close to failure the material comes.
20000 Top of Tibia
Values of 30,000 or more indicat e gauge f ailure
15000 Peak Strain [uS]
10000
5000 10727 11734

18291
PMA-3
VS-50
C4-50
PMA-2
20000 Bottom of Tibia

Values of 30,000 or more indicate gauge failure
15000
Peak Strain [uS]
10000
5000
0 PMA-3 VS-50 C4-50 PMA-2
Figure 58. Effect of mine type on maximum amplitude of strain (first 5ms) for CB/OB footwear. The colour of the bars indicates individual shots
Despite these restrictions, the strain gauge information was analysed to assess the influence of mine type and footwear combination on the uniaxial peak strain at the bottom and top locations of the tibia. Simple consideration of
30000
4706
6536
7454
1671
4995
5255
9130
718
30000
2816
5393
4672
4585
4713
6114
7090
95
peak strain within the first 5ms after detonation reveals some of the overall features of the mine strike event. Figure 58 and Figure 59 show the magnitude of peak strain as a function of mine type and footwear combination, respectively. The effect of mine type is seen from Figure 58. The data for the PMA-3 mine, obtained from four different tests, show the importance of repeating a given test since there are inherent variations from test to test. Although the composition of each strain signal cannot be determined with certainty, the peak amplitude still provides a clear indication of the relative response from mine type to the next. Furthermore, the trends are similar for the bottom and top gauge locations. A comparison of the data from the three mine types with lesser amounts of explosive (PMA-3, VS-50 and C4-50) shows that the variation of peak strain is relatively minor, being within the scatter from test to test. The data for the PMA-2 clearly show the effect of the greater amount of explosive in this mine. The peak values for these shots were significantly greater than for the other mines. The destructive effect of the PMA-2 is also evident. For the two shots under consideration, the bottom gauges and one top gauge failed during the event. In one case, failure occurred sufficiently late to record a first peak value, while in the other case the signal was driven to saturation with no useful data being acquired. The effect of footwear combination is seen from Figure 59 for peak strain at the bottom location for shots against the PMA-2 and PMA-3 mines, respectively. For the PMA-2 mine, the results do not show any clear difference between footwear. Very large values of peak strain were reached in all cases. The data for the PMA-3 shots provided somewhat more useful information with some trends possibly emerging. The peak values for shots against the BB and CB without additional protection are relatively small. Yet, these two tests resulted in traumatic amputation of the foot and lower leg segment. The small values of peak strain probably reflect the high degree of venting associated with the complete destruction of the foot, thereby preventing further load transmission up the leg. Comparing the peak strain for the BB and CB used in conjunction with the OB is useful. The results suggest that wearing the OB with the BB offers a significant reduction in the average peak strain. The reason for this result is not apparent, but might be related to the additional mass associated with two metal deflectors within the soles; these might be mitigating the vertical momentum transfer to the heel of the FSL. This should be investigated further as it might relate to the mine blast load transfer mechanism to the leg and could be useful in the design of protective footwear. The tests involving the Spider Boot did not appear to depend on the type of footwear fitted to the FSL.
96
20000
Bottom of Tibia PMA-2 Mine
15000
Peak Strain [uS]
10000
5000
40000
40000
30000
18291
39915
16286
30000
14705
40000
0 CB BB CB/OB BB/OB CB/SB BB/SB
20000
Bottom of Tibia PMA-3 Mine
15000 Peak Strain [uS]
10000
5000
1890
2363
4706
6536
7454
1304
1364
2168
CB
BB
CB/OB
BB/OB
CB/SB
2273
718
BB/SB
Figure 59. Effect of footwear combination on maximum amplitude of strain (first 5ms) for two mines. The colour of the bars indicates different shots
5.5.2 Load Cell Results

The tibia load cell was used to obtain data that could be compared directly with the results from the LEAP program. Furthermore, the load cell provided information about the integrated load transferred through the mid-tibia section, which is deemed more useful than the single point strain data. Annex C provides a complete record of the load cell data acquired during this CFSL test series.
15857
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Figure 60 and Figure 61 show time records of forces (upper plot) and moments (lower plot) over the 20ms after detonation for FSL specimens that were fitted with a BB with and without an OB, respectively. In each case, the threat mine was a PMA-3. The moment traces show a region of high frequency oscillations during the early part of the event, but these die off and only a lower frequency component remains. The moments last significantly more than the 20ms duration plotted here. The force traces are of greater interest. The general nature of the waveforms differs significantly whether the OB is used or not. In each case, the vertical force component, Fz, is more significant than the other two components. For the case without an OB, the load cell senses the beginning of the vertical load about 0.2ms after detonation. The force increases rapidly to peak approximately 0.3ms later, and immediately decreases to become insignificant 1ms after detonation. Thus the whole event lasts a very short period of time. The addition of an OB results in a substantial change of the waveform. Because of the additional standoff and mass, the load cell senses the beginning of the vertical load around 0.4ms, which is about 0.2ms later than for the unprotected case. It then takes nearly 0.5ms for the force to peak, about twice as long as for the unprotected case. The force decreases steadily afterward until it reaches about 30% of the peak value around the 2ms mark, at which point the slope of the force history becomes nearly flat. This indicates that there is a continued push on the tibia, probably from the additional inertia of the OB with its second blast deflector. The vertical force does not reach a near zero value until 20ms after detonation. Thus, to summarise, the event without an OB is over with very quickly, while the presence of the OB appears to lengthen the event considerably. The integral of the force over time, i.e., the impulse, shows this clearly with the value of the protected case being nearly twice as large as for the unprotected case after 20ms. It is now useful to compare the peak RMS force and impulse results for the eight shots where a load cell was used. It should be noticed that from these eight shots, the test conditions, i.e., the same combination of footwear and mine, was repeated only twice. The reader should keep this in mind when interpreting the results. It should also be noted that the impulse was computed for a 2ms duration starting from the time of arrival. This integration period was selected to be long enough to encompass the full duration of the main peak and to reduce the effect of the long-term push afterward. The upper graph of Figure 62 shows the distribution of peak RMS force and impulse as a function of mine type and footwear. At first glance, the peak RMS force for the protected footwear does not appear to depend much on neither the mine type nor the basic footwear (CB versus BB). The average peak force for the BB with OB (16161N) is 6% greater than the corresponding average peak force (15194N) for the CB with OB. However, the scatter for the latter footwear combination is larger, with its minimum and maximum peak force values bracketing the values for the other footwear
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combination. The peak RMS force values for the unprotected footwear appear to be larger than for the protected cases. The average for the unprotected cases (18795N) is 16% to 24% greater than the corresponding averages where an OB was used. The lower graph of Figure 62 shows the impulse computed from the time of arrival to 2ms later. Again, the cases with an OB show little dependence on the mine type for the two mines used. The type of inner footwear did not have a significant influence either, with the average impulse for the CB/OB combination (16855N-ms) being only 11% greater than the average for the BB/OB combination (15159N-ms). On the other hand, the impulse for the unprotected cases was 9099N-ms, which is only 40% to 46% of the impulse values where the OB was used. This is significant and reflects the different nature of the event. Figure 63 displays the time of arrival and time at peak RMS force, which provide further evidence about the influence that the OB has on the event. The average time of arrival for the unprotected footwear is 0.19ms while the corresponding average values for the CB and BB with OB are 0.30ms and 0.46ms, respectively. These results are likely explained as follows. When the basic footwear is used without the OB, the physical path for the transmission of the stress waves is shorter; hence the load reaches the load cell location faster. When the OB is used, the load path is longer, but the second blast deflector also adds mass that requires time to be accelerated. This principle might also explain why the time of arrival for the BB/OB combination is consistently more than for the case where the CB is used with the OB. The average time to reach the peak RMS force is 0.93ms and 0.98ms for the combination of CB and BB with the OB, respectively. This difference is small, indicating that the mine type and the basic footwear have little influence on this parameter. However, the average time for the unprotected footwear is 0.49ms, which is approximately half of the corresponding time for the cases with an OB. This difference is systematic and indicates a change in the process. The same trend is observed when considering the average time required to reach the maximum, i.e., the difference between the time to peak RMS force and the time of arrival. This quantity is 0.30ms for the unprotected cases, which is 40% to 50% of the corresponding values for the cases with an OB.
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M99265B: PMA-3 versus Unprotected Wellco Blast Boot

25000 20000 15000 10000 5000 Force [N] 0 -5000 -10000 -15000 -20000 -25000 0 2 4 6 8 10 Time [ms] Fx Fy Fz Frms Irms 12 14 16 18 20 50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 Impulse (rms) [N-ms]

150
100
50 Moment [N-m]
-50
-100
-150 0 2 4 6 8 10 Time [ms] Mx My Mz Mrms 12 14 16 18 20
Figure 60. Sample time record from the tibia load cell for an unprotected FSL
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M99258A: PMA-3 versus Wellco Blast Boot and Overboot

25000 20000 15000 10000 5000 Force [N] 0 -5000 -10000 -15000 -20000 -25000 0 2 4 6 8 10 Time [ms] Fx Fy Fz Frms Irms 12 14 16 18 20 50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 Impulse (rms) [N-ms]

150
100
50 Moment [N-m]
-50
-100
-150 0 2 4 6 8 10 Time [ms] Mx My Mz Mrms 12 14 16 18 20
Figure 61. Sample time record from the tibia load cell for an FSL with protective footwear
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25000
CB/OB BB/OB CB BB
20000
RMS Peak Force [N]
15000
10000
5000
20859
PMA-3 Mine Type
20000
CB/OB BB/OB CB BB
15000 RMS Impulse at ta+2ms [N-ms]
10000
5000
16925
14611
17547
14904
18408
PMA-3 Mine Type
Figure 62. Peak RMS force and impulse (after 2ms) values show the effect of protection
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13647
8510
9671
15596
10907
17151
16904
17772
15736
16732
VS-50
VS-50
1.2
CB/OB BB/OB CB BB
0.8 Time of Arrival [ms]
0.6
0.4
0.2
0.41
PMA-3 Mine Type 1.2
0.49
0.27
0.49
0.17
0.34
0.28
0.2
VS-50
CB/OB BB/OB CB BB
Time to Peak Force [ms]
0.8
0.6
0.4
0.2
1.11
0.88
1.07
0.45
0.85
PMA-3 Mine Type
Figure 63. Time of arrival and peak force are significantly smaller without protection
0.98
0.84
0.52
VS-50
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6.
Conclusions and Recommendations

The primary objective of the current test series was to assess the feasibility of the FSL as a test model that could be used in routine AP mine blast tests of protective footwear. The main attributes that a model must have for this task are repeatability and sensitivity. Repeatability refers to the ability of the model to reproduce the same results, within reason, over and over when it is subjected to the same explosive stimulus. Sensitivity refers to the ability of the model to produce different results as the explosive stimulus is changed, e.g., to gradually produce more damage as the strength of the explosion increases. This CFSL test series was successful in achieving its primary objective; the tests showed that the FSL is a good tool, but improvements could, and should, be made to allow the potential of the FSL to be fully realised. Another facet of the primary objective is to correlate the FSL response with human injury from AP land mines. To perform this task, it must first be established that the FSL is suitable for the job and then calibrate its response to mine blast against the LEAP reference database. Such a calibration could not be made for the FSL because of differences in test conditions between the CFSL and LEAP tests. The most important of these differences was not obtaining M14 mines in time for the tests. The PMA-3 substitute used in this CFSL test series is more powerful than the M14, which meant that one-to-one comparison could not be done in the regime where protective footwear can make a difference. Despite not having M14 mines for these tests, most other test parameters were well controlled, including soil type, placement of the mines, and most footwear. Thus, the data generated was very useful to achieve all secondary objectives of the programme, which were:
Obtain structural response data for mines with an explosive mass between those of the M14 (29 gram) and PMA-2 (100 gram), which were used during LEAP; Evaluate the relative protective performance of a small selection of footwear; and Acquire physical data using strain gauges and a load cell to determine their potential as instrumentation for the FSL.
6.1 Visualisation of the Mine Blast Trauma Process

The high-speed video was useful to observe how fast mine blast trauma occurs, but this optical process does not show the core of the phenomenon: the early part of the event, when the injury is actually happening. Flash x-ray photography is not subject to the same constraints and allowed the capture of time-frozen images of the FSL and footwear during the injury process. The flash x-ray images show the existence of a hemispherical zone of high-pressure gas that imparts localized damage to those parts of the footwear in the immediate vicinity of the mine. There exists a small zone
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directly above the mine where the vertical push from the gas is particularly focussed, as evidenced by the deformed shape of the blast deflector embedded in the sole of the Wellco blast boot. When a blast boot is used in conjunction with a Wellco overboot, it is seen that this zone of focussed momentum transfers significant loading to the deflector located immediately above. The flash x-ray images also demonstrate that the force of the impact can be so severe that the closer bones are pulverized, as is the case with the calcaneus in some instances. Furthermore, it is clear that the damage to the leg starts distally and travels upwards, remaining relatively localized. The flash x-ray images that involved the Canadian Army combat boot show that the steel shank in the sole of this boot undergoes substantial deformation. It sometimes pushed against the sole of the FSL foot with sufficient force to penetrate, suggesting that dense objects in the sole of a boot can become projectiles under the impulsive force from a land mine explosiona principle that should be taken into account for future designs of protective footwear. The flash x-ray images also suggest that standoff from the mine plays an important role in attenuating the force transmitted to the plantar region of the foot. In the present tests, additional standoff was obtained using the Wellco overboot or the Med-Eng Systems Spider Boot.
6.2 Footwear Damage Assessments

When the Canadian Army combat boot or the Wellco blast boot was used unprotected, even the smallest mine destroyed the footwear. The addition of protective equipment affected the outcome of the tests. These protective measures were sacrificial, diverting some of the force of the explosion while distancing the inner footwear from the zone of very high-pressure close to the mine. For the smallest mine, the PMA-3, the overboot prevented total destruction of the inner footwear, but momentum transfer to the blast deflector of the overboot, particularly in the area located directly above the mine, was large enough to deform the blast deflector located in the sole of the inner boot. The arch of the boot was increased permanently. As the explosive content of the threat increased, the permanent arch of the inner boot also increased and tears began to appear in the upper and rear vamp of the inner boot. For the PMA-2 mine, the force transfer from the explosion was so strong that the foot of the FSL burst, ripping the boot open in the process. The Spider Boot, which provided increased standoff combined with displacement of the detonation point outside the footprint, produced the best protection results during this test series. There were no major disruptions of the heel and ankle bones of the FSL and the structural integrity of the basic footwear was preserved for all tests performed against a Spider Boot during this series. However, the flash x-ray images clearly show that a significant potential of injury still exists. The gas pressure and soil ejecta apply a strong push on the portion of the Spider Boot that is closest to the explosion, which locally crushes the deflector shell and bends the top and hinge plates upward. Mine detonation under a front leg of the Spider Boot might require further consideration since the large moment arm between the effective point of application of the blast load and the ankle may result in severe ankle dislocation.
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6.3 Medical Assessments of the FSL Specimens

The medical assessments form the core results from this test series. Potentially, they provide the best vehicle to compare the FSL performance against the LEAP database. The level of confidence in the methodology adopted by the medical staff is high because the lead surgeon for LEAP was involved in the process. The other surgeon involved, having treated mine victims in the past, provided invaluable experience. The present study confirmed that an ideal scoring system for mine blast trauma tests does not exist. The AIS and NISSA scales were found to be too coarse and relied on systemic response of the patient, which only exists when the patient is alive. The ICRC score was more relevant, but it was designed to handle all mine victims, with a significant portion of the score being for victims injured by fragmentation mines. These findings prompted the LEAP team to invent the MTS, and independent specialists unconnected with LEAP corroborated the LEAP findings. For small mines against unprotected footwear, the MTS scores obtained with the FSL model were lower than with the LEAP model. This was contradictory given that the PMA-3 mine contains more explosive than the M14. However, this behaviour is partly attributable to the use of gelatine to simulate soft tissues in the FSL. Gelatine greatly attenuates the vertical propagation of the detonation products, while in human tissues, the gas propagates between self-dissecting planes along the facia that divide the compartments of the leg. Thus, obtaining lower MTS scores with the FSL relative to LEAP is consistent with the conclusion from the LEAP study that, for unprotected footwear, the amputation level was largely determined from the extent of soft tissue damage. When the Wellco overboot was used against the smaller mines, it produced a useful reference range of damage to the FSL. It was found that mine class and protective footwear were the main factors affecting the MTS scores; the inner footwear had little influence on the medical outcomes. The FSL MTS scores differed enough from those for LEAP that it warranted a closer look at the physical details of the injuries. The MTS scores were first broken down into two components: the amputation level and the extent of soft tissue contamination. Considering the MTS score in this manner reveals more clearly some of the differences in behaviour between the FSL and cadaver models. The soft tissue scores indicate that the FSL skin is significantly more fragile than human skin. This was known a priori when a cost-driven decision was made to use a nylon skin for the Mk IV FSL. A tougher chamois skin had been used on previous versions of the FSL. Although significant, the difference in behaviour of the FSL skin is not deemed to be as important as the difference in amputation level. During this phase of the CFSL programme, the FSL under-predicted the amputation level for small mines even though the more powerful PMA-3 mine replaced the M14 used during LEAP. For the larger PMA-2 mine, the FSL over-predicted the amputation level. In order to explain this behaviour, it was necessary to examine details of the bone damage extracted from the medical reports for the CFSL and LEAP studies.
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A scoring system was designed to compare bone damage. Based on four levels, from intact to completely crushed or missing, it considered five bones: calcaneus, talus, pilon area, tibia, and fibula. Although coarse, this scoring system proved sufficiently sensitive to capture gross differences in bone behaviour. Using this system to assess the bone damage in both the FSL and LEAP produced consistent results. The unprotected cases produced a more severe score than the protected cases for a given mine. For the same protection level, the score severity increased gradually with mine size. This scoring system also captured the localization of bone injuries, generally producing a more severe score for the bones closest to the explosion, and gradually decreasing in severity as the distance from the explosion increases. Using the bone damage score for protected footwear against small mines, it was clearly shown that the FSL calcaneus did not behave properly. It often survived or suffered only minor damage where the same bone in the cadaver model was destroyed. The survival of this bone meant that too much force was transferred further up the leg, increasing the level of damage to the talus, pilon area and the long bones of the lower leg. The net result was an intact, or nearly intact calcaneus, and repairable breaks further up the leg, suggesting possible avoidance of amputation. Comparison with the LEAP data suggests that a destroyed calcaneus would likely require amputation, even without the breaks in the bones above. Modifying the FSL calcaneus should minimise this discrepancy. The strain gauge instrumentation provided only partial information. Because of the complex geometry of the ankle joint, it is difficult to capture the exact stress flow through any cross-section of the tibia. The strain measured is a combination of compression and bending and it is impossible to differentiate between the two. A different strain gauge arrangement is therefore required. Changes to the cross-section over a short segment of the tibia might be an option. The load cell data was useful. It demonstrated that the addition of protective footwear changes the load profile with respect to time. It appears that the additional mass of the blast deflectors might contribute to a slight reduction of peak force, but mostly, momentum imparted to this mass continues to exert a push on the leg for a longer period of time compared to unprotected footwear. On the negative side, the introduction of a dissimilar material in the tibia appears to generate a stress riser that causes artificial bone breaks where the bone meets with the interface cups of the load cell.
6.4 Recommendations for Future Work

This first test series with the FSL model has demonstrated that the FSL is suitable to test the performance of protective footwear against AP mine blasts. Although the response of the FSL soft tissues does not reproduce the deep penetration of highpressure gas into the leg and the skin is too weak, the response of the bones appears to be repeatable and sensitive, the two main attributes that a test model must have. There is nevertheless more work required to decrease the strength of the calcaneus and talus
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bones. This should decrease the load transfer up the leg bones and improve the overall response of the FSL. While the tests were structured to explore the performance of the FSL, in most cases, only one test was performed for a given combination of basic footwear, protective footwear, and mine type. Repeatability was assessed only for a few combinations. There is a need to perform more tests with fewer changes to the test configuration if the repeatability of the FSL is to be assessed with more confidence. The substitution of the PMA-3 mine for the M14 mine was a significant problem. This changed the load imparted to the footwear and FSL, thereby making it very difficult to do direct comparisons with the LEAP data. Based on the results and observations made during the present test series, the following recommendations are made:
Acquire M14 mines for the purposes of performing a limited number of additional tests against a modified FSL model. These tests should concentrate on fewer footwear combinations and mine types to further investigate the repeatability of the model; Decrease the strength of the calcaneus and talus bones of the FSL to levels commensurate with their human counterparts; In future tests, discontinue the use of the AIS, NISSA and ICRC scoring systems and use only the MTS scores in combination with some form of bone injury scoring system; Investigate the possibility of improving the flash x-ray setup to obtain more images per test and use variable timings to record the deformation process, allowing determination of the impact speed of the blast deflectors on the sole of the foot; Investigate the possibility of increasing the skin strength, taking into consideration that skin behaviour might not affect the overall usefulness of the model if the scoring system focuses on bone damage; Consider alternatives to measure the effective load through the tibia or tibia/fibula combination. This might include a modification of the cross-section over a small segment of the tibia; Consider using only the lower segment of the FSL given that AP mine damage is strongly localized in the distal segment of the leg.
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References
1. Anon. (2000). Landmine Casualty Data Report: Deminer Injuries. Office of the Assistant Secretary of Defence for Special Operations / Low Intensity Conflicts, OASD(SOLIC). 2. Anon. (1999). Final Report of the Lower Extremity Assessment Program, Volume I, (LEAP 99-1), US Army Institute of Surgical Research.
3. Harris, R.M., Rountree, M.S., Griffin, L.V., Hayda, R.A., Bice, T., Mannion, S.J. (2000). Final Report of the Lower Extremity Assessment Program (LEAP), Volume II. Report no. ATC-8199. 4. Carruthers, A.R., McFee, J.E., Bergeron, D.M., Das, Y., Chesney, R.H., Russell, K. (1999). Scoping Study for Humanitarian Demining Technologies. (DRES TR 1999-121). Defence R&D Canada Suffield. 5. Nechaev, E.A., Gritsanov, A.I., Fomin, N.F., Minnullin, I.P. (1995). [Mine Blast Trauma Experience from the war in Afghanistan]. Vreden Research Institute of Traumatology, Russian Ministry of Public Health and Medical Industry, Russian R.R. (Originally published in Russian; translated by the Council Communication, Stockholm, Sweden). 6. Morris, B.L. (1993). Analysis of Improved Crew Survivability in Light Vehicles Subjected to Mine Blast. Final report for contract no. DAAK70-92-C-0058 for the U.S. Army Belvoir RDEC, Ft. Belvoir, Virginia. 7. Bergeron, D.M., Walker, R.A., Coffey, C.G. (1998). Detonation of 100-gram antipersonnel mine surrogate charges in sand; A test case for computer code validation. (Suffield Report No. 668). Defence Research Establishment Suffield. 8. Edlich, R.F., Moghtaler, J.C. (1998). Thermal burns. Rosen, P., Barkin, R. (ed.), Emergency Medicine, 4th ed, Mosby, St. Louis, MO. 9. Coupland, R.M., Korver, A. (1991). Injuries from antipersonnel mines: the experience of the International Committee of the Red Cross. Br. Med. J., 303, 1509-1512. 10. Fomin, N .F. (1994). The Mechanogenesis of Injuries to the Organs and Tissues in Explosive Mine Avulsions of the Lower Extremities. Voenno-Meditsinskii Zhurnal, 5, 12-16. 11. Gustilo, R.B., Mendoza, R.M., Williams, D.N. (1984). Problems in the management of type III severe open fractures: a new classification of type III open fractures. J. Trauma, 24, 742-746. 12. Luchette, F.A., Bone, L.B., Born, C.T., Delong, W.G., Hoff, W.S., et al (2000). EAST practice management guideline workgroup: practice guidelines for prophylactic antibiotic use in open fractures. Eastern Association for Surgery in Trauma [electronic journal]. URL: http://www.east.org/ 13. Coupland, R.M. (1992). Amputation for War Wounds. International Committee of the Red Cross. 14. Gray, R. (1994). War Wounds: Basic Surgical Management. International Committee of the Red Cross.
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15. Coupland, R.M. (1989). Amputation for antipersonnel mine injuries of the leg: preservation of the tibial stump using a medial gastrocnemius myoplasty. Ann. R. Coll. Surg. Eng., 71, 405-408.
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Annex AInjury Assessment Scoring Systems Overview

Injury to the lower extremity due to land mine blast is described as a high-energy trauma and represents a challenge for the medical staff in regard to reconstruction and rehabilitation of the patient. Over several decades, the medical community has developed a variety of injury scoring systems to describe the extent and gravity of injuries in general. The intent of lower extremity injury scoring systems is to quantify the severity of the trauma and to generate a numerical score to guide the decision whether to amputate or salvage the limb. The LEAP program found that, for various reasons, none of these systems was suited to adequately describe land mine blast injuries. (For example, most scoring systems were designed for injury mechanisms other than the explosion of a blast mine below the lower extremity.) Detailed descriptions of the available injury scoring systems will illuminate the reasons for choosing the MTS for the purposes of this trial. Suggestions for further reading on this subject can be found in the Bibliography. In the descriptions that follow sensitive refers to the probability that limbs requiring amputation will have limb-salvage scores at or above the index threshold; and specific refers to the probability that salvaged limbs will have limb-salvage scores below the threshold.
AIS Scoring System

A committee for the Advancement of Automotive Medicine first established the Abbreviated Injury Score in 1969. The AIS is based on a list of several hundred injuries scored from one (minor) to six (nearly always fatal). It has undergone many revisions, the latest in 1990 (AIS-90). The AIS assigns severities to individual injuries and requires summary scores to classify multiple traumas. Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe and 6 a non-survivable injury. This represents the 'threat to life' associated with an injury and is not meant to represent a comprehensive measure of severity. The AIS is not an injury scale, in that the difference between AIS1 and AIS2 is not the same as that between AIS4 and AIS5.
Table 10. Abbreviated Injury Score AIS SCORE

0 1 2 3
INJURY LEVEL
No Injury Minor Moderate Serious
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4 5 6
Severe Critical Not Survivable
ICRC Scoring System

The International Committee of the Red Cross scoring system was established to grade primarily missile wound injuries. It does not lend itself easily for scoring traumatic amputation. Amputations are divided into two rough categories: grade 3 type F, for a below knee amputation; and grade 3 type VF, for an above knee amputation.
Table 11. International Committee of the Red Cross Score TYPE
Type ST Type F Type V Type VF
GRADE 1
Small simple wound 1F 1V 1 VF
GRADE 2
2 ST 2F 2V 2 VF
GRADE 3
3 ST 3F 3V Large wound(s) threatening life of limb
DATA SECTION
E = Entry wound diameter (cm) X = Exit wound diameter (cm) C = Cavity? C = 0, 1 Estimate diameter of entry hole Estimate maximum diameter of exit hole(X = 0 if no exit wound) Can the cavity of the wound take two fingers before surgery? No C = 0; Yes C = 1 No fracture F = 0Simple fracture, hole of insignificant comminution F= 1Clinically significant comminution F = 2 Are brain, viscera (breach of dura, plura or peritoneum) injured? No V = 0; Yes V = 1
F = Fracture? F = 0, 1, 2
V = Vital Structures? V = 0,1
Land mine blast injuries fall outside these classifications and are difficult to categorize: Grade 3, type F, below knee amputation = 3 F BK Grade 3, type F, above knee amputation = 3 F AK
NISSA Scoring System

The NISSA scoring system (Table 6) was developed in 1994 to address perceived weaknesses in another scoring system, the MESS, which was itself designed to address
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limbs with combined vascular and orthopaedic injuries. Specifically, the NISSA added a nerve-injury component, giving the highest weight to the loss of plantar sensation, and divided tissue injury into soft and skeletal variables. A study that scored twentysix limbs retrospectively with the MESS and NISSA methods found that the NISSA score was more sensitive (81.8% compared with 63.6%) and more specific (92.3% compared with 69.2%). Both scores were reported to be highly accurate in predicting amputation. The LEAP study did not confirm these findings. The NISSA had sensitivity of 33% when applied to all type-III tibia fractures and of 13% when immediate amputations were excluded. The performance did not improve when the type-IIIB and IIIC tibia fracture subgroups were analyzed separately.
Table 12. NISSA Scoring System SCORE
NERVE INJURY 0 1 2 3 ISCHEMIA 0 1* 2* 3* SOFT TISSUE INJURY / CONTAMINATION 0 1 2 3 SKELETAL INJURY 0 1 2 3 Low energy Medium energy High energy Very high energy Low Medium High Severe None Mild Moderate Severe Sensate Loss of dorsal Partial plantar Complete plantar
FACTOR
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SHOCK / BLOOD PRESSURE 0 1 2 AGE (YEARS) 0 1 2 > 50 < 30 30 50 Normotensive Transient hypotension Persistent hypotension
NOTES ABOUT APPLICATION OF NISSA SCORE TO CFSL PROGRAM: * Ischemia scores are to be doubled if duration of ischemia exceeds 6 hours. No corrections were made for a 6 hour delay in treatment. Age was uniformly assumed to be <30 years It was assumed that most casualties would have transient hypotension except those who had extremely severe injuries, which were weighted to the more severe score.
MTS Scoring System

The Mine Trauma Score was developed during the LEAP program because of the poor performance of the scoring systems listed previously for tests involving non-living human. The use of cadaver parts for the LEAP tests meant that scoring factors involving vital signs could not be used and that using these scores involved a subjective decision by the surgeon, albeit this decision was based on experience. It was therefore decided to design a new scoring system better adapted to the land mine blast scenario and the use of protective footwear. Table 7 lists and describes the MTS scores.
Table 13. Mine Trauma Score developed for the LEAP program SCORE
0 1 1A 1B 2 2A 2B
INJURY
Minimal Closed Open contained Open contaminated Closed Open contained Open contaminated
SURGERY REQUIRED
No major surgery required
Surgery required and limb is salvageable
Surgery required; definite below knee amputation
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Open contaminated
Surgery required; could lead to either below or above knee amputation Surgery required; definite above knee amputation
4 NOTES:
Open contaminated
Closed injury: any injury to the lower extremity that does not violate the skin, thereby minimizing the risk of infection. Open contained injury: any injury to the lower extremity that violates the skin (lacerations, tears), but is not contaminated by the outside environment because the inner footwear was not compromised. Open contaminated injury: any injury to the lower extremity that does violate the skin and has contamination of the soft tissues and bones from the environment where the blast occurred.
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Annex B Detailed Boot Damage Assessments

This Annex provides a detailed assessment of the physical damage imparted to the boots and protective overboots used during the CFSL program. To ease cross-reference with the data from Annex A, a short table lists the test conditions for individual shots. This data precedes a series of pictures followed by a detailed description of the damage. In general, the description includes a summary of the overall damage, a description of the damage to the boot fitted to the FSL specimen, and then, if applicable, a description of the damage to the additional protective footwear such as the Wellco overboot or the Spider boot. The terminology used to describe various parts of the boots and overboots is depicted on the following pages.
Table of Contents Annex B

Shot ID M99256A M99257A M99257B M99257C M99257D M99258A M99259A M99259B M99259C M99260A M99260B M99260C M99260D M99263A M99263B M99263C M99263D M99263E M99264A M99264B M99264C M99264D M99264E M99265A M99265B Load Cell No No No No No Yes Yes No No Yes No No No No Yes No No No Yes Yes No No No Yes Yes Bone Type Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Boot Type Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Blast (Wellco) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco) Protection Overboot Overboot Overboot Overboot Overboot Overboot Overboot Spider boot Spider boot Overboot Spider boot Spider boot Spider boot Spider boot Overboot Overboot None Overboot Overboot Overboot None Overboot Overboot None None Explosive VS-50 PMA-3 PMA-2 PMA-2 PMA-2 PMA-3 PMA-3 PMA-3 PMA-2 PMA-3 PMA-3 PMA-2 PMA-2 PMA-2 PMA-3 PMA-3 PMA-2 PMA-2 VS-50 VS-50 PMA-2 C4-50 C4-50 PMA-3 PMA-3 Page A6 A8 A10 A12 A14 A16 A18 A20 A22 A24 A26 A28 A30 A32 A34 A36 A38 A40 A44 A46 A48 A50 A52 A54 A56
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118
119
120
121
Shot ID
M99256A
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
VS-50
Description of Boot Damage: Summary: Boot outer sole and upper intact. Boot inner sole torn and breached. Overboot heel destroyed. Overboot upper partially torn free of sole.
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Detailed Description: Boot: The outer sole of the boot has been bent upward into an exaggerated arch. There is a 35mm vertical tear in the vamp beginning at the front edge of the heel cap on the medial side. Also on the medial side, the bottom three eyelets have been torn. No other damage is visible to the outside of the boot. The leather insole has been torn along both sides of the steel shank. At the front of the shank there is a sideways tear that runs almost across the width of the insole. At the rear of the shank multiple tears radiate out toward the counter. The steel shank is no longer well attached to the outer sole. The head of a staple is showing through the leather insole near the rear-most edge. Overboot: The outer sole of the overboot has been destroyed in the heel cap and outer midfoot areas. The fragment of the outer sole left in the midfoot area has serious erosion damage and has cracks that run diagonally forward from the centre line toward the start of the toe treads. The blast deflector, still in the overboot sole, has been pinched, flattened and bent upward by about 20mm. The attenuator and attenuator plate (also still in the sole) show typical signs of crushing and deformation. The outer sole, Kevlar insole and upper are attached in the toe tread section. About 50mm of the medial side panel and 120mm of the lateral side panel have separated from the Kevlar insole at the heel. Both side panels have separated cleanly at the backstrap seam. The backstrap is missing. The facing on the side panels has broken and partially peeled off but remains attached to both panels. On the medial side panel both ventilation inserts are missing and the outer covering fabric has 3 vertical tears measuring 20mm, 10mm and 10mm long. These are located 95mm, 130mm, and 145mm ahead of the back edge of the side panel. The lateral side panel shows a broken rear buckle and tears in the outer covering fabric. The first is 20mm long and appears 50mm ahead of the rear edge of the panel. Another 20mm ahead is a 60mm long vertical tear. From this point forward to the rear buckle the bottom 50mm of the outer covering fabric has been torn off. The next 50mm of fabric has been torn and has a small piece of the outer sole still attached and hanging loose from the rest of the overboot. The toe cap is intact and undamaged.
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Shot ID
M99257A
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Description of Boot Damage: Summary: Boot outer sole and upper intact. Boot inner sole torn. Overboot heel destroyed. Overboot upper partially torn free of sole. Overboot blown off boot.
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Detailed Description: Boot: The outer sole and upper of the boot show no visible signs of damage. There is also no obvious external sign of deformation or bending of the sole or shank. The only visible damage inside the boot is a series of interlocking cracks in the heel portion of the leather insole. There is a slight bulge in the insole just above the rear end of the steel shank, and another right at the extreme lateral edge of the insole at the end of a crack. Peeling up the insole revealed similar cracks on the underlying pressed paper layer. The shank appears to be firmly attached to the surrounding structure and shows no signs of having been loosened, bent, or otherwise damaged. It is possible that the cracks in the insole were the result of the bones in the foot impacting and cutting into the insole from above rather than being from the shank below. Overboot: The heel section of the outer sole has been destroyed, with a tear running as far forward through the instep area as the attenuator and blast plate used to reach. On the medial side the outer fabric of the side panel is attached to the sole from the toe to the point where the outer sole disappears, just ahead of where the heel cap began. The inner structure of the side panel has delaminated from the outer sole at a point about half way along this length, approximately where the toe tread ends. With the separation of these components, the Kevlar insole is also loose along the medial side to about the same place. The lateral side panel and its outer fabric are firmly attached from the toe all the way back to where the outer sole disappears but for the last 3cm. Both side panels of the upper have separated cleanly at the backstrap seam, and are essentially intact. The lateral side panel shows three vertical tears in the outer fabric. The rear-most, right near the backstrap seam runs vertically about 20mm, with the second about 30mm ahead being of similar size. The third tear, about 30mm further forward, is about 60mm long. The rear buckle has been broken. The side panel and the Kevlar insole are separated from the sole for about 30mm but appear to be firmly attached forward of this point. The medial side panel shows 7 small vertical tears ranging in length from about 10mm to 30mm. These tears are evenly distributed from the backstrap seam to just before the rear ventilation hole. Both ventilation inserts are missing. The panel separates from the Kevlar insole at the point where the outer sole disappears, approximately where the heel cap would start. The lateral panel separates from the Kevlar insole about half way from the backstrap seam to the point where the outer sole disappears. The toe cap appears intact and undamaged. Aside from a slight upward deformation, there appears to be no major damage to the Kevlar insole. The covering cloth shows a star shaped tear pattern right at the heel, covering a circular area about 50mm in diameter. The covering cloth is separated from the insole in an area about 70mm long near the backstrap seam. The attenuator, attenuator plate and blast plate have all been separated from each other and from the rest of the overboot. The blast plate has been pinched, crushed and bent upward by about 20mm. Right at the point of maximum deformation the plate has been split; a tear about 40mm long runs along the line of the crease in the plate. The attenuator has been crushed by the blast plate in the rear section, but the front of the attenuator shows relatively little deformation. The outermost 5 strips of corrugated metal on the lateral side have been pulled off the attenuator and remain attached to the attenuator plate. The attenuator plate has been badly deformed and dished upward.
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Shot ID
M99257B
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-2
Description of Boot Damage: Summary: Boot outer sole intact. Boot upper torn. Boot inner sole torn and breached. Overboot heel destroyed. Overboot upper torn free of sole. Overboot blown off boot. Boot found several metres away with foot fragments inside.
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Detailed Description: Boot: Aside from being bent into an exaggerated arch, the outer sole of the boot appears to be intact and undamaged. The bottom of the heel cap has also been dished by about 1mm. Inside the boot, the leather insole has been torn along the lines of the steel shank, the last 25mm of which has been separated from the sole. The insole has also been torn from one side to the other right at the rear end of the shank, and a part of the heel section of the insole is missing. The pressed paper layer beneath the insole has been flattened and torn, and pieces of it are missing. The medial side upper has separated from the lower sole from the front of the heel cap forward by about 60mm. A vertical tear runs from the front of the heel cap up to the notch in the eyelet flap. A 30mm long horizontal tear follows a line of stitching at the front corner of the quarter. On the lateral side a tear follows the backstrap seam up from the sole, and almost 60mm into the quarter. The counter has also been torn away along this line. The next 55mm of the outer layer of the vamp is partially attached to the sole but has multiple tears including one that follows the line of where the counter edge was. This stops just short of the vamp/quarter seam where there is a 35mm long horizontal tear along the seam. From the front of the heel cap forward by 70mm the upper has been completely separated from the sole. At this point, just before the start of the toe tread, there is a 35mm long tear diagonally forward in the outer layer of the vamp. The inner layer has peeled away on the inside surface for another 50-60mm forward but is otherwise intact. Overboot: The outer sole has been completely destroyed from just behind the toe tread back. The blast deflector and attenuator are missing, while the attenuator plate remains attached to the Kevlar insole. The rear 50mm of the attenuator plate has been peeled from the Kevlar insole and bent downward. The Kevlar insole has been deformed upward by about 20mm. The inner covering of the Kevlar insole has been torn from the back of the heel forward by about 120mm Only the front 40-50mm of the sole, Kevlar insole medial upper and toe cap remain attached to each other. The lateral side panel of the upper has been completely separated from the rest of the overboot. The lateral upper is missing its rear buckle and its facing. It has separated cleanly at the seam between the side panel and the backstrap. The medial side panel of the upper has also separated cleanly at the seam between the panel and the backstrap. The two ventilation inserts are missing along with the male portion of the rear buckle. One tooth has been broken off the male portion of the front buckle. The facing used to cap both side panels and the backstrap remains attached only to the front-most 20mm of the side panel. A vertical tear approximately 70mm long is seen in the outer covering about 70mm back from the rear air vent location. About 30mm of the lateral side of the toe cap has been pulled from under the Kevlar insole.
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Shot ID
M99257C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-2
Description of Boot Damage: Summary: Boot outer sole intact. Boot upper torn. Boot inner sole torn. Overboot heel destroyed. Overboot upper torn free of sole. Overboot blown off boot. Boot found several metres away with partial foot inside.
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Detailed Description: Boot: The outer sole of the boot is intact and undamaged except that it has been permanently bent upward into a more exaggerated arch position. In the area of the toe treads, the only visible damage to the upper is a few scratches on the toe, and a single 55mm long horizontal tear along one of the lines of stitching where the medial side quarter attaches to the vamp. The upper is still firmly attached to the sole from the toe to a point 30mm beyond the toe tread on the medial side. On the lateral side, it is 15mm beyond the toe treads. At the rear of the boot the upper is well attached to the sole from the lateral side of the backstrap seam to a point 20cm beyond the medial side backstrap seam. The remaining area on the medial side (about 130mm) has been separated from the sole. On the lateral side the outer layer of the boot remains attached to the sole in the counter area, but the inner leather lining has separated. From the counter forward, about 70mm of the upper has completely separated from the sole. On the lateral side, just ahead of the counter, a tear runs 55mm vertically up to the quarter seam, then runs back along the seam for 25mm, and finally vertically up into the quarter for 20mm. Only the bottom 55mm portion has penetrated the inner leather lining. About 35mm back from this tear, a 200mm long vertical cut rises from the sole. A further 25mm back, a 30mm long vertical tear has cut through the outer layer but not the inner leather lining. This tear does not start at the sole, but rather, starts about 15mm above the sole. Finally, a 105mm long tear follows the backstrap seam through the vamp and into the quarter. On the bottom, 100mm of this tear has penetrated the inner leather lining. On the medial side, a 25mm long tear starts at the sole and follows the backstrap seam up. Right at the forward edge of the heel cap, a tear runs vertically 135mm through the vamp and quarter into the eyelet flap. This tear runs just behind the notch in the eyelet flap and almost reaches the eyelet above the notch. From the toe tread forward the inside of the boot appears undamaged. In the midfoot area the leather insole has been torn longitudinally. A piece in the middle, still attached to the forward part of the insole remains firmly glued to the steel shank. The pieces on either side of this have separated from the sole and are attached at the edges where the upper rolls under. In the heel section both the leather insole and the pressed paper layer have been torn away. The back of the shank is no longer fixed down to the heel. Overboot: The heel and midfoot portions of the overboot have been completely destroyed. The outer sole, Kevlar insole and side panels remain connected only near the toe cap. The deflector plate, attenuator and attenuator plate were removed as a single unit. They show that the deflector plate has been pinched, flattened and bent upward by about 25mm. In the area of maximum deformation, a 30mm long tear is seen in the plate right along the crease, and the crease area has been folded over. The attenuator has been completed crushed in this area. While the upper surface of the Kevlar insole is slightly uneven, and the rear 90mm of the covering fabric has been removed, the Kevlar insole appears relatively intact and undamaged. The toe cap portion of the upper appears intact and undamaged. On the medial side panel both ventilation inserts are missing along with the rear buckle section. The front buckle piece has been broken. Where the side panel separated from the sole the lower edge of the outer covering fabric has been frayed and torn. One 55mm tear runs from the bottom of the fabric up to the rear buckle attachment strap. Thirty millimetres further back is a 30mm vertical tear in the outer fabric followed by a 90mm vertical tear 30mm further
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back from that. The bottom 25-50mm of the covering fabric on the lateral side panel has been torn away. In the area just behind the rear buckle the covering fabric has been torn away up to 35mm further up. Just behind the rear buckle location the outermost yellow Kevlar layer has sustained a 40mm long vertical cut. It has penetrated the inner layer for 30mm of its length. The rear buckle is also missing. Both side panels separated cleanly at the backstrap seams.
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Shot ID
M99257D
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-2
Description of Boot Damage: Boot outer sole heel split and damaged. Boot upper torn. Overboot heel Summary: completely destroyed. Overboot upper torn free of sole. Overboot blown off boot. Detailed Description: Boot: The sole of the boot shows a damage pattern unlike any others in this trial series. While the outer sole shows no blast, heat, or erosion damage, there is a clean, straight split right along the centre line of the sole. This split runs along the centre line ridge from right at the back of the boot to a point 15mm before the toe tread. This corresponds to the area of minimum rubber thickness created by the presence of the crushable insert. Unlike the other damaged boots where a damaged sole would be driven upward into the boot, the Kevlar insole has been driven downward and out of the boot. Examination of the videotapes failed to prove whether this damage was caused in the early stages by the blast or by impact of some part of the leg with the overhead supporting structure. It is clear, however, that the damage was done before the foot/leg/boot came back down to the test platform.
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The blast deflector, attenuator and attenuator plate have been separated from the boot. The deflector plate has been flattened and bent upward by almost 20mm. The attenuator has been flattened along most of its length and remains firmly attached to the attenuator plate. Aside from the tearing of the foam insole and the aforementioned pulling downward of the Kevlar insole, there is no other visible damage to the inner sole of the boot. The upper has separated from the outer sole from the front of the heel cap to the start of the toe treads on the lateral side. A vertical tear runs from the sole almost straight up through the vamp, quarter and eyelet flap just behind the lace clamping eyelet. There are two other tears on the lateral side that penetrate the outer layer but not the inner lining. One runs vertically about 50mm long at about the mid point of the heel cap, while the other runs vertically about 30mm right where the bootstrap seam would be if the bootstrap extended right to the sole. Notwithstanding the statement that the inner lining was spared, the boot was breached in these two locations since the inner lining has separated from the insole all around the counter. The lateral half of the counter is also missing. On the medial side the upper is separated from the sole beginning at the seam between the front and rear vamps. This separation runs back about 90mm. Just at the front edge of the counter a 55mm tear runs vertically and the slightly forward through the rear vamp. This tear only partially penetrates the inner lining, but again, the lining has separated from the insole so the boot has been completely breached in this location also. One final piece of damage to note is that there is a rip in the outer layer between the bottom two eyelets on the medial side. The lower eyelet is partially torn loose while the upper is gone. The tear does not extend through both layers of leather so it was not caused by the boot lace cutting through the leather. More likely, some sharp object such as an exposed staple from the overboot snagged the boot at this point. Overboot: The only part of the upper left attached to the outer sole of the overboot is the toe cap. About 40-50mm along each side of the toe cap has separated from the sole but it remains firmly attached in the area of the front seam. The toe cap is otherwise intact and undamaged. The outer sole is destroyed and missing from the start of the toe tread back. A small piece along the centre line through the mid-step area remains attached but there are tears on either side that run into the start of the toe tread. The entire insole, the blast deflector, the attenuator and the attenuator plate are missing. The lateral side panel has been completely separated from the rest of the overboot. It separated cleanly at the backstrap seam and along the sole except that a 30mm wide strip of the outer covering fabric has been torn off the rear 210mm of the panel. The front buckle has been damaged and the rear buckle completely broken off. The rear 120mm of facing has peeled from the upper edge of the panel but remains attached. The medial side panel has also separated cleanly at the backstrap seam and sole. The outer covering fabric has suffered vertical and horizontal tears along its lower edge. A vertical tear runs 80mm up from the sole line about 80mm ahead of the backstrap seam. A strip 30mm wide has been torn off the lower edge of the panel from just ahead of the backstrap seam to just below the rear buckle strap. From that point forward by 130mm, the fabric has been torn horizontally but remains attached. The rear 90mm of facing has come loose, the rear buckle is missing and both ventilation inserts are missing. Two loose backstraps were found and included in the photos. Obviously one was from another trial.
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Shot ID
M99258A
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-3
Description of Boot Damage: Summary: Boot outer sole intact and partially peeled from upper. Boot upper intact. Overboot outer sole destroyed. Overboot upper intact. Detailed Description: Boot: The outer sole of the boot shows a slight (about 10mm) arch along the centre line of the heel cap, and a 50mm split right along the centre line of the heel cap. In addition, there is a separation of the upper from the outer sole. This occurs from the front of the heel cap on the medial side and runs around the heel to the front of the heel cap on the lateral side. On disassembly of the boot the blast deflector is seen to have caused partial crushing of the attenuator. The deflector plate has been bent upward by about 10mm. The foam insole shows a small star shaped crack in the heel area along with minor scuffs in the upper surface. The Kevlar insole shows only a small pimple in the heel area. On disassembly of the boot it was evident that there were, in fact, 3 such pimples one at the heel, one at the arch and one near the ball of the foot. There was nothing to indicate an intrusion from below or any damage due to blast. It seems likely that these are characteristics of the manufacturing process rather than the result of any blast damage.
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Also evident on disassembly of the boot was a series of at least 3 vertical cracks in the counter. Finally, despite the outer sole being visually intact and undamaged, disassembly of the boot revealed that the attenuator had been partially crushed and the blast deflector bent upward by about 5-10mm. Overboot: The heel cap of the overboot has been destroyed and there are several small cracks and tears that run through the midfoot region about half way to the toe treads. There is a small amount of erosion damage to the midfoot section of the outer sole. On the lateral side the upper remains attached to the outer sole from the rear buckle forward. On the medial side they are attached from a point 25mm before the toe treads forward. The upper remains attached to the Kevlar insole all the way around. The lateral side rear buckle has been broken and there are two small vertical tears in the outer covering fabric at 55mm and 70mm ahead of the backstrap seam. They measure 30mm and 20mm respectively. On the medial side the bottom 60mm of backstrap seam stitching has been broken and both ventilation inserts are damaged but still present. A 60mm long split in the Kevlar insoles covering fabric can also be seen.
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Shot ID
M99259A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Description of Boot Damage: Boot outer sole and upper intact. Boot inner sole torn. Overboot outer sole Summary: destroyed. Overboot inner sole torn and breached. Overboot upper torn in heel area. Detailed Description: Boot: The outside of the boot shows no visible signs of damage whatsoever. Inside the boot the only visible sign of damage are tears in the leather insole. One tear runs across the insole from one side to the other right at the rear of the steel shank. From the middle of this tear, another runs straight back almost to the extreme back edge of the insole. Two tears run forward along the sides of the steel shank for about 40-50mm. The edges of the leather insole have lifted along the cracks. Flexing of the boot shows that the rear of the steel shank has come loose from the heel. Overboot: The outer sole of the overboot has had the heel destroyed. Erosion damage can be seen in the midfoot area, and cracks run diagonally outward and forward from the centre line at the heel cap to toward the start of the toe treads. The rear toe tread on both sides shows signs of starting to peel from the sole. The blast deflector, attenuator and attenuator plate are all still in the sole. The back half of the attenuator has been completely crushed
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and the deflector plate has been pinched, flattened, bent upward by about 20mm, and folded over at the crease in the area of maximum deformation. At this point there is also a 40mm long split in the deflector plate. About 40mm of the upper is separated from the remains of the outer sole on the medial side. Otherwise the upper is firmly attached to the sole all the way around to where the outer sole ends on the lateral side. The Kevlar insole is attached to the outer sole in the entire toe tread area. The upper has separated from the Kevlar insole for a distance of about 70mm on either side of the heel centre line. Otherwise the upper and Kevlar insole appear fully attached. The bottom 90mm of the backstrap has had the stitching broken from both side panels. The medial side panel shows two vertical tears in the outer covering fabric. The first, 20mm long is 60mm ahead of the rear edge of the panel. The second, 90mm ahead of the rear edge, is 55mm long. Both ventilation inserts are missing. On the lateral side panel the rear buckle has broken off. A 55mm long vertical tear is located 90mm ahead of the rear edge of the panel, and three 10mm long vertical tears are spaced equally behind this longer tear. The toe cap is intact and undamaged.
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Shot ID
M99259B
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider boot
Explosive
PMA-3
Description of Boot Damage: Boot apparently undamaged. Spider boot rear legs destroyed. Summary: Abrasion/erosion damage to bottom face of Spider boot body. Detailed Description: Boot: The boot showed no signs of damage whatsoever. After a thorough inspection it was reused in trial M99264A. Overboot: The complete binding system, the top plate and the hinge plate are all free of any visible damage. There are also no visible cracks, delaminations, or other signs of damage to the deflector shell. The front legs and pods look untouched and there is only a tiny amount of erosion damage to the rear edge of the front leg attachment panel. The rear leg attachment plate has been twisted sideways and the two rear bolts appear to have been bent. Their holes in the leg attachment plate may also have been stretched. Both legs and pods have been destroyed. Both legs were broken off right where they curved into the attachment plate. On the lateral side, there is a crack that runs in to the attachment bolt hole on the attachment plates top surface. A second crack on the lower surface runs about 100mm long from near the leg, outside of the bolt location, around the
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side of the attachment plate and back toward the front again. There is some erosion and deformation damage to the attachment plate just between the legs. A small crack appears on the front edge of the rear leg attachment panel. This crack runs to the upper surface of the panel, which is hidden from view.
138
Shot ID
M99259C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider boot
Explosive
PMA-2
Description of Boot Damage: Boot apparently undamaged. Spider boot rear legs destroyed. Summary: Abrasion/erosion damage to bottom face of Spider boot body. Detailed Description: Boot: The combat boot showed no signs of damage whatsoever. After a thorough inspection it was reused in trial M99264C. Overboot: This trial had the mine under the rear medial pod. The front medial leg shows 2 cracks, each about 60 degrees off the front centre line of the leg, and each converging with the other, extending about 30-35mm up the leg. The rear part of the threaded section of the leg has broken off and remains inside the pod. The front of the threaded section is still attached to the rest of the leg. A small amount of erosion damage is visible on the rear medial corner of the front leg mounting panel. No other damage is visible on any other part of the front half of the Spider boot. Both rear legs of the Spider boot have been blown off. Only a few fragments were recovered, including one pod. The lateral leg is broken off just as it curves into the leg mounting panel while the medial leg is broken off right next to the mounting bolt. In
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addition to being twisted sideways, the mounting panel shows cracks on both its upper and lower surface. The two rear mounting bolts have been bent, and the holes in the lower surface of the leg mounting panel stretched. The medial side bolt spacer has also been broken. A small crack in the surface layer of the deflector shell can be seen on upper edge of the medial side, near the middle of the binding system base. On the lateral side a similar crack can be seen at the rear of the binding system base. Delamination around the edge of the shell structure is very obvious from about the middle of the base plate on the lateral side, around the back of the shell to about the back of the binding system base on the medial side. Significant area of the reinforcing fabric can be seen in the portion of the shell. Portions of the rear 130mm of the deflector shell are soft to the touch and have clearly been compromised by delamination, cracks, etc. The top plate and hinge plate have been permanently deflected upward at the rear of the Spider boot. This deflection is most obvious in the rear 110mm of the top plate, and measures almost 10mm. There is no other visible damage to the top plate, hinge plate or binding system.
140
Shot ID
M99260A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Description of Boot Damage: Boot outer sole and upper intact. Boot inner sole torn and breached. Overboot Summary: outer sole heel destroyed. Overboot inner sole torn and breached. Overboot upper torn in heel area. Detailed Description: Boot: After the trial the boot upper was intentionally cut along the lateral side of the backstrap seam to allow the FSL to be removed without damaging the leg. Otherwise the boot outer sole and upper appear intact and undamaged. It is possible that the steel shank may have been bent, arching the sole of the boot upward, but could not be confirmed by a simple visual check. The leather insole appears intact and undamaged in the area ahead of the heel. The heel area shows a tear from one side all the way across to the other, and another tear from the middle of the first back about 30mm. The steel shank is visible through the first tear, and one of the staples holding the shank down has been forced up through the insole into the foot area. After peeling up the leather insole it is clear that there is a slight curve to the shank. The pressed paper layer under the heel of the leather insole also showed small tears
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and signs of deformation, thus indicating that the rear end of the shank had been lifted or bent. Overboot: The outer sole of the overboot has been destroyed leaving one tear down the centreline to about 30mm short of the toe treads and another curving off to the medial side just under the ventilation insert location. The blast deflector, attenuator and attenuator plate are all firmly in place. The back 90mm of the deflector has been pinched, flattened and bent upward by about 20-25mm. Where it was pinched and flattened it was folded over and a 40mm long tear shows along the crease. The attenuator has been crushed in this 90mm area. The attenuator plate has also been dished upward. The sole has separated from the upper at the start of the toe treads on the medial side and at the rear buckle on the lateral side. The toe cap is intact and undamaged. Aside from the upper separating from the sole, the only damage visible to the medial side panel is that the front ventilation insert is missing and the outer portion of the rear insert is missing. The inner portion of the rear insert is still embedded in the fabric, although it has been deformed leaving sharp edges inside the overboot. The lateral side panel shows slightly more damage. The rear buckle has been broken and the panel has separated cleanly at the backstrap seam. The facing is intact and is keeping the panel from separating completely from the backstrap. The outer fabric on this side panel shows 2 small vertical tears. The first is right where the sole ends, just under the rear buckle and measures less than 10mm long. The second is 35mm behind the first and is about 15mm long. Both side panels and the backstrap remain firmly fixed under the Kevlar insole. The Kevlar insole exhibits a slight bulge in the heel area and its covering fabric shows 3 small tears each measuring about 20mm long. They are separated by 10mm. There is also a very small cut in the fabric at the edge of the Kevlar insole immediately below the ventilation insert
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Shot ID
M99260B
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider boot
Explosive
PMA-3
Description of Boot Damage: Boot apparently undamaged. One Spider boot front leg destroyed, one Summary: severely damaged. Abrasion/erosion damage to bottom face of the deflector shell. Detailed Description: Boot: The combat boot showed no signs of damage whatsoever. After a thorough inspection it was reused in trial M99264D. Overboot: The entire spider boot appears intact and undamaged from the mid point back except for a minute amount of erosion damage at the front edge of the rear leg mounting panel. The front leg attachment panel has been twisted, enlarging the two front bolt holes. A crack on the lower surface runs from the moulding seam at the inside base of the lateral leg to the lateral leg bolt hole, and another 35mm beyond. A similar crack on the medial side runs along the upper surface at least as far as its bolt hole. The medial side front leg has been broken off right at the leg attachment panel. The lateral leg is still attached but for the threaded portion at the end and the leading tip of the leg. Both front pods are missing.
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A 15mm long vertical crack occurs on the medial side of the deflector shell just at the front of the binding system base. Some localized delamination may have occurred at this location. In the front of the deflector shell between the front legs one can see several cracks in the surface layer. Tapping this area reveals that some delamination has also occurred here, particularly at the upper edge.
144
Shot ID
M99260D
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider boot
Explosive
PMA-2
Description of Boot Damage: Boot apparently undamaged. Spider boot front legs destroyed, one rear leg Summary: damaged. Abrasion/erosion damage to bottom face and front of the Spider boot deflector shell. Detailed Description: Boot: The combat boot showed no signs of damage whatsoever. After a thorough inspection it was reused in trial M99264E. Overboot: This trial had the mine under the front medial pod rather than the usual rear pod location. The rear lateral pod has been broken off with a part of its leg. The break is a clean fracture with no appreciable missing material. It is assumed that this damage was caused by the pod or leg striking the ground or some other object rather than by blast damage; blast damage should probably show more erosion and fragmentation. Both front legs have been blown off and shattered. Only one of the front pods (likely the lateral pod) was recovered. It is intact with the short threaded section of leg still inside. The front medial leg has broken off right at the deflector shell. The front lateral leg is also missing but the outer 10-20mm of the leg mounting section has also been broken away to
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the point where the front lateral mounting bolt is no longer effectively holding anything. Both front mounting bolts show signs of having been stretched and bent. The front leg mounting section shows a 15mm crack at the front medial bolt and a crack at the rear mounting bolt which runs from the bolt hole diagonally toward the lateral side. Total length of this crack is in the order of 60mm. The leading edge of the front leg mounting section, right between the legs has been torn and rolled back by 10mm and 20mm on the bottom and top faces respectively. The medial side of the deflector shell shows a 30mm long crack from its upper edge straight downward near the front edge of the binding systems mounting plate. This crack also exhibits some delamination of the shell. Right at the turn of the toe, 110mm ahead of the first crack is a small, 8mm long crack in the outer layer of the shell. It is at this point that delamination of the front of the shell becomes pronounced. Cracks and delamination along the front edge are obvious to about 30mm on the lateral side of the centre line. Serious erosion and perhaps impact damage combine with a complete delamination of the shell structure on the shell centre line just ahead of the front leg mounting panel. It appears that at least the front 70mm of the shell has been compromised by delamination. Several locations on the sides and bottom of the shell show abrasion or surface scratches. The complete binding system appears intact and undamaged as does the hinge plate, although the stretched mounting bolts described above may have expanded their holes through the hinge plate. The top plate also appears undamaged except that it has been permanently deflected upward. This deflection is obvious from the front edge of the binding system base plate forward, and amounts to perhaps 5mm total deflection right at the toe.
146
Shot ID
M99263A
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
Spider boot
Explosive
PMA-2
Description of Boot Damage: Boot apparently undamaged. Spider boot rear legs destroyed, front leg mount Summary: cracked. Abrasion/erosion and cracking damage to bottom face of Spider boot body. Detailed Description: Boot: The boot showed no signs of damage whatsoever. Overboot: The Spider boot in this trial has the mine under the rear medial pod. Both rear pods and legs have been blown off; one pad and a few leg fragments were recovered. The front leg mounting panel shows a spiral crack around the front lateral mounting bolt. The crack runs from just behind the bolt, around the outside of the bolt and out to the centre line just short of the moulding line between the upper and lower surfaces. The total visible length of the crack is about 90mm. A very small amount of erosion damage is seen on the rear, lower edge of the front mounting plate. No other damage can be seen on any of the front part of the Spider boot or its binding system. Both rear legs have been broken off right where the legs curve into the mounting panel, and both show tears into the mounting plate and tails of material torn from the legs. On the lateral side the tears have completely exposed the mounting bolt, and one tear running
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close to the moulding line runs to a point about 25m beyond the bolt. The medial side shows a Y shaped crack on the bottom surface, in which the arms of the Y begin to circle mounting bolt cavity and the stem point along the line of the leg. The stem of the Y is 20mm long while the arms are 10mm and 20mm long. There is also a 15mm long crack in the lower surface of the mounting panel right at the front bolt. In addition to this damage, the rear leg mounting panel had been twisted sideways, possibly enlarging the bolt holes. There is an edge crack in the surface of the deflector shell near the rear of the binding system base on the lateral side. This is accompanied by some local delamination. There are no obvious edge cracks on the medial side but there are numerous small surface cracks where the bottom of the shell rolls into the depression for the leg mounting panel. Tapping these cracks reveals that at least the outer layer has suffered delamination. The 150mm around the extreme rear edge of the deflector shell shows severe delamination. This continues along the bottom surface of the shell to at least the leg mounting panel and possibly further. Clearly at least the rear 70mm of the shell have been compromised by delamination, with another 90mm along the lower medial side being highly suspect. There is a separation of almost 5mm between the top plate and the deflector shell right at the rear. It appears to be partly due to an upward deflection of the top plate and partly to a downward deflection of the deflector shell.
148
Shot ID
M99263B
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-3
Description of Boot Damage: Boot outer sole intact and partially peeled from upper. Boot upper intact. Summary: Overboot outer sole heel destroyed. Overboot upper torn in heel and side areas. Detailed Description: Boot: The outside of the boot shows no visible damage whatsoever except for a slight upward arch under the heel and a separation of the upper from the outer sole. The separation begins just on the lateral side of the boot centre line and extends 105mm around the medial side. On disassembly of the boot the blast deflector plate is seen to have bent upward by about 10mm, with the attenuator having been partially crushed. The upper side of the foam insole shows minor scuffs and two small cracks (10mm and 20mm long) in the heel area. Overboot: The outer sole of the overboot has had the heel cap and part of the midfoot area destroyed. The blast deflector has been removed from the sole and has been flattened, pinched, and deflected upward by about 15mm. The pinched area has been folded over and shows a 45mm long split along the crease. The back half of the attenuator shows typical crushing while the front half is virtually untouched. It remains attached to the
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attenuator plate that is firmly attached to the Kevlar insole, although the plate and attenuator have been bent down right at the back end. The entire upper appears to have maintained its connection all the way around the Kevlar insole. This intact combination has separated from the outer sole at about the mid point in the toe treads on the medial side and near the start of the toe treads on the lateral side. The medial side panel is missing both ventilation inserts and the bottom 30mm of backstrap seam stitching has been broken. On the medial side, about 50mm of backstrap seam stitching has been broken, and the rear buckle has been broken. The outer covering fabric on this side panel shows vertical tears measuring 20mm, 25mm, 20mm, 30mm, and 50mm long. These occur at 40mm, 60mm, 90mm, 135mm, and180mm (respectively) from the back edge of the panel. The Kevlar insole shows a 50mm long tear in its covering cloth at the heel but shows no other visible signs of damage.
150
Shot ID
M99263C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Description of Boot Damage: Boot outer sole and upper intact. Boot inner sole torn. Overboot outer sole Summary: heel destroyed. Overboot upper torn and badly damaged in heel area. Detailed Description: Boot: This was an old, well worn combat boot. The outer sole shows no obvious signs of any kind of damage. Except for a few small tears, the upper appears undamaged. One 30mm tear runs horizontally through a line of stitching on the medial side quarter at the front corner of the quarter/vamp seam. A 20mm vertical tear occurs right at the leading edge of the counter on the medial side and has penetrated both the outer and inner layers. On the lateral side the only apparent damage to the upper is a cut through the outer layer of the lower eyelet flap. This cut runs through all four lower eyelets but has not penetrated the second layer. In all probability this damage was done by a sharp object such as an exposed staple from the overboot. Inside the boot, the shank has come completely free from the sole. It shows considerable surface rust, which is also apparent under the leather insole. The leather insole has broken from side to side at the front of the shank and is in pieces from there back.
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Overboot: The heel of the overboot outer sole has been destroyed leaving a tear along the sole centre line as far forward as the toe treads.. The blast deflector has been removed from the sole and has been pinched, flattened, bent upward by about 20mm, and split along the crease (about 40mm long) in the area of maximum deformation. The rear 40mm of the attenuator is missing. The next 60mm has been crushed but remains in the sole with the attenuator plate. The upper, Kevlar insole, and outer sole are attached from the leading edge of the attenuator plate forward but have separated back of that point. The Kevlar insole has been warped upward slightly and shows a slight unevenness in its upper heel surface. The covering fabric in this are has been torn. The toe cap is intact and undamaged. The lateral side panel has separated cleanly at the backstrap seam and at the rear 120mm of the sole. The rear 100mm of the outer covering fabric has been torn off leaving a short horizontal tear in the fabric right at the rear buckle. The rear buckle has been broken and its attachment loop has been partially torn free. The back 180mm of facing has pulled off the upper edge of the panel but remains connected through the backstrap loop to the medial side panel. On the medial side, the panel has partially separated from the backstrap but both the panel and the backstrap remain firmly attached to the underside of the Kevlar insole. About half of the facing stitching on the back 70mm of the panel has been broken but the facing remains well attached to the panel. A 25mm wide vertical strip of the outer covering fabric remains attached to the medial side panel right at the backstrap. Forward of that an 80mm wide strip running from top to bottom has been torn and is only held on by a small tag of fabric. Both ventilation inserts are missing.
152
Shot ID
M99263D
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
None
Explosive
PMA-2
Description of Boot Damage: Boot completely destroyed. Boot upper shredded and completely separated Summary: from sole. Detailed Description: Boot: This boot was completely destroyed. The outer sole had the heel cap demolished and
there are three major tears radiating forward through the instep areas. Two very small gouges have been taken out of the toe tread but the outer sole in the toe tread area looks relatively undamaged. The blast deflector, attenuator and attenuator plate have all been separated from the sole, and the only portion of the upper left attached is the vamp above the toe treads. The Kevlar insert is almost completely intact and is attached to the sole but only in the first 20-30mm of the toe section. The Kevlar insole shows a few pinholes from nails or staples but no sharp edges are obvious. The rear half of the foam insole has been destroyed, leaving the toe section and a torn and ragged instep section. Most of the attenuator has been lost. The small portion left attached to the front of the attenuator plate has been crushed almost completely flat. The attenuator plate has been cupped and bent upward. The blast deflector has been pinched, flattened and bent upward by about 25mm. In the area of maximum deformation, right at the crease, there is a 35mm tear in the metal.
153
Shot ID
M99263E
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-2
Description of Boot Damage: Boot sole heel completely destroyed. Heavy damage to boot upper in heel Summary: area. Boot and overboot thrown several metres away. Overboot blow off boot. Overboot destroyed. Overboot upper torn free of sole. Overboot sole destroyed from midfoot back.
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Detailed Description: Boot: The outer sole of the boot is relatively intact compared to most other results. The heel pad split from the bootstrap forward along the sole centre line as far as the front of the heel cap. A split developed at this point which runs across the front of the counter. The lateral half of the heel is completely separated while the medial half remains attached but only by a small portion of the rubber. The rest of the sole appears to be intact. The blast deflector has been flattened and bent upward by about 15mm. The attenuator, crushed in the area of maximum deflect of the blast deflector, remains embedded in the sole along with the attenuator plate. The lateral side upper shows a 70mm long vertical tear right at the backstrap seam followed by a 25mm long tear 40mm later. Just short of the front lip of the counter a vertical tear starts and progresses up by 110mm. It diverges forward into the reinforced eyelet flap where it follows the line of stitching as far as the second-from-top eyelet. Two more tears occur at the lower edge of this side. The first occurs right near the lip of the counter and extends diagonally up and forward by 70mm. Finally, just before the vamp seam, a 25mm long vertical tear occurs. The upper does not reattach until about 50mm forward of this tear. A horizontal tear shows at the extreme forward end of the rear vamp. This creates a short rip into the tongue along a stitch line. On the medial side, the upper and sole are separated as far forward as the arch where the front and rear vamps meet. A 80mm vertical tear occurs right at the backstrap seam but stops just short of actually reaching the bottom edge of the material. About 80mm forward of this point a 40mm long horizontal tear occurs right where the upper rolls under the Kevlar insole. This transitions into a tear that follows a stitch line between the front and rear vamps. This tear diverges from the stitch line about 50mm before the end of the stitching. Another tear picks up about 10mm beyond where the previous one diverges and runs to the end of the material. This tear then changes direction and runs about 15mm into the tongue along more stitching. The lateral, rear corner of the foam insole is partially torn off, while several small tears appear as far forward as the start of the toe tread. Several nails or staples are showing on the upper surface of the Kevlar insole but none are sharp. The inside of the boot is also heavily contaminated with sand, suggesting that any open wound might well have been contaminated also. Overboot: The overboot heel has been demolished and tears run as far forward as the toe treads. The sole appears to have been bent upward in the toe treads area. This is particularly evident about 90mm back from the front of the sole. The Kevlar insole remains attached to the outer sole only near the front of the structure in the area of the toe cap. Aside from having been deformed upward, and having the 100mm of its covering fabric torn, it shows no obvious signs of damage. The attenuator plate remains attached to the Kevlar insole. It has been warped but is relatively flat compared with most other trials. The attenuator, which was separated from the sole, has been crushed for most of its length. The blast deflector plate, also separated from the sole, has been pinched, flattened and bent upward by about 15mm. The medial side panel has been completely separated from the sole except for a portion of its covering fabric. A strip 25mm to 40mm wide runs from the toe cap back as far as the
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outer sole extends and is firmly attached to the sole. This panel separated cleanly at the backstrap seam. A 490mm long piece of facing remains tucked under the front edge of the medial side panels covering fabric, but it otherwise hangs loose. The medial side panel is missing both ventilation inserts and the rear buckle. The front buckle has been damaged and contains part of the male portion of the buckle from the lateral side panel. In addition to the strip of covering cloth left with the sole, a piece of the outer covering fabric 75mm has been torn from the rear of the panel. The lateral side panel remains attached to the sole only at the front 80mm. Both buckles have been broken off, and the rear buckle attachment has had most of the stitching broken. A tear in the outer fabric runs from this location down to the edge of the fabric. Like the medial side, a piece of the covering fabric at the back of the panel has been torn off. In this case it is 95mm wide. The facing has peeled from the top edge of the panel for the rear-most 130mm. The toe cap is intact and undamaged.
156
Shot ID
M99264A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
VS-50
Description of Boot Damage: Boot outer sole intact. Boot upper torn. Boot inner sole torn. Overboot blown Summary: off boot. Overboot sole destroyed in heel area. Overboot upper torn partially free of sole. Detailed Description: Boot: This boot was reused from trial 99259B. The outer sole of the boot is intact and undamaged except that it has been permanently bent upward into a more exaggerated arch position. The upper shows a few tiny nicks in the arch area of the vamp (medial side), and two tears can be seen on the lateral side. A 60mm long tear follows the backstrap seam as far as the quarter seam, and a second 60mm long tear starts at the front of the counter and runs up just through the seam and into the quarter. Both tears fully penetrated the inner leather lining. No other damage can be seen on the outside of the boot. From the toe tread forward the inside of the boot appears undamaged. In the midfoot area the leather insole has been torn longitudinally. A piece in the middle, still attached to the forward part of the insole covers the steel shank but has separated from it. The pieces on either side of this are still attached to the sole. The leather insole is fractured into small pieces in the heel area but all remain glued down. Many staples or nails can be felt around
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the perimeter of the insole and one large staple is clearly visible right at the back of the heel. Peeling up the leather insole shows that the pressed paper layer is similarly fractured, and that the back of the shank has pulled free and stands about12mm higher than its proper position. Overboot: The outer sole heel of the overboot has been destroyed. The midfoot area has been torn along the centre line to the toe treads and off to the lateral side leaving the lateral midfoot section of the sole attached only to a fragment of the side panels covering fabric. The attenuator and attenuator plate remain attached to the sole but the deflector plate is missing. The attenuator has been crushed for most of its length in a shape that indicates that the deflector plate was pinched, flattened and bent upward by 20-25mm. Aside from a slight unevenness in the heel section, and the loss of the rear 200mm of the covering fabric, the Kevlar insole appears intact. The insole and side panels are attached to the sole for almost the full length of the toe treads. Both side panels separated cleanly at the backstrap seams. The backstrap is still attached by a few stitches at the bottom of the medial side panel, and the facing still runs through the backstrap loop, although at has been peeled off 140mm on the lateral side and 240mm on the medial side. The medial side panel retains a 25mm wide vertical strip of covering fabric right along its rear edge. A section of this fabric about 80mm wide is missing just ahead of this to a point where the outer sole starts/stops. Both ventilation inserts are missing and the rear buckle has been damaged. The covering fabric on the lateral side panel is almost the same except that the 80mm wide piece has not been ripped completely free. The rear buckle has been broken off and about half the stitching has been torn on the rear buckle attachment loop. The toe cap is intact and undamaged.
158
Shot ID
M99264B
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
VS-50
Description of Boot Damage: Boot outer sole and upper intact. Overboot blown off boot. Overboot outer Summary: sole heel badly damaged. Overboot inner sole torn. Overboot upper torn in heel area.
159
Detailed Description: Boot: The outside of the boot shows no visible damage whatsoever except for a slight upward arch under the heel and a very slight separation of the upper from the outer sole. This 35mm long area right at the back of the heel/counter does not appear to have breached the boot. Based on the disassembly of the boots from trials M99258A and M99263B, it is expected that the blast deflector plate will be bent upward and that the attenuator will be partially crushed. The only visible damage inside the boot is to the upper side of the Kevlar insole. A 30mm long cut or abrasion has worked through the upper layer or two of the hard Kevlar surface. There does not appear to be any bulging or deformation of the insole. The underside of the foam insole (on top of the Kevlar insole) shows a few scuffs on the upper surface and two small cracks in the heel area. One crack is only about 2mm long while the second measures10mm. Only the 10mm crack penetrates the full depth of the foam insole. Overboot: The overboot outer sole heel has been virtually destroyed. The bulk of the heel cap is missing, leaving only two loose strips of rubber along the centre line of the sole. Tears in the outer sole stop about 25mm short of the toe tread. The blast deflector is missing, while the attenuator and attenuator plate remain attached to the underside of the Kevlar insole. The rear half of the attenuator has been crushed showing that the deflector plate would have been flattened, pinched and bent upward by about 10-15mm. The front half of the attenuator has suffered only minor deformation. In addition to the normal, slight surface irregularities, the Kevlar insole shows only three short longitudinal tears in the covering fabric. These tears, measuring 15mm, 35mm and 40mm, do not reveal any damage to the Kevlar insert itself. The toe cap is intact and undamaged. The medial side panel has separated from the sole to about 45mm into the toe tread section but has remained well attached to the underside of the Kevlar insert. The outer covering has three short tears running vertically up from the bottom edge. Measuring 10mm, 15mm, and 25mm, the area respectively located 50mm, 70mm, and 100mm ahead of the backstrap seam. The side panel has separated cleanly from the backstrap. The rear ventilation insert is missing and the inside of the front insert has been damaged. The lateral side panel has also maintained contact with the Kevlar insole throughout but has separated from the outer sole to about 45mm into the toe tread section. The panel is still attached to the bottom and top of the backstrap but the stitching has been broken through the middle part of the backstrap seam. Six tears can be seen along the lower edge of the outer covering fabric. Their lengths are 25mm, 15mm, 35mm, 15mm, 30mm, and 25mm, and they occur (respectively) at 25mm, 35mm, 80mm, 120mm, 135mm, and 165mm from the back edge of the panel. The rear buckle has been broken.
160
Shot ID
M99264C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
None
Explosive
PMA-2
Description of Boot Damage: Boot completely destroyed. Summary: Detailed Description: Boot: This boot was reused from trial 99259C. The heel of the outer sole of the boot has been almost completely destroyed, although a small portion of the heel cap remains. One large tear runs from the heel cap through the midfoot area and leads off toward the medial edge of the sole. The outer sole appears intact and undamaged from the midfoot area forward. The front end of the steel shank remains embedded in the sole. Longitudinal tears in the leather insole run the full length of the shank. A strip of the leather insole remains above the shank but there is nothing left of the insole from the midfoot area back. The rear portion of the upper has been completely shredded and torn from the rest of the boot. On the lateral side a tear runs diagonally up and forward from the start of the toe tread to the forward corner of the quarter. The tear continues through the tongue where it was stitched to the vamp. On the medial side of the upper the tear runs back through the vamp to approximately the midfoot area, and then diagonally down to the forward end of the heel cap. The vamp has torn along the edge of the outer sole to the toes treads where
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the tear angles slightly upward and continues forward to end about 60mm short of the extreme forward end of the boot.
162
Shot ID
M99264D
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
C4-50
Description of Boot Damage: Boot outer sole intact. Boot inner sole torn. Boot upper torn. Overboot outer Summary: sole heel destroyed. Overboot upper torn and partially separated from sole. Detailed Description: Boot: This boot was reused from trial M99260B. The outer sole is intact throughout but has been bent upward. The leading edge of the heel cap is about 10mm off the ground, and the natural upsweep of the toe section of the boot has been flattened. While the outer sole is intact, the leather insole has been broken and torn from the heel forward about 140mm to the instep area. The steel shank has been torn free at the rear and now stands about 10-15mm above its previous position. The 2 pressed paper inserts from the heel cavity have separated and are loose. With the leather insole broken and torn there are numerous staples exposed around the perimeter of the counter From the instep area forward the boot upper appears undamaged. Similarly, around the back of the heel (the counter), the upper appears undamaged. On both sides, however, there is a vertical tear just ahead of the counter. The tear on the lateral side runs up about 110mm. The medial side tear runs up about 40mm to the quarter/vamp seam, back along
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the seam about 30mm and then up and back through the quarter about 110mm. On this side the vamp has torn away from the sole beginning just behind the front of the counter, and extending forward about 80mm. On the lateral side there is a 40mm area in about the same location where the vamp has separated from the sole. Overboot: The heel portion of the overboot sole has been completely destroyed, and there are 3 major tears running through the instep area almost to the start of the toe treads. One of these runs along the centre line while the other two head from the centre line (near the heel) toward the lateral and medial sides (near the toe treads). The rear-most toe tread on the medial side shows some erosion damage. The attenuator is mostly missing. Small fragments remain at the back, and bout 80mm at the front. The rear 40mm of this is completely crushed and deformed, while the front 40mm is only moderately damaged. The attenuator plate, while heavily deformed, dished and cupped upward, remains well attached to the Kevlar insole. The blast deflector has been pinched, crushed and bent upward by about 25mm along most of its length. The rear 220mm of the Kevlar insole has delaminated from the outer sole. The toe cap is intact and undamaged. The two side panels of the upper have separated cleanly at the backstrap seam. The backstrap, found separately, shows heat and erosion damage at its lower end but is otherwise intact. The rear buckle has been broken from the lateral side panel, and the facing has been pulled from all but the front 100mm of the panel. The outer covering fabric has 5 vertical tears beginning near the backstrap seam. The first, near the seam is about 40mm long. The second, 30mm ahead, is 20mm long. Another 20mm forward is a 70mm tear. The fourth tear, 10mm further along is only about 20mm long, while the last one, 20mm ahead and almost at the rear buckle, is about 40mm long. From this point forward there is an 80mm long horizontal tear. In this area the bottom portion of the fabric remains attached to the rubber outer sole, while the main body of the side panel has separated from the outer sole and the insole. The facing on the medial side panel has been partially peeled off. The front 240mm remains attached to the side panel, and another 160mm is hanging freely. Both ventilation inserts are missing. A small piece of the outer covering fabric has been torn off near where the rear buckle strap is attached. One major tear, about 70mm long, is evident about 80mm ahead of the backstrap seam. This side panel has separated from the outer sole and insole from the backstrap to where the front buckle strap attaches.
164
Shot ID
M99264E
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
C4-50
Description of Boot Damage: Boot outer sole intact. Boot inner sole torn. Boot upper torn. Overboot blown Summary: off boot. Overboot outer sole heel completely destroyed. Overboot upper torn and partially separated from sole.
165
Detailed Description: Boot: This boot was reused from trial M99260D. The outer sole of the boot appears to be intact and relatively undamaged. The sole has clearly been bent upward into an exaggerated arch, and the heel cap might have been dished upward slightly (about 12mm), although it is difficult to determine whether this is the way the bottom of the cap appeared prior to the trial. From the toe treads forward, the upper and the inner parts of the boot appear to be intact. The leather insole shows longitudinal tearing along the steel shank, which has been lifted at the rear and is only connected to the sole at its front end. The leather insole has been torn from side to side right at the rear end of the shank. The back part of the insole has been pushed backward by about 20mm and is riding up onto the counter. Along with the insole, the upper has separated from the outer sole from the backstrap seam to the front treads on the lateral side. The counter has torn vertically at the lateral backstrap seam and has come free from the sole. A 25mm long tear in the vamp along the lateral backstrap seam is followed by a 170mm long vertical tear through the vamp and quarter. This starts at the sole right at the front of the heel cap. On the medial side, the insole has lifted to the start of the toe tread, while the upper has separated from the sole from the middle of the heel cap forward by 100mm. Two tears start at the front edge of the heel cap. One runs 45mm diagonally forward while the other runs 135mm vertically straight through the vamp and quarter. Dozens of shallow, superficial cracks appear in the outermost surface of the vamp from the start of the toe tread back to the backstrap seam on both sides. These cracks do not penetrate the vamp with the exception of the diagonal tear on the medial side, which follows one of the cracks. These cracks tend to be vertical in the heel/counter area, and become more angled through the midfoot area until they are about 45 degrees diagonally forward. Overboot: The heel of the outer sole of the overboot has been destroyed. Several cracks radiate forward and out from the front of the heel cap at the centre line. All stop before they reach the toe treads. The toe treads show no visual signs of damage. The deflector plate has been pinched, flattened, bent upward by more than 30mm and split along the crease for 70mm at the point of maximum deformation. The rear part of the attenuator has been crushed completely flat and has been broken away from the overboot. Fragments that were recovered separately are only 1-2mm thick. The forward half of the attenuator remains in the overboot. The rear half is crushed to match the profile of the deformed deflector plate while the front portion is only mildly deformed. The attenuator plate remains firmly fixed to the Kevlar insole, and has been driven into the insole. The plate shows a cracked area about 45mm long and up to 30mm wide. The Kevlar insole is badly deformed and split at the point where the attenuator plate shows the most deformation and the worst cracking. The covering fabric on the rear 100mm of the Kevlar insole has been torn off. Forward of the midfoot area the Kevlar insole appears intact. The insole and the outer sole have separated except for about 100mm right at the front of the overboot. The medial side panel is still attached to the outer sole for all but the rear 30mm. From 15mm to 45mm of the fabric along the bottom edge of the medial side has been torn away, and the fabric shows a vertical tear that runs about half way up the side panel at the forward edge of the heel cap. The male portion of the rear buckle has been broken and
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both ventilation inserts are missing. Both side panels have separated cleanly at the backstrap seam. On the lateral side the rear buckle and its attachment loop are missing. The outer covering fabric has been torn in this area. Several small vertical tears occur in the outer fabric along the back 60mm. A single large vertical tear in the outer fabric starts at the front of the heel cap and runs up to within 25mm of the top of the side panel. The toe cap is intact and undamaged.
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Shot ID
M99265A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
None
Explosive
PMA-3
Description of Boot Damage: Boot completely destroyed. Summary: Detailed Description: Boot: Three quarters of the heel cap has been destroyed the remaining portion of the heel cap has a tear that runs into the midfoot area and then diverges sharply toward the lateral side. This tear follows the medial side of the steel shank and then diverges just before the front end of the shank. Anchored only at its front end, the shank has been pulled to the lateral side. The remains of the leather insole are torn along the lines of the shank. Starting in the midfoot area on the medial side, about 70mm before the toe treads, and extending around the toe to the start of the toe tread on the lateral side, the upper remains attached to the outer sole. As to the upper, both quarters, the tongue, and the backstrap are missing along with the entire counter area and everything up to the midfoot area. The vamp is torn approximately the same way on both sides, running diagonally forward from this point toward the bottom end of where the tongue attached. Finally, the cut that had been made in the
168
forward part of the vamp to allow the foot to be inserted has been torn open by another 30mm.
169
Shot ID
M99265B
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
None
Explosive
PMA-3
Description of Boot Damage: Boot completely destroyed in heel and rear portion of the leg. Boot upper and Summary: sole relatively intact from midfoot forward. Detailed Description: Boot: From the start of the toe tread forward the outer sole and upper appear intact. The only visible damage is the eyelets second from bottom on both sides have pulled out. The front of the leg portion of the upper survived on both sides of the boot, in a line running approximately from the leading edge of the heel cap upward. Aside from a few hanging shreds, none of the upper behind this line remained attached. The intact cuff and one large piece of the medial side of the upper were recovered. The heel section of the outer sole has been completely destroyed. No rubber fragments were recovered. The attenuator plate has been dished upward by about 10mm and is loose. The rear 90mm of the blast deflector has been pinched, flattened and bent upward
170
approximately 20mm. The attenuator in this rear section has been completely crushed by the blast deflector. Both the blast deflector and the attenuator remain attached to the rest of the sole. Two small fragments of the attenuator have been bent around the side of the blast plate and are protruding through a 40mm cut in the remains of the rubber sole. The foam insole in the forward part of the boot is undamaged as is the Kevlar insole. In the rear portion, the foam insole shows heat damage, and the edge has been torn away from about mid-arch, around the heel, to a point about 50mm forward of the back of the heel. The Kevlar insole is basically intact but for some fraying around the edges. There are numerous indications where the staples have been driven up through the Kevlar insole, but have then withdrawn. No staples were felt along the top of the insole but several were located on the underside.
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Annex C Detailed Medical Assessments

This Annex provides a detailed assessment of the injuries imparted to the Frangible Surrogate Leg specimen as a function of footwear and explosive type. The results were compiled from several sources, including the radiologist report from the local hospital, the post-test examination conducted by one or more medical surgeons, and the later examination of the 3D reconstruction from the CT imagery. The data is organised in chronological order, as indicated by the Shot ID serial. For each test, four pictures from the 3D bone rendition of the CT scan are presented followed by a written description of the results for this shot. A header table presents a summary of the key conditions for this particular test, including: Shot ID: the ID is composed of a letter followed by 5 numbers that are the last two digits of the year and the Julian day in which the test was performed, and another letter indicating the number of tests performed that same day, i.e., A for the first test of the day, B for the second test, etc.; Load Cell: indicates whether or not a force transducer (load cell) was used in the midtibia; Bone Type: During the first test series, all bones were of the hard type, which proved too strong for the calcaneus and talus bones, thereby affecting the medical scores; softer materials were used in the construction of these bones during a following test series; Boot Type: indicates the boot that was fitted on the specimen, including the standard Canadian Forces combat boot (first test series), the standard US Army combat boot (second test series) or the Wellco blast boot; Overboot: indicates the overshoe used, including the standard Wellco blast overshoe or the Med-Eng Systems Spider Boot; in some cases, no overboot was used; Explosive: states the actual land mine or surrogate explosive charge that was used for the test.
The sections that follow are: Pre-Test Notes: list the Shot ID and describes any special condition(s) for that particular test; Post-Test Damage Assessment: describes of gross situation immediately following the test, including the visual state of the footwear;
173
Post-Test Diagnostic Imaging: describes the assessment from medical examination of the x-rays and from the 3D reconstruction of the CT scan; Post-Test Clinical Examination Notes: provides the details obtained from the dissection of the specimen; Overall Assessment: gives a synopsis of the diagnostic from the dissection and damage inflicted to the specimen; Recommended Treatment of Injury: states whether or not an amputation would be recommended, the level of the amputation and gives an assessment of the likelihood of neurological or vascular damage to a real leg; Scores: lists the likely medical scores, including the MTS developed for the US Army LEAP program, the ICRC score, the AIS score and the NISSA score. For convenience, the definitions of the different scoring systems are repeated below.
MINE TRAUMA SCORE DEVELOPED FOR THE LEAP PROGRAM SCORE

0 1 1A 1B 2 2A 2B 3
INJURY
Minimal Closed Open contained Open contaminated Closed Open contained Open contaminated Open contaminated
SURGERY REQUIRED
No major surgery required
Surgery required and limb is salvageable
Surgery required; definite below knee amputation
Surgery required; could lead to either below or above knee amputation Surgery required; definite above knee amputation
4 NOTES:
Open contaminated
Closed injury: any injury to the lower extremity that does not violate the skin, thereby minimizing the risk of infection. Open contained injury: any injury to the lower extremity that violates the skin (lacerations, tears), but is not contaminated by the outside environment because the inner footwear was not compromised. Open contaminated injury: any injury to the lower extremity that does violate the skin and has contamination of the soft tissues and bones from the environment where the blast occurred.
174
ABBREVIATED INJURY SCORE AIS SCORE

0 1 2 3 4 5 6
INJURY LEVEL
No Injury Minor Moderate Serious Severe Critical Not Survivable
INTERNATIONAL COMMITTEE OF THE RED CROSS SCORE TYPE

Type ST Type F Type V Type VF
GRADE 1
Small simple wound 1F 1V 1 VF
GRADE 2
2 ST 2F 2V 2 VF
GRADE 3
3 ST 3F 3V Large wound(s) threatening life of limb
DATA SECTION
E = Entry wound diameter (cm) X = Exit wound diameter (cm) C = Cavity? C = 0, 1 Estimate diameter of entry hole Estimate maximum diameter of exit hole(X = 0 if no exit wound) Can the cavity of the wound take two fingers before surgery? No C = 0; Yes C = 1 No fracture F = 0Simple fracture, hole of insignificant comminution F= 1Clinically significant comminution F = 2 Are brain, viscera (breach of dura, plura or peritoneum) injured? No V = 0; Yes V = 1
F = Fracture? F = 0, 1, 2
V = Vital Structures? V = 0,1
Land mine blast injuries fall outside these classifications and are difficult to categorize: Grade 3, type F, below knee amputation = 3 F BK Grade 3, type F, above knee amputation = 3 F AK
175
NISSA SCORING SYSTEM SCORE

NERVE INJURY 0 1 2 3 ISCHEMIA 0 1* 2* 3* None Mild Moderate Severe Sensate Loss of dorsal Partial plantar Complete plantar
FACTOR
SCORE
SKELETAL INJURY 0 1 2 3 SHOCK / BLOOD PRESSURE 0 1 2 AGE (YEARS) 0 1 2
FACTOR
Low energy Medium energy High energy Very high energy
Normotensive Transient hypotension Persistent hypotension
SOFT TISSUE INJURY / CONTAMINATION 0 1 2 3 Low Medium High Severe
< 30 30 50 > 50
NOTES ABOUT APPLICATION OF NISSA SCORE TO CFSL PROGRAM: * Ischemia scores are to be doubled if duration of ischemia exceeds 6 hours. No corrections were made for a 6 hour delay in treatment. Age was uniformly assumed to be <30 years It was assumed that most casualties would have transient hypotension except those who had extremely severe injuries, which were weighted to the more severe score.
176
Table of Contents Annex C

SHOT ID
M99256A M99257A M99257B M99257C M99257D M99258A M99259A M99259B M99259C M99260A M99260B M99260C M99260D M99263A M99263B M99263C M99263D M99263E M99264A M99264B M99264C M99264D M99264E M99265A M99265B
LOAD CELL
No No No No No Yes Yes No No Yes No No No No Yes No No No Yes Yes No No No Yes Yes
BONE TYPE
Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard Hard
BOOT TYPE
Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Blast (Wellco) Blast (Wellco) Combat (CDN) Blast (Wellco) Combat (CDN) Combat (CDN) Combat (CDN) Combat (CDN) Blast (Wellco)
PROTECTION
Overboot Overboot Overboot Overboot Overboot Overboot Overboot Spider Boot Spider Boot Overboot Spider Boot Spider Boot Spider Boot Spider Boot Overboot Overboot None Overboot Overboot Overboot None Overboot Overboot None None
EXPLOSIVE
VS-50 PMA-3 PMA-2 PMA-2 PMA-2 PMA-3 PMA-3 PMA-3 PMA-2 PMA-3 PMA-3 PMA-2 PMA-2 PMA-2 PMA-3 PMA-3 PMA-2 PMA-2 VS-50 VS-50 PMA-2 C4-50 C4-50 PMA-3 PMA-3
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Shot ID
M99256A
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
VS-50
Pre Test Notes: M99256A Post Test Damage Assessment: Boot outer sole and upper intact. Boot inner sole torn and breached. Overboot heel destroyed. Overboot upper partially torn free of sole. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the lower extremity demonstrate no fracture of the femur, knee, or proximal tibia. There is a segmental comminuted fracture of the mid and distal third of the tibia with a severe comminuted pilon fracture, and subluxation of the tibia talar joint. There appears to be a subtalar dislocation of the talus and the calcaneus. b. CT Scanning: 3D CT reconstruction of the foot and ankle demonstrate a severely comminuted pilon fracture that involves the medial and posterior medial aspect, fracture through the body of the talus and disruption of the Choparts joint between the talar head and the navicular. The visualized femoral shaft, knee and proximal shafts of the tibia and fibula are intact.
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Comminuted fractures are present throughout the mid and distal portions of the tibia. These enter the distal tibia articular surface. The fracture fragments are in reasonable alignment and are separated by up to 1 cm, but most are separated by 5 mm or less. The fracture fragments vary in size with the smallest measuring 2 x 7 mm. There is an oblique fracture in the mid fibular shaft, but there is no significant displacement. There is a vertical, non-displaced fracture through the mid portion of the talus. Small, minimally displaced fractures are present at the lateral aspect of the medial cuneiform, the extreme distal aspect of the middle cuneiform and through the distal aspect of the lateral cuneiform. Non-displaced transverse fractures are present through the proximal shafts of the fourth and fifth metatarsals and through the distal shafts of the second and third metatarsals. No fractures are seen in the first metatarsal, nor the toes. The calcaneus is intact. Post Test Clinical Examination Notes: a. Forefoot: b. Hind Foot: There is disruption of Choparts joint, the talonavicular joint, and Lisfrancs joint. c. Ankle Joint / Plafont: d. Tibia / Fibula: At the junction of the mid/distal third there is a large highly comminuted multi fragmented fracture of the tibia that is open. High comminuted fracture of the pilon area involving the anterior medial and posterior medial aspects of the ankle joint. e. Knee Joint: f. Femur: No obvious lacerations or breaks in the skin. The knee appears to be stable g. Soft Tissue: On the plantar surface there is a large stellate laceration that extends to the forefoot with contamination. There is a 5040mm open area over the mid to distal third tibia. Subcutaneous stripping to proximal third of the tibia with multiple fissures of the ballistic gelatine to the same level. Removal of the outer covering reveals large laceration and fissuring of the ballistic gelatine over the distal 1/3, anterior and anterior medial portion. h. Contamination: Overall Assessment: Open commminuted distal third tibia fracture with highly comminuted pilon fracture, talar body fracture, disruption of Choparts and Lisfrancs joints. The tibia fracture is graded as a IIIB (Gustillo and Anderson) Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: c. Likelihood of neurologic / vascular injury: Distal 1/3 tibia injury with plantar trauma. Some neurovascular injury likely. Scores:
MTS
2B
ICRC
2VF
AIS
3
NISSA
9
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Shot ID
M99257A
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Pre Test Notes: M99257A Post Test Damage Assessment: Boot outer sole and upper intact. Boot inner sole torn. Overboot heel destroyed. Overboot upper partially torn free of sole. Overboot blown off boot. Post Test Diagnostic Imaging: a. X-ray: knee and proximal tibia show no fractures. Segmental tibia fracture with breaks in proximal, mid, distal third of tibia, fracture subluxation of ankle joint, severe pilon fracture, fracture through body of talus and joint depression, calcaneus fracture with disruption of Choparts joints. b. CT scanning: The femur, knee and proximal tibia are intact. There is a transverse fracture through the distal shaft of the tibia, which is not significantly displaced. Severely comminuted fracture is present through the distal tibia with disruption of the ankle joint. There is a vertical component anteriorly with anterior displacement of the fragments. There are several small fragments present around the mid and posterior aspect
180
of the main fragment of the tibia. The foot is displaced forward in relation to the tibia shaft. The talus is displaced laterally. This is associated with transverse fracture of the distal fibula with angulation of the distal fragment laterally. There is a small non-displaced fracture through the inferior lateral aspect of the calcaneus, which is very minimal. Cuboid bone appears intact. The talus and navicular bones appear intact. Through the cuneiform region there is a long vertical fracture extending from the anterior articular surface of the talus anteriorly with a smaller associated fracture extending laterally with no significant displacement. Non-displaced fracture through the proximal shaft of the fourth metatarsal. Post Test Clinical Examination Notes: a. Forefoot: no fractures of MT, disruption of Lisfrancs joint, Choparts joint b. Hind Foot: 8030mm stellate laceration over calcaneus, , lacerations over antero-lateral mid foot measuring 70mm. Lacerations over antero-lateral area of calcaneus measuring 90mm with open fracture of distal third tibia, ankle mortis, hind foot, mid foot, talus has coronal fracture line running from antero-lateral to posterior medial, no obvious fracture of calcaneus c. Ankle Joint / Plafont: unstable ankle fracture, mortise fractured, distal fibula comminuted, d. Tibia / Fibula: motion at mid/proximal tibia, e. Knee Joint: stable on exam f. Femur: no apparent fracture of soft tissue penetration, g. Soft Tissue: majority of tissue over calcaneus missing h. Contamination: mild contamination of ankle Overall Assessment: Open contaminated mangled lower extremity Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: Scores:
MTS
2B
ICRC
3FBK
AIS
3
NISSA
11
181
Shot ID
M99257B
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-2
Pre Test Notes: M99257B Post Test Damage Assessment: Boot outer sole intact. Boot upper torn. Boot inner sole torn and breached. Overboot heel destroyed. Overboot upper torn free of sole. Overboot blown off boot. Boot found several metres away with foot fragments inside. Post Test Diagnostic Imaging: a. X-ray: No fracture of the proximal femur, shaft or distal femur, distal 1/3 of tibia, all of foot and ankle is completely missing, comminuted fracture of mid fibula b. CT Scanning: The femur and knee are intact. There are fractures through the mid shaft of the tibia which are Non-displaced. Fractures are present through proximal and mid tibia, also Non-displaced. Fracture is present through the distal tibia and the fragment along with the ankle and entire foot are missing. There are several fractures through the distal fibula. There are several bony fragments displaced proximally into the soft tissues of the proximal and mid thigh.
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Post Test Clinical Examination Notes: a. Forefoot: mid foot except for med cuneiform is missing, disruption of Lisfrancs joint, fractures M 2-4, head of M1 b. Hind Foot: missing c. Ankle Joint / Plafont: medial maleolus anterior, lateral, posterior aspect pilon intact but most of distal 1/3 tibia missing d. Tibia / Fibula: crepitus proximal third of tibia, skin compromised at distal 1/3, mod contamination of sand up mid tibia, fissure medial aspect proximal 1/3 tibia e. Knee Joint: no evidence soft tissue damage, intact ACL, PCL, medial collateral ligaments f. Femur: no breaks in skin g. Soft Tissue: h. Contamination: Overall Assessment: Open highly contaminated below knee amputation with evidence of soft tissue stripping to distal 1/3 of tibia, contamination of mid tibia proximal tibia fracture Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: AKA c. Likelihood of neurologic / vascular injury: non-viable foot Scores:
MTS
2B
ICRC
3FBK
AIS
4
NISSA
13
183
Shot ID
M99257C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-2
Pre Test Notes: M99257C Post Test Damage Assessment: Boot outer sole intact. Boot upper torn. Boot inner sole torn. Overboot heel destroyed. Overboot upper torn free of sole. Overboot blown off boot. Boot found several metres away with partial foot inside. Post Test Diagnostic Imaging: a. X-ray: Fracture of distal 1/3 femur. A segmental tibia fracture art the proximal 1/3 resulting in a floating knee. There is an obvious amputation of the distal 1/3 of the tibia with large soft tissue damage that is highly contaminated. The distal 1/3 of the tibia has a segmental shaft fracture and missing the hind foot to include the calcaneus, talus, which have been completely extruded. In the amputated forefoot, there is disruption of the Lisfrancs joint with fracture of the base of the first through fifth of the metatarsal heads. b. CT Scanning: Non-displaced transverse fracture is present through the distal shaft of the femur. Comminuted non-displaced fracture is present through the proximal shaft of the
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tibia. There are non-displaced fractures through the proximal and mid shaft of the fibula. Severe injury has occurred at the distal end of the tibia and fibula involving both bone and soft tissue. The soft tissue is basically fractured through the fracture lines involving distal tibia and fibula with bony fragments present distally. The foot has been blown off and there are multiple bony fragments from the ankle and foot lying over the posterior mid calf and distal thigh. Post Test Clinical Examination Notes: a. Forefoot: amputated, disruption of Lisfrancs joint and fracture of basses of all metatarsals b. Hind Foot: missing calcaneus and tibia completely extruded c. Ankle Joint / Plafont: d. Tibia / Fibula: The distal 1/3 of the leg, and hind foot is missing. e. Knee Joint: large 180mm long break in gelatine on posterior aspect of knee and popliteal fossa f. Femur: femur is fractured in distal 1/3 causing a floating knee injury g. Soft Tissue: h. Contamination: Overall Assessment: Severe highly comminuted traumatic below knee amputation with soft tissue stripping to proximal 1/3 of tibia. Floating knee secondary to closed distal femur fracture and laceration of popliteal area would compromise neurovacular structures. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: AKA c. Likelihood of neurologic / vascular injury: popliteal wound could cause vascular disruption of leg Scores:
MTS
3
ICRC
3FBK
AIS
4
NISSA
13-14
185
Shot ID
M99257D
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-2
Pre Test Notes: M99257D Post Test Damage Assessment: Boot outer sole heel split and damaged. Boot upper torn. Overboot heel completely destroyed. Overboot upper torn free of sole. Overboot blown off boot. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the femur reveal no obvious fracture. There is a questionable fracture on the medial femoral condyl. No obvious fracture of the tibia plateau. There is a comminution of the distal part tibia/pilon area, which is vastly comminuted. There is a segmental fibula fracture and the distal third of the fibula is missing. There is a fracture with missing pieces of the calcaneus; talus is fractured with a plantar dislocation. Disruption of Choparts joint, and Lisfrancs joint with fracture of the cuboid, and cuneiforms. There is a fracture at the neck of the great metatarsal and possible the second.
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CT Scanning: The femur is intact. Fracture is present through the mid tibia with an approximately 80mm length of bone missing. There is a distal tibia fragment remaining measuring about 120mm. Fracture through the proximal shaft of the fibula with a 40mm segment of bone missing. Fracture mid shaft of the fibula with a gap of about 20mm. The distal end of the fibula has been fractured into multiple fragments. The ankle joint has been completely disrupted with destruction of the articular surface of the distal tibia, and fibula as well destruction of the talus and calcaneus with multiple bony fragments present. The talonavicular and calcaneocuboid articulations are disrupted and there are multiple fractures through the proximal foot with multiple bony fragments present. Nondisplaced fractures are present through some of the metatarsals. Post Test Clinical Examination Notes: a. Forefoot: Open fracture over Lisfrancs joint with fractures of the cuboid, and all cuneiform bones. The stellate skin lesion extends to the base of the fifth metatarsal. There is a comminuted fracture of the fifth MT and fractures through the heads of all the metatarsals and second through fourth metatarsal shafts. b. Hind Foot: Tissue is missing from the medial aspect of the hind foot, the majority of the calcaneus is missing except for the medial wall. The talus has a talar body fracture dislocation (the remainder of the talus body is missing). c. Ankle Joint / Plafont: Open stellate laceration over the plantar and medial surface of the calcaneus d. Tibia / Fibula: There is crepitus in the proximal third of the tibia, obvious deformity of the mid and distal tibia. There is an open segmental fracture of the tibia with a severe open comminuted pilon fracture. e. Knee Joint: There is disruption of the anterior/posterior cruciate ligaments, medical collateral ligament. f. Femur: No obvious fracture or lacerations g. Soft Tissue: 110mm stellate laceration of popliteal fossa seen after removal of the skin. h. Contamination: Overall Assessment: Open highly contaminated distal 1/3 traumatic amputation with soft tissue stripping to the mid of the tibia, and with a knee dislocation. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: High below knee or above knee depending on vascular injury to popliteal fossa. c. Likelihood of neurologic / vascular injury: high with knee dislocation. Scores: b.
MTS
3
ICRC
3FBK
AIS
4
NISSA
13-14
187
Shot ID
M99258A
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-3
Pre Test Notes: M99258A Post Test Damage Assessment: Boot outer sole intact and partially peeled from upper. Boot upper intact. Overboot outer sole destroyed. Overboot upper intact. Post Test Diagnostic Imaging: a. X-ray: Femur no obvious fractures. Possible medial plateau fracture, Fracture of the proximal and distal pot of the tibia. There is a highly comminuted fracture of the distal third of the tibia and pilon area. The fracture is distal to the load cell pot and is transverse in nature followed by a highly comminuted distal third tibia, and pilon fracture. There is a fracture of the talar body and disruption of the talonavicular joint (Choparts joint). No obvious fractures of the calcaneus. b. CT Scanning: The femur is intact. Slightly comminuted fracture is present through the proximal tibia with no significant displacement. Transverse fracture is present through mid shaft with displacement of fragments anteriorly by almost the full width of the shaft
188
and slightly posteriorly. The tibia below this is fractured into multiple fragments with a vertical component. The inferior and posterior aspect of the tibia, involving the articular surface is displaced and rotated posteriorly in relation to the shaft and overlies the talus. Fractures are also present in the posterior aspect of the foot. The calcaneus is largely intact, although in its upper portion there is a linear fracture along its medial aspect. The talus is fractured into multiple fragments and there is widening of the talonavicular joint. There are several small non-displaced fractures in the proximal metatarsals. Post Test Clinical Examination Notes: a. Forefoot: There is a fracture at the base of the fifth metatarsal with the open laceration approximately 40mm with a stellate extension of 50mm. Fractures of 2 through 5 metatarsal necks. There is a 50mm plantar laceration in the ballistic gelatine over the head of the great toe metatarsal. b. Hind Foot: A fracture of the medial sustentaculum tali of the calcaneus, and there is a coronal split in the body of the talus that remains attached to the sustentaculum tali. The body and tuberosity of the calcaneus remain intact which normally would have been crushed c. Ankle Joint / Plafont: Examination of the ankle there is a highly comminuted pilon fracture with four major fragments. d. Tibia / Fibula: Palpation of the proximal tibia reveals crepitus and deformity. The distal third of the tibia reveals crepitus and instability of the foot and ankle. Removal of the outer tissue reveals a tibia fracture proximal to the load cell and lacerations in the ballistic gelatine over the distal third. There is a highly comminuted segmental tibia fracture at 40mm distal to the distal pot. There is fracture at the distal fibula e. Knee Joint: f. Femur: The thigh and knee reveal no obvious lacerations or instability of the knee. g. Soft Tissue: h. Contamination: Overall Assessment: Closed segment tibia fracture, highly comminuted distal third tibia fracture with a severely comminuted distal third tibia fracture with a severely comminuted pilon with fractures of the talus and calcaneus Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: Scores:
MTS
2A
ICRC
3F
AIS
3
NISSA
7
189
Shot ID
M99259A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Pre Test Notes: M99259A Post Test Damage Assessment: Boot outer sole and upper intact. Boot inner sole torn. Overboot outer sole destroyed. Overboot inner sole torn and breached. Overboot upper torn in heel area. Post Test Diagnostic Imaging: a. X-ray: No obvious fractures of femur or knee. There is a fracture of the tibia at the proximal and distal load cell pots, transverse in nature most likely due to stress risers. On the lateral there is a comminuted pilon fracture that extends to the distal third of the tibia. A minimally displaced navicular fracture and no other obvious fractures from plain radiographs of the hind foot or fore foot. b. CT Scanning: The patient had a force transducer that had been inserted in the mid tibia. This acted as a stress riser as there are transverse fractures of the tibia and fibula at its proximal and distal cuffs. On the initial plain films the distal leg and foot were
190
angled medially 65 degrees and displaced laterally 4 cm, but this angulation was corrected for the CT scan. Unrelated to the force transducer, there is a vertical, intra-articular fracture of the distal tibia shaft. The distal fracture fragment is displaced anteriorly 3 mm, but is not displaced in the coronal or axial planes. A non-displaced, longitudinal, linear fracture is present in the lateral aspect of the navicular. A non-displaced fracture is present in the upper medial aspect of the calcaneus. Non-displaced transverse fractures are present in the proximal and distal shafts of the fifth metatarsal. No fractures are present in the proximal tibia or fibula, nor the distal femoral shaft. Post Test Clinical Examination Notes: a. Forefoot: A vertical split between the middle and lateral cuneiform and disruption of Lisfrancss joint, from the first metatarsal across to the fifth metatarsal. There are nondisplaced fractures of the neck at the second through fifth metatarsals. b. Hind Foot: There is an open stellate laceration over the plantar aspect of the calcaneus and mid foot. There is a traumatic laceration of the mid foot dorsal aspect measuring 140mm in length and a complex fracture of the mid foot to include disruption of the Choparts joint. c. Ankle Joint / Plafont: d. Tibia / Fibula: There are surgical incisions over the distal 1/3 of the tibia where the load cells were removed. Fracture of the proximal tibia at the proximal load cell and again a fracture of the distal third of the tibia at the load cell epoxy interface. Fracture of the fibula 120mm from the tip. There is a pilon fracture consisting of the anterior medical portion of the pilon area. The distal tibia fracture is 90mm from the joint. e. Knee Joint: No instability of the knee. f. Femur: No obvious lacerations of the proximal femur / thigh. g. Soft Tissue: h. Contamination: Overall Assessment: Open minimally contaminated with pilon fractures of the tibia, complex mid foot fractures with pilon fracture Recommended Treatment of Injury: a. Amputation: Yes No X b. Level: c. Likelihood of neurologic / vascular injury: possible Scores:
MTS
1B
ICRC
2VF
AIS
2
NISSA
7
191
Shot ID
M99259B
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider Boot
Explosive
PMA-3
Pre Test Notes: M99259B; The mine was located under a rear pod. Post Test Damage Assessment: Boot apparently undamaged. Spider Boot rear legs destroyed. Abrasion/erosion damage to bottom face of Spider Boot body. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the femur, knee, proximal, middle, distal tibia, foot, ankle reveal no fractures b. CT Scanning: On this exam, no fractures are seen to involve the thigh, tibia, fibula, or skeletal structures of the foot. Post Test Clinical Examination Notes: a. Forefoot: b. Hind Foot: c. Ankle Joint / Plafont: Surgical examination of the ankle reveals no obvious fractures or dislocations. The solid ankle has movement but no obvious fractures. There is
192
circumferential laceration in the deltoid ligament at the level of the ankle mortise. There is a soft tissue contusion and a laceration of the posterior aspect of the ankle at the insertion of the achilles tendon on the tuberosity of the calcaneus. d. Tibia / Fibula: e. Knee Joint: There is compromise of the medial aspect with some contamination; also lacerations along the posterior aspect of the medial thigh. Close examination of the medial aspect of the patella reveals no obvious intra-articular penetration of the knee joint. f. Femur: g. Soft Tissue: There is evidence of penetration of the outer garment over the proximal femur and gluteus maximus area, and of the inner aspect of the thigh midway along the area of the adductor magnus and medial capsule of the knee. There is no obvious break in the garment over the calcaneus. There is passive motion at the ankle joint (plantar and dorsal flexion h. Contamination: Overall Assessment: Closed ankle / soft tissue contusion possible severe ankle sprain. No obvious fractures with secondary lacerations of the medial knee and inner thigh. Recommended Treatment of Injury: a. Amputation: Yes No X b. Level: c. Likelihood of neurologic / vascular injury: Scores:
MTS
0
ICRC
1ST
AIS
1
NISSA
0
193
Shot ID
M99259C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider Boot
Explosive
PMA-2
Pre Test Notes: M99259C; The mine was located under a rear pod. Post Test Damage Assessment: Boot apparently undamaged. Spider Boot rear legs destroyed. Abrasion/erosion damage to bottom face of Spider Boot body. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the femur, knee, and proximal tibia show no obvious fractures. There is a mid shaft tibia fracture (and fibula 20mm proximal). There are no other obvious fractures in the ankle. b. CT Scanning: In the mid shafts of the tibia and fibula there are single transverse fractures. The distal fracture fragments are angled slightly, but are not significantly displaced. No other tibia or fibular fractures. There is a vertical, non-displaced fracture in the talus. This begins in the upper mid portion and extends obliquely downward and posteriorly through the talus. No other fractures are seen in the ankle or foot. No femoral shaft fractures are present.
194
Post Test Clinical Examination Notes: a. Forefoot: b. Hind Foot: No obvious break in the stocking over the plantar calcaneal area. There is some contamination present. c. Ankle Joint / Plafont: There is a fissure over the anterior aspect of the ankle, which measures 90mm in length. d. Tibia / Fibula: There is motion and crepitus at the mid portion of the tibia. After removal of the outer covering there is a fissure in the ballistic gelatine 40mm over the antermedial aspect of the tibia. Exposure of the tibia fracture reveals a transverse fracture at the mid diaphysis. e. Knee Joint: f. Femur: g. Soft Tissue: There is no break in the soft tissue of the proximal thigh around the knee. h. Contamination: Overall Assessment: Closed mid shaft tibia fracture Recommended Treatment of Injury: a. Amputation: Yes No X b. Level: c. Likelihood of neurologic / vascular injury: Scores:
MTS
1
ICRC
1F
AIS
2
NISSA
1
195
Shot ID
M99260A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Pre Test Notes: M99260A Post Test Damage Assessment: Boot outer sole and upper intact. Boot inner sole torn and breached. Overboot outer sole heel destroyed. Overboot inner sole torn and breached. Overboot upper torn in heel area. Post Test Diagnostic Imaging: a. X-ray: There is a fracture of the proximal tibia at the junction of the load cell. A fracture at the distal third of the tibia 35mm below the distal aspect of the load cell. There is a fracture of the pilon area involving the anterior surface with impaction. There is a highly comminuted of the talus, a subtalar dislocation, fracture dislocation of Choparts joint, with dorsal dislocation of the navicular and disruption of Lisfrancs joint. AP radiographs of the ankle demonstrate the pilon fracture is comminuted and extends to the distal third of the tibia. There is a segmental fracture of the fibula and a coronal split in the talus, with a small avulsion fracture of the distal fibula.
196
b. CT Scanning: The specimen had a force transducer in the mid tibia shaft that acted as a stress riser to cause transverse fractures through the proximal tibia and fibula at the upper cuff. There are also comminuted fractures of the mid tibia and fibula 40mm below the lower cuff. The tibia fracture fragment is displaced laterally 20mm and the distal leg is angled anteriorly 40 degrees and medially 25 degrees. There is a non-displaced fracture of the distal fibula just above the lateral malleolus. A sliver-like fracture is present off the medial malleolus. The talus is highly comminuted and with various other fragments that are separated by up to 8mm. The navicular and distal portions of the foot are dislocated dorsally. The navicular is most severely dislocated with a minimally displaced fracture off its anterior superior aspect. There is an oblique, non-displaced fracture through the lateral aspect of the cuneiform and non-displaced fractures in the bases and proximal shafts of the 1st-4th metatarsals; these fractures enter the proximal articular surfaces, but are not significantly displaced nor are there step deformities at the articular surfaces. The cuboid and calcaneus are intact. No femoral fractures. Post Test Clinical Examination Notes: a. Forefoot: Mid-shaft fractures of the 4th and 5th; metatarsal neck fractures of the 2nd and rd 3 . Fractures of the base of metatarsal 3 through 5. b. Hind Foot: There is a large stellate laceration over the plantar surface of the calcaneus that is 5080mm that extends to the mid/lateral portion of the plantar surface. The talus is highly comminuted through the body. The calcaneus remains intact, except for a small fracture off the medial sustentaculum tali. There is a subtalar dislocation and extrusion of the calcaneus from the soft tissue. Segmental fibula fracture, disruption of Choparts joint, and Lisfrancs joint. c. Ankle Joint / Plafont: d. Tibia / Fibula: Gross motion and crepitus in the distal third of the tibia and the ankle joint. Circumferential laceration of the gelatine due to removal of the load cell and proximal pot fracture at the epoxy bone interface. Transverse fracture 40mm above the distal pot with moderate comminution on the anterior lateral aspect. Dissection of the distal third of the tibia reveals there is a fracture of the medial malleolus, posterior malleolus, anterior and lateral portions of the plafond are also fractured. e. Knee Joint: The knee appears to be stable. f. Femur: g. Soft Tissue: There is no obvious laceration of the outer covering or breaks in the thigh. h. Contamination: Overall Assessment: Open contaminated, highly comminuted, distal third tibia with pilon fracture dislocation, and fracture dislocation of the midfoot. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: Scores:
MTS
2B
ICRC
3FBK
AIS
3
NISSA
9
197
Shot ID
M99260B
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider Boot
Explosive
PMA-3
Pre Test Notes: M99260B; The mine was located under a front pod. Post Test Damage Assessment: Boot apparently undamaged. One Spider Boot front leg destroyed, one severely damaged. Abrasion/erosion damage to bottom face of the deflector shell. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the femur, knee, and proximal tibia demonstrate no fractures. There is a minimally displaced minimally angulated mid shaft tibia fracture demonstrated on the AP. On the AP radiographs of the ankle, there appears to be a lateral tilt of the talus and an increase in the talocrural angle. Lateral radiograph demonstrates a transverse fracture of the mid shaft of the tibia. No obvious fractures of the talus, calcaneus, hind foot, mid foot, or fore foot. b. CT Scanning: An oblique fracture is present in the mid shaft of the tibia. There is only minimal lateral angulation of the distal tibia shaft. No accompanying fibular fractures are
198
seen. No other fractures are seen in the lower leg. No fractures are seen in the femur, ankle or foot. Post Test Clinical Examination Notes: a. Forefoot: Removal of the of the outer garment reveals there are fractures of the neck of the 2nd through the 4th metatarsals b. Hind Foot: c. Ankle Joint / Plafont: d. Tibia / Fibula: There is motion at the mid shaft of the tibia, and there is no apparent break in the gelatine. . The mid shaft tibia fracture is closed. Surgical dissection demonstrates a mildly comminuted mid shaft tibia fracture. e. Knee Joint: The knee appears to be stable. f. Femur: Examination of the thigh and knee reveals no obvious lacerations. g. Soft Tissue: h. Contamination: Overall Assessment: Recommended Treatment of Injury: a. Amputation: Yes No X b. Level: c. Likelihood of neurologic / vascular injury: no Scores:
MTS
1
ICRC
1F
AIS
2
NISSA
1
199
Shot ID
M99260C
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
Spider Boot
Explosive
PMA-2
Pre Test Notes: M99260C; The mine was located under a front pod. Post Test Damage Assessment: Boot apparently undamaged. Spider Boot front legs destroyed. Abrasion/erosion damage and delamination of bottom face of Spider Boot body. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the femur, knee, and proximal tibia demonstrate no fractures. In the tibia shaft there is a segmental comminuted fracture at the proximal to mid 1/3 and distal 1/3. There appears to be an injury to the anterior surface of the pilon, with fractures of the multiple metatarsal shaft and neck. On the plain films of the foot and ankle, there is slight medial tilting of the talus. This suggests that ligamentous damage of the ankle could also occur with this injury. No femoral fractures. b. CT Scanning: Plain films of the femur, tibia, fibula and foot plus contiguous, axial CT images from the mid thigh through the foot.
200
An oblique, slightly comminuted fracture is present at the junction of the proximal and mid thirds of the tibia shaft. The fracture extends over a distance of 45mm. The fracture fragments are not significantly displaced. A non-displaced tibia fracture is present in the mid shaft. This involves mainly the posteromedial aspect of the cortex. At the distal shafts of the tibia and fibula there are transverse fractures. The tibia fracture is slightly comminuted. The fracture fragments are not significantly displaced nor angulated. A non-displaced fracture is present at the base of the second metatarsal and there are nondisplaced fractures in the distal shafts of the second fifth metacarpals. Post Test Clinical Examination Notes: a. Forefoot: There is a transverse laceration over the great toe metatarsal MTP joint, which measures 35mm. Fractures of the neck of the second metatarsal, proximal metatarsal of the third, mid shaft of the fourth and neck and mid shaft of the fifth metatarsals. Fracture dislocation of the PIP joint of the 1st, 2nd, and 3rd toes. b. Hind Foot: Soft tissue over the plantar aspect of the foot and ankle appear to be intact. c. Ankle Joint / Plafont: There is a laceration over the medial aspect of the ankle joint at the level of the medial malleolus 40mm in length. d. Tibia / Fibula: There is obvious crepitus at the distal third of the tibia. There is a circumferential break in the ballistic gelatine at the level of the distal aspect of the tibia fracture. Surgical exploration of the tibia shaft fracture demonstrates a segmental comminuted mid shaft tibia fracture. e. Knee Joint: The knee appears stable. There is a 10mm deep laceration over the anterior aspect of the patella. f. Femur: g. Soft Tissue: Physical examination of the outer covering reveals there is an anterior laceration over the anterior lateral aspect of the patella tendon and the mid shaft of the tibia. Compromise of the soft tissue to the distal 1/3. h. Contamination: Overall Assessment: Grade IIIA open comminuted segmental tibia shaft fracture with multiple metatarsal fractures possible open joints. Recommended Treatment of Injury: a. Amputation: Yes No X b. Level: c. Likelihood of neurologic / vascular injury: unlikely Scores:
MTS
1A
ICRC
2F
AIS
2
NISSA
2
201
Shot ID
M99260D
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Spider Boot
Explosive
PMA-2
Pre Test Notes: M99260D; The mine was located under a front pod. Post Test Damage Assessment: Boot apparently undamaged. Spider Boot front legs destroyed, one rear leg damaged. Abrasion/erosion damage to bottom face and front of the Spider Boot deflector shell. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the femur, knee, and proximal tibia demonstrate no fracture or abnormality. AP and lateral of the tibia, foot, ankle demonstrate a mid shaft transverse fracture with evidence of a break in the ballistic gelatine consistent with an open fracture. Possible injury in the pilon area to the anterior aspect of the ankle, otherwise possible non-displaced segmental fibula fracture. b. CT Scanning: At the junction between the proximal and mid thirds of the tibia, there is a compound fracture. There is a butterfly fragment at the posterior aspect that measures 50mm in maximal length. The fracture fragments are in good alignment and are only separated by up to 3 mm. There is a non-displaced transverse fracture at the
202
fibular shaft at this same level. In the distal fibular shaft there is a non-displaced, oblique fracture. No corresponding tibia fractures at this level. No fractures are seen to involve the ankle, foot or femur. Post Test Clinical Examination Notes: a. Forefoot: There is a 90mm laceration over the plantar aspect over the metatarsal heads. There are open injuries of the MTP joint of the great, 2nd, 3rd, 4th, and IP of the 4th. b. Hind Foot: c. Ankle Joint / Plafont: There is a 25mm laceration in the ballistic gelatine below the medial malleolus and an 80mm laceration in the gelatine over the medial aspect of the mid foot over the junction of Henrys Knot. d. Tibia / Fibula: The open mid-shaft tibia fracture is comminuted with a butterfly fragment. There is some evidence of ligamentous instability of the ankle but no obvious fractures, dislocations of the tibiotalar, Choparts and Lisfrancs joint. e. Knee Joint: f. Femur: g. Soft Tissue: The examination of the proximal thigh and knee demonstrates two 1-cm anterior lacerations secondary to fragment penetration. There is a 1030mm laceration over the anterior medial aspect of the tibia that communicates directly with the fracture. There is moderate contamination of this area. The remainder of the lower extremity demonstrates no obvious breaks in the soft tissue covering. Removal of the outer covering demonstrates there is a Z shaped laceration in the ballistic gelatine 10 X 3 X 16 with a near complete circumferential break in the ballistic gelatine. This is the area previously described compromised outer skin with communication to the tibia fracture. h. Contamination: Overall Assessment: Grade IIIA/B open tibia fracture with multiple MTP joint fracture / dislocations. Recommended Treatment of Injury: a. Amputation: Yes No X b. Level: c. Likelihood of neurologic / vascular injury: considerable soft tissue injury. Possible Scores:
MTS
1B
ICRC
2F
AIS
3
NISSA
2
203
Shot ID
M99263A
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
Spider Boot
Explosive
PMA-2
Pre Test Notes: M99263A; The mine was located under a rear pod. Post Test Damage Assessment: Boot apparently undamaged. Spider Boot rear legs destroyed, front leg mount cracked. Abrasion/erosion and cracking damage to bottom face of Spider Boot body. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: An oblique fibular shaft fracture begins 375mm distal to the knee. This runs obliquely for a distance of 80mm. On the plain film the distal fibular shaft is displaced laterally by 20mm and the fragments are separated by 10mm. No corresponding tibia fractures are seen. There is an oblique fracture through the posterior aspect of the talus. This runs through the connecting post, which could act as a stress riser. The fracture fragments are not displaced. There is an oblique, non-displaced fracture through the cuboid-lateral cuneiform complex. In the metatarsals there are non-
204
displaced fractures in the mid shaft of the 1st and distal shafts of the 2nd 5th. No fractures are present in the femoral shaft or knee. Post Test Clinical Examination Notes: a. Forefoot: There were closed simple fractures of the MT 1-5, and 4th and 5th proximal phalanxes. b. Hind Foot: c. Ankle Joint / Plafont: d. Tibia / Fibula: fracture distal fibula 70mm from distal joint. Distal fibular fracture tented the skin. There was little soft tissue trauma to the remaining foot. The distal tibia, joint surface, maleoli are intact. e. Knee Joint: no # f. Femur: ok g. Soft Tissue: h. Contamination: Overall Assessment: This is a closed or more likely minor open fracture but almost certainly would be preserved Recommended Treatment of Injury: a. Amputation: Yes No X b. Level: c. Likelihood of neurologic / vascular injury: Scores:
MTS
1A
ICRC
1F
AIS
2
NISSA
0
205
Shot ID
M99263B
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-3
Pre Test Notes:

M99263B Post Test Damage Assessment: Boot outer sole intact and partially peeled from upper. Boot upper intact. Overboot outer sole heel destroyed. Overboot upper torn in heel and side areas. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: There is a force transducer in the proximal tibia shaft. This is 120mm below the knee and extends for a distance of 155mm. At the proximal cuff there are transverse fractures through the tibia and fibular shafts. These are not significantly displaced nor angulated. 285mm distal to the knee there is an oblique tibia fracture, which extends for a distance of 50mm. There is a lateral butterfly fragment and the main portions of the fractures are separated by 10mm. There is a corresponding fibular fracture, which begins 310mm distal to the knee and extends longitudinally through the fibula for a distance of 35mm. On the plain films the distal tibia and fibular fracture
206
a. b.
c. d.
e. f. g. h.
fragments are angled medially 15 degrees and anteriorly 20 degrees. There is a comminuted fracture within the talus. The main fracture runs obliquely in an AP direction. There are smaller fracture fragments at the posterior aspect. In the calcaneus there are small fractures at the anterior and lateral aspects. There is a longitudinal fracture that runs along the medial aspect of the calcaneus. This is not significantly displaced. There are two non-displaced fractures through the mid aspect of the cuneiform complex. No cuboid fractures. There are fractures at the bases of the 3rd, 4th and 5th metatarsals. The fracture at the base of the 5th enters the proximal articular surface. There is a transverse fracture in the distal 2nd metatarsal. No fractures are present in the 1st metatarsal. The tarsal fractures are not displaced. No fractures involve the femoral shaft or knee region Post Test Clinical Examination Notes: Forefoot: The MT 4,5 are fractured Hind Foot: Talus appears fractured, calcaneus is intact but has several fragments or chips surrounding it and is dislocated. There is significant dislocation of talo-navicular joint. However there is very severe comminution of the talus with shattering, bone loss, Calcaneus is less damaged with the sustentaculum tali avulsed from the body of calcaneus. There is dislocation of the talo navicular joint with comminution of the navicular Ankle Joint / Plafont: Tibia / Fibula: # proximal tibia 110 mm below knee joint. (just at upper location of load cell), comminuted fracture tib fib 30 mm below the load cell, there is some comminution and vertical splitting of distal tibia (12 cm) tib - talo dislocation Knee Joint: No fracture seems stable of exam Femur: No fracture Soft Tissue: There are large transverse fissures of the gelatine at the level of the upper and lower cup inserts used to install the load cell in the tibia Contamination:
Overall Assessment:
Interesting and difficult to score. There is severe comminution of the distal tibia but the way the pseudo skin stayed on the model, the foot would be attached to the leg and considerable soft tissue intact and possible to remain viable. Recommended Treatment of Injury: a. Amputation: Yes No X (possibly) b. Level: c. Likelihood of neurologic / vascular injury: would determine success of conservative therapy Scores:
MTS
1B
ICRC
3F
AIS
3
NISSA
6
207
Shot ID
M99263C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
PMA-3
Pre Test Notes: M99263C Post Test Damage Assessment: Boot outer sole and upper intact. Boot inner sole torn. Overboot outer sole heel destroyed. Overboot upper torn and badly damaged in heel area. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: The upper most fracture in the tibia is a transverse fracture and occurs 160mm below the level of the knee joint. There is an associated transverse fibular fracture 10mm below this level. These are fairly straightforward transverse fractures with no visible comminution. Another non-displaced transverse fibular fracture is 75mm below the first. 310mm distal to the knee joint there is an oblique tibia fracture, which extends for a distance of 10mm. There is a corresponding fibular fracture. 430mm distal to the knee joint there is a compound fracture of the distal tibia shaft, which extends for a distance of 60mm and enters the distal tibia articular surface. The main fragments are
208
posterior and are separated from each other by up to 10mm. There is a corresponding fibular fracture 15mm below the upper aspect of the tibia fracture at this level. On the plain films, the distal tibia and fibular fracture fragments are displaced anteriorly and laterally 10mm and are angled slightly medially and anteriorly. There is a comminuted fracture of the talus. The main fracture extends vertically through the waist. There is a second fracture through the posteromedial aspect. The fracture fragments are separated by 5 mm. There is a non-displaced, oblique fracture through the medial aspect of the navicular. At the upper anterolateral corner of the calcaneus there is a minimally displaced oblique fracture. There are fractures in all of the metatarsals, but these are not significantly displaced. Fractures are seen in the proximal and distal aspects of the 2nd, 3rd, and 5th metatarsals and in the distal aspects of the 1st and 4th. The proximal fracture fragment of the 2nd metatarsal affects the articular surface. These fracture fragments are not significantly displaced or angulated. No fractures are present in the femur or knee region Post Test Clinical Examination Notes: a. Forefoot: Fore foot appears intact b. Hind Foot: On X Ray the foot appears intact but there is a dislocation of tibia talar joint, talo navicular joint and Lisfranc joint. Calcaneus is relatively intact but there is severe soft tissue contamination of heel soft tissues with dislocation of talonavicular, Lisfranc, distal tibia joints. c. Ankle Joint / Plafont: d. Tibia / Fibula: # proximal neck fibula. Simple # tib fib 100mm below knee joint, second segmental # tib fib 160mm below first # and severely comminuted # distal tibia with 100mm length e. Knee Joint: f. Femur: g. Soft Tissue: There are large transverse fissures of the gelatine at the lower and upper 1/3rd levels of the tibia. The foot would still be attached to the leg with considerable soft tissues, distal tibia is comminuted but would be dependent of soft tissue h. Contamination: Overall Assessment: Severely injured hind foot with relatively less severely fractured tibia might survive if vascular injury not too significant Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKW c. Likelihood of neurologic / vascular injury: significant possibility and this would determine the need for amputation. Scores:
MTS
1B
ICRC
2VF
AIS
3
NISSA
8
209
Shot ID
M99263D
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
None
Explosive
PMA-2
Pre Test Notes: M99263D Post Test Damage Assessment: Boot completely destroyed. Boot upper shredded and completely separated from sole. Post Test Diagnostic Imaging: a. X-ray: There are no apparent fractures in the femur, knee, or proximal tibia. Radiographs demonstrate an open traumatic amputation of the distal third of the tibia. There is a segmental fracture of the distal 1/3 of the tibia. On the lateral radiograph, the anterior 1/3 of the cortex is missing as well as the ankle joint and the entire foot. b. CT Scanning: The foot and ankle have been traumatically amputated just above the ankle. There are two fractures in the tibia shaft. The most superior one is approximately 35mm distal to the knee joint. The fracture fragments are separated by 5 mm. 30mm distal to this there is another transverse fracture, which is separated from the intervening fracture fragment by 5 mm. It is also displaced laterally 6 mm. The amputation occurs 110mm distal to this. There are no fractures in the fibular shaft until the distal end where
210
the amputation occurred. The fibula is amputated 50mm more proximally than is the tibia. No fractures are seen to involve the knee or femoral shaft. There are no remnants of the foot on this exam. Post Test Clinical Examination Notes: a. Forefoot: The forefoot remains with fractures at the neck of 1,2,3,4 with the metatarsals missing. b. Hind Foot: The hind foot to include the calcaneus, talus, navicular, cuboid, and all the cuneiforms are missing. c. Ankle Joint / Plafont: d. Tibia / Fibula: There is a traumatic below knee amputation 360mm below the inferior pole of the patella. There is a sense of stripping and contamination to the proximal third of the tibia and soft tissue of the FSL. The medial aspect of the distal tibia and pilon area remain attached by a ligament but has been stripped of all soft tissue. Removal of the outer covering demonstrates there has been extensive soft tissue stripping and contamination of the distal third traumatic amputation. There is extensive comminution at the remaining distal tibia with dirt and debris up to the level of the fracture. There is a segmental fibular fracture with the distal tip of the fibula missing. e. Knee Joint: The knee is stable f. Femur: No fracture of the femur. g. Soft Tissue: Examination of the superficial covering of the FSL demonstrates there is some blast residue up to the level of the buttock with sand, however there is no break in the outer covering. h. Contamination: Overall Assessment: Open highly contaminated below knee traumatic amputation with a segmental tibia fracture of the remaining tibia. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: severe injury with obvious amputation already present. Scores:
MTS
2B
ICRC
3FBK
AIS
4
NISSA
13
211
Shot ID
M99263E
Load Cell
No
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
PMA-2
Pre Test Notes: M99263E Post Test Damage Assessment: Boot sole heel completely destroyed. Heavy damage to boot upper in heel area. Boot and overboot thrown several metres away. Overboot blow off boot. Overboot destroyed. Overboot upper torn free of sole. Overboot sole destroyed from mid-foot back. Post Test Diagnostic Imaging: a. X-ray: Radiographs of the femur, knee, proximal tibia demonstrate no obvious fractures or dislocations. Radiographs of the tibia demonstrate a traumatic distal 1/3 tibia, foot, and ankle amputation. There is also a segmental tibia fracture with comminution that appears to be open. There is a segmental fibula fracture and distal third of the tibia is missing. The amputated portion of the foot has some portions of the metatarsal remaining and parts of the medial cunneiform, and great toe with fractures at the base of the great toe. b. CT Scanning: The foot and ankle have been traumatically amputated just above the ankle. The remaining portions of the foot have been placed beside the tibia for the plain films. The first metatarsal is intact, but the second-third metatarsals are fractured in there mid shafts and the proximal portions of the second and third metatarsals are not present
212
in the specimen. The medial cuneiform is still present and appears to be intact. There is a complex fracture in the mid shaft of the tibia. The tibia fracture fragments are distracted by 40mm. There is a 25mm butterfly fragment at the upper posterior aspect of this fracture. There are two fractures in the shaft of the fibula. The first is in the proximal shaft and the second is in the mid shaft. The fracture fragments are distracted by 20mm. The fracture of the fibula involving the amputation of the ankle and foot occurs 40mm higher up the fibular shaft than that of the tibia shaft. No fractures are seen to involve the femoral shaft or knee. Post Test Clinical Examination Notes: a. Forefoot: b. Hind Foot: Calcaneus bone, talus, navicular, cuboid, the cuneiforms are all missing. There are portions of the great toe metatarsal, 2nd, 3rd, 4th metatarsals that are present in the amputated foot part. c. Ankle Joint / Plafont: d. Tibia / Fibula: There is crepitus with movement at the mid portion of the tibia, and a traumatic contaminated distal third amputation. The amputated foot demonstrates the loss of soft tissue on the plantar surface and posterior lateral aspect of the calcaneus. Removal of the outer covering demonstrates there is a 100mm laceration of the anteromedial aspect of the mid tibia over the segmental tibia fracture site, which demonstrates comminution at the fracture site. The distal 1/3 amputated portion demonstrates contamination approximately 50mm proximal to the open site. Surgical dissection of the proximal tibia and knee demonstrates there is a four-ligament (anterior, posterior cruciate, medial and lateral collateral ligament) disruption consistent with a knee dislocation. There is always a possibility of a vascular injury to the popliteal artery in high-energy trauma. e. Knee Joint: There is movement at the knee indicative of ACL, PCL, medial, and lateral collateral ligament injury consistent with a knee dislocation. f. Femur: Physical examination of the proximal femur reveals no obvious fractures or movement. g. Soft Tissue: Examination of the outer covering of the specimen reveals no obvious compromise or contamination of the proximal thigh. h. Contamination: Overall Assessment: Open highly contaminated traumatic distal 1/3 below knee amputation with segmental tibia fracture, which is open. Grade IIIA and an ipsilateral knee dislocation with possible arterial compromise. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA or AKA c. Likelihood of neurologic / vascular injury: dislocated knee has very high incidence of injury Scores:
MTS
3
ICRC
3FBK
AIS
4
NISSA
13
213
Shot ID
M99264A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
VS-50
Pre Test Notes: M99264A Post Test Damage Assessment: Boot outer sole intact. Boot upper torn. Boot inner sole torn. Overboot blown off boot. Overboot sole destroyed in heel area. Overboot upper torn partially free of sole. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: A non-displaced transverse fracture is present through the mid femoral shaft, 205mm proximal to the knee. There is a force transducer in the tibia shaft. This begins 110mm below the knee and extends for a distance of 155mm. As the force transducer acts as a stress riser there are transverse fractures through the tibia and fibular shafts at its proximal distal cuffs. These fractures are 115 and 270mm distal to the knee. 295mm distal to the knee there is an oblique tibia shaft fracture that extends for a length of 50mm. There is a corresponding transverse fibular fracture 325mm distal to the knee. Another transverse fibular shaft fracture is 375mm distal to the knee. The distal fracture
214
fragment is displaced laterally by the width of the shaft and the fragments overlap by 5 mm. At the extreme distal lateral aspect of the tibia there is a sliver-like fracture that extends into the articular surface. This is separated by 3 mm. There is a non-displaced fracture through the posterior aspect of the talus. There are minimally displaced, small fractures at the anterior and lateral aspects of the navicular. The middle cuneiform is essentially crushed. There is a non-displaced fracture through the lateral aspect of the lateral cuneiform. The medial cuneiform is intact. The cuboid bone is intact. There is an oblique fracture through the anterior aspect of the calcaneus. On the plain film the calcaneus is displaced inferiorly and dorsally relative to the talus. Non-displaced fractures are present in the proximal aspects of the 1st, 2nd, and 4th metatarsals and nondisplaced fractures are present in the distal aspects of the 2nd 4th metatarsals. The entire foot including the talus is dislocated laterally 15mm relative to its normal position. Post Test Clinical Examination Notes: a. Forefoot: b. Hind Foot: Severe soft tissue injury to the heel, calcaneus fractured, severe injury of talus and navicular including bone loss. c. Ankle Joint / Plafont: there is fracture of the anterior plafont. d. Tibia / Fibula: Tibia fracture comminuted, compound, contaminated, ant plafont fracture with a fracture of the tibia at the proximal end of load cell 110mm from knee joint. There is fracturing and comminution of the distal tibia with two segments of both tibia and fibula each segment is 6 and 110mm. e. Knee Joint: f. Femur: Femur has simple fracture 190mm proximal to knee joint g. Soft Tissue: h. Contamination: Overall Assessment: This would have a severe wound requiring BKA. Femur fracture might complicate things and if infected might require an AK amputation. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: Scores:
MTS
2B
ICRC
3FBK
AIS
4
NISSA
9
215
Shot ID
M99264B
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
Wellco
Explosive
VS-50
Pre Test Notes: M99264B Post Test Damage Assessment: Boot outer sole and upper intact. Overboot blown off boot. Overboot outer sole heel badly damaged. Overboot inner sole torn. Overboot upper torn in heel area. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: There is a pressure cuff monitor in the tibia shaft. This begins 110mm distal to the knee and extends for a distance of 155mm. There is no fracture at its proximal aspect, but there is an oblique tibia fracture near its distal aspect. This begins 270mm distal to the knee and extends for a distance of 35mm. There is a corresponding transverse fibular fracture 280mm distal to the knee. An oblique fibular fracture, which extends for a distance of 1 cm, is present 330mm distal to the knee. 350mm distal to the knee there are severely comminuted fractures of the distal tibia and fibula. The distal tibia fractures enter into the articular surface. There are some fairly large fracture
216
fragments, but there are numerous smaller fracture fragments, which are scattered in the adjacent area. The distal tibia articular surface is quite disordered. There is an oblique fracture through the navicular. The middle cuneiform is split down the middle and the fragments are separated by at least 10mm. The lateral cuneiform appears to be intact, as does the cuboid. There are numerous fractures at the anterior aspect of the calcaneus. The fracture fragments are widely dispersed. In the metatarsals there are non-displaced fractures at the proximal aspects of the 3rd 5th, a non-displaced fracture in the mid 2nd and a non-displaced fracture in the distal 1st. The fractures of the distal leg and foot are best appreciated on the plain films. From this it can be seen that there are numerous small widely distributed fracture fragments at the ankle and proximal foot. There is a traumatic dislocation at the junction between the talus/calcaneus and the tarsal bones. Post Test Clinical Examination Notes: a. Forefoot: There is fissuring of the gelatine of plantar surface of the foot extending medically to the neck of 1st MT. b. Hind Foot: The calcaneus is relatively intact but talus and navicular were shattered into dozens of fragments. c. Ankle Joint / Plafont: d. Tibia / Fibula: No fracture proximal to load cell, there is a comminuted spiral fracture of tibia 10mm distal to the load cell and is segmental for another 60mm. The distal fragment of tibia including the plafont is 50mm long. Fibula also fractured. The distal tibia joint surface is intact (artefact) but had a comminuted spiral fracture of the tibia. e. Knee Joint: Stable; No fracture f. Femur: No fracture g. Soft Tissue: The wound was open but the foot would have likely remained attached to the leg although with high risk of peripheral nerve and vascular injury. h. Contamination: Overall Assessment: Severe talar injury may be artefact. The possibility of nerve or vascular injury could easily make this an amputation injury. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: possible and if absent might permit conservative therapy. Scores:
MTS
2B
ICRC
3FBK
AIS
3
NISSA
8
217
Shot ID
M99264C
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
None
Explosive
PMA-2
Pre Test Notes: M99264C Post Test Damage Assessment: Boot completely destroyed. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: A non-displaced fracture is present in the distal tibia shaft 295mm distal to the knee joint. This fracture is mostly transverse, but there is an oblique portion, which runs for a distance of 15mm. There is no corresponding fibular fracture. The distal tibia and fibula along with the ankle and foot have been traumatically amputated. The tibia amputation begins 360mm distal to the knee and the fragmented fracture through the stump of the distal tibia shaft runs for a distance of 25mm. The tibia has been amputated fairly cleanly 385mm distal to the knee. There are no fragments of the foot or ankle on this exam. No fractures involve the femoral shaft or knee.
218
Post Test Clinical Examination Notes: a. Forefoot: b. Hind Foot: There is no foot with the specimen. c. Ankle Joint / Plafont: d. Tibia / Fibula: Fracture distal tibia and fibula with amputation of foot above the tibialtalar joint. There is a segmental fracture of the tibia just above where the ankle joint would have been. The fibula has a single fracture at the distal end just above where the lateral maleolus would have been. e. Knee Joint: f. Femur: g. Soft Tissue: h. Contamination: There is a very dirty stump from an amputation. The entire end of the stump is covered with dust and sand. Overall Assessment: This would have required a BKA. There is no other tissue separate to the amputated leg with the "specimen." Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: Scores:
MTS
2B
ICRC
3FBK
AIS
4
NISSA
14
219
Shot ID
M99264D
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
C4-50
Pre Test Notes: M99264D Post Test Damage Assessment: Boot outer sole intact. Boot inner sole torn. Boot upper torn. Overboot outer sole heel destroyed. Overboot upper torn and partially separated from sole. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: The femur and knee are intact. Transverse fracture through the mid shaft of the tibia with separation of fragments with no significant displacement of the main distal fragments. Distal to this there is a markedly comminuted fracture of the distal shaft of the tibia. There are multiple horizontal fractures through the length of the fibula. Most of the fragments remain in fairly good alignment. The distal tibia and fibula are shattered into multiple fragments and the foot is displaced anteriorly and laterally in relation to the shafts of the long bones. The talus, calcaneus and tarsal bones are separated and fractured into multiple fragments with disarticulation through the proximal
220
foot. There are several non-displaced transverse fractures through several of the metatarsals. Post Test Clinical Examination Notes: a. Forefoot: b. Hind Foot: Hind foot severely comminuted Fractures and bone loss of navicular, cuneiforms, talus and calcaneus, which is shattered but a large fragment with lateral ligament and fib attached is present as a separate fragment. c. Ankle Joint / Plafont: d. Tibia / Fibula: severe comminuted multi segmental # tibia 150mm below knee joint, segment 140mm long, e. Knee Joint: ok f. Femur: ok g. Soft Tissue: h. Contamination: Contamination with foreign material from boot in wound Overall Assessment: Severe comminution of tib fib would need either high BK or AK amputation Recommended Treatment of Injury: No a. Amputation: Yes X b. Level: high BKA or AKA c. Likelihood of neurologic / vascular injury: Scores:
MTS
3
ICRC
3FBK
AIS
4
NISSA
14
221
Shot ID
M99264E
Load Cell
No
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
Wellco
Explosive
C4-50
Pre Test Notes: M99264E Post Test Damage Assessment: Boot outer sole intact. Boot inner sole torn. Boot upper torn. Overboot blown off boot. Overboot outer sole heel completely destroyed. Overboot upper torn and partially separated from sole. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: There is a non-displaced transverse fracture through the mid/distal shaft of the femur. The knee is intact. Comminuted fracture proximal shaft of the fibula with no significant displacement of the main fragments. There is a markedly comminuted fracture of the distal shaft of the tibia, proximal to the ankle. There is no significant displacement of most of the fragments. Two of the larger fragments are displaced slightly laterally. There are several fractures through the proximal and mid fibula, which are not displaced. Fracture through the distal fibula with slight lateral displacement of a
222
fragment. The ankle is disarticulated and the calcaneus is displaced posteriorly. The talonavicular and calcaneocuboid articulations are completely disrupted and there are fractures through the tarsal bones as well as several non-displaced fractures through metatarsals. Post Test Clinical Examination Notes: a. Forefoot: Fore foot severely injured with fracture navicular, MT 2,3,4,5 necks b. Hind Foot: Hind foot bones severely comminuted with severe bone loss, fracture and disloc talo cuneiform joints. Talus vertical fracture and attached to distal 70mm piece of tibia. Calcaneus missing. Numerous small fragments, severe contamination of tissues with sand c. Ankle Joint / Plafont: d. Tibia / Fibula: Slightly comminuted fracture proximal tibia 110mm below knee joint, mid tibia and fibula has severely comminuted fracture with distal joint surface striped and absent. e. Knee Joint: stable f. Femur: Simple # mid shaft femur g. Soft Tissue: Severe wound to the lower leg, no evidence of fragments above the amp h. Contamination: Overall Assessment: Note there is a thought the femur # might have happened to the model before the blast event.. Distal leg spontaneously amputated with severe comminution and bone loss of hind foot. This would need a proximal BK amputation. If there were complications at the proximal tibia might end up with a AK amputation. The femur # causes problems here as it might require high AK. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKA c. Likelihood of neurologic / vascular injury: significant Scores:
MTS
3
ICRC
3FBK
AIS
5
NISSA
14
223
Shot ID
M99265A
Load Cell
Yes
Bone Type
Hard
Boot Type
Combat (CDN)
Overboot
None
Explosive
PMA-3
Pre Test Notes: M99265A Post Test Damage Assessment: Boot completely destroyed. Post Test Diagnostic Imaging: a. X-ray: # at lower level of load cell of tibia, # comminuted distal tib, vertical splitting, affecting medial post maleolus, anterior plafont, calcaneus missing, shattering of hind foot bones and talus b. CT Scanning: The femur appears intact. Transverse fractures are present through the mid to distal shaft of both the tibia and fibula with small bony fragments adjacent to the fracture site. There is some separation of the fragments, but no major displacement. There is a fracture through the distal tibia with all the bones distal to this including the ankle and foot having been completely blown off with multiple bony fragments lying adjacent to the distal part of the leg.
224
Post Test Clinical Examination Notes: a. Forefoot: all MT fractured with bone loss of M1, 4, 5 b. Hind Foot: shattered, calcaneus is missing c. Ankle Joint / Plafont: fractured d. Tibia / Fibula: e. Knee Joint: f. Femur: g. Soft Tissue: soft tissue of foot open and severely contused h. Contamination: Overall Assessment: Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKW c. Likelihood of neurologic / vascular injury: of distal tib fib area Scores:
MTS
2B
ICRC
2FBK
AIS
4
NISSA
14
225
Shot ID
M99265B
Load Cell
Yes
Bone Type
Hard
Boot Type
Wellco
Overboot
None
Explosive
PMA-3
Pre Test Notes: M99265B Post Test Damage Assessment: Boot completely destroyed in heel and rear portion of the leg. Boot upper and sole relatively intact from mid-foot forward. Post Test Diagnostic Imaging: a. X-ray: b. CT Scanning: The femur and knee are intact. Transverse fractures through the junction of mid and distal tibia and fibula with slight separation, but no significant displacement of the fragments. There is complete amputation through the distal tibia and fibula with the bones distal to this including the ankle and foot fractured into multiple pieces lying in the adjacent region.
226
Post Test Clinical Examination Notes: a. Forefoot: There is a dislocation of 2,3 MTP joint, # of 4,5 proximal phalanges and 4, 5 MT b. Hind Foot: Hind foot bones severely comminuted or missing, talus and calcaneous missing, one small fragment of calcaneus present (Achilles tendon insertion) c. Ankle Joint / Plafont: d. Tibia / Fibula: # distal tibia with entire distal joint missing, # at lower edge of load cell. The hind foot has been completely shattered, with 70mm of distal tibia missing. e. Knee Joint: f. Femur: g. Soft Tissue: h. Contamination: Overall Assessment: This would need BK above or at the level of lower load cell. This would be a severe BK amp. Appears as classic AP Mine injury. Note: no evidence of fragments in the proximal leg above the site of amputation. Recommended Treatment of Injury: a. Amputation: Yes X No b. Level: BKW c. Likelihood of neurologic / vascular injury: Scores:
MTS
2B
ICRC
3FBK
AIS
4
NISSA
14
227
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228
Annex D Load Cell Force and Moment Records

This Annex provides the time traces, on a shot by shot basis, for the forces and moments recorded by the load cells inserted in the middle of the tibia bones of the FSL specimens. The combined data from the x, y and z axes is plotted only for a 5ms duration since most of the action was found to take place during this time frame. In addition, the RMS data was also computed, integrated and the results are plotted. The data is organised in chronological order, as indicated by the Shot ID serial. It will be noticed that when an overboot was used, the force data had not returned to zero over the 5 ms duration considered. This is a basic characteristic of this data, showing the effect of the continued upward force from the combined blast deflector inserts in the boot and overboot. The force duration is significantly shorter for the shots without an overboot. With respect to the moment data, it never returned to zero during this short period as residual moments were sensed for a long time period due to flailing of the FSL lower components. For each shot, a table at the bottom of the page provides the main statistics that describe the data. These are defined as follows: ta: designates the time of arrival, as defined by the earliest time that the RMS signal increased over 100 N on the force trace. The only exception is with the M99265B data for which the threshold was 200 N; Fmax: designates the peak RMS force, in Newton, within the 5ms window; t | Fmax: time in ms at which the peak RMS force occurs; I | ta+2: value of the integral of the RMS force data over a 2ms duration starting from time ta; Mmax: designates the peak RMS moment, in Newton-meter, within the 5ms window; t | Mmax: time in ms at which the peak RMS moment occurs.
229
Table of Contents Annex D

SHOT ID
M99258A M99259A M99260A M99263B M99264A M99264B M99265A M99265B
LOAD CELL
Yes Yes Yes Yes Yes Yes Yes Yes
BONE TYPE
Hard Hard Hard Hard Hard Hard Hard Hard
BOOT TYPE
Blast (Wellco) Combat (CDN) Combat (CDN) Blast (Wellco) Combat (CDN) Blast (Wellco) Combat (CDN) Blast (Wellco)
PROTECTION
Overboot Overboot Overboot Overboot Overboot Overboot None None
EXPLOSIVE
PMA-3 PMA-3 PMA-3 PMA-3 VS-50 VS-50 PMA-3 PMA-3
230

25000 20000 15000 10000 5000 Force [N] 0 -5000 -10000 -15000 -20000 -25000 0.0 0.5 1.0 1.5 2.0 2.5 Time [ms] Fx Fy Fz Frms Irms 3.0 3.5 4.0 4.5 5.0 0 5000 10000 15000
Impulse (rms) [N-ms]
25000
20000

150
100
50 Moment [N-m]
-50
-100
-150 0.0 0.5 1.0 1.5 2.0 2.5 Time [ms] Mx My Mz Mrms 3.0 3.5 4.0 4.5 5.0
ta 0.41
Fmax 15736
t | Fmax 0.88
I | ta+2 14904
Mmax 41.1
t | Mmax 1.42
231
M99259A: PMA-3 versus Combat Boot and Wellco Overboot

25000 20000 15000 10000 5000 Force [N] 0 -5000 -10000 -15000 -20000 -25000 0.0 0.5 1.0 1.5 2.0 2.5 Time [ms] Fx Fy Fz Frms Irms 3.0 3.5 4.0 4.5 5.0 0 5000 10000 15000 Impulse (rms) [N-ms] 5.0 20000 25000

150
100
50 Moment [N-m]
-50
-100
-150 0.0 0.5 1.0 1.5 2.0 2.5 Time [ms] Mx My Mz Mrms 3.0 3.5 4.0 4.5
ta 0.27
Fmax 10907
t | Fmax 1.11
I | ta+2 14611
Mmax 120.6
t | Mmax 2.76
232

25000 20000 15000 10000 5000 Force [N] 0 -5000 -10000 -15000 -20000 -25000 0.0 0.5 1.0 1.5 2.0 2.5 Time [ms] Fx Fy Fz Frms Irms 3.0 3.5 4.0 4.5 5.0 0 5000 10000 15000 Impulse (rms) [N-ms] 20000 25000

150
100
50 Moment [N-m]
-50
-100
ta 0.28
Fmax 17772
t | Fmax 0.84
I | ta+2 17547
Mmax 36.4
t | Mmax 1.44
233
M99263B: PMA-3 versus Wellco Blast Boot and Overboot

M99263B: PMA-3 versus Wellco Blast Boot and Overboot

150
100
50 Moment [N-m]
-50
-100
ta 0.49
Fmax 17151
t | Fmax 1.07
I | ta+2 16925
Mmax 51.0
t | Mmax 1.07
234
M99264A: VS-50 versus Combat Boot and Wellco Overboot

M99264A: VS-50 versus Combat Boot and Wellco Overboot

150
100
50 Moment [N-m]
-50
-100
ta 0.34
Fmax 16904
t | Fmax 0.85
I | ta+2 18408
Mmax 119.8
t | Mmax 1.42
235
M99264B: VS-50 versus Wellco Blast Boot and Overboot

M99264B: VS-50 versus Wellco Blast Boot and Overboot

150
100
50 Moment [N-m]
-50
-100
ta 0.49
Fmax 15596
t | Fmax 0.98
I | ta+2 13647
Mmax 52.7
t | Mmax 0.92
236
M99265A: PMA-3 versus Unprotected Combat Boot

M99265A: PMA-3 versus Unprotected Combat Boot

150
100
50 Moment [N-m]
-50
-100
ta 0.20
Fmax 16732
t | Fmax 0.52
I | ta+2 8510
Mmax 51.9
t | Mmax 0.59
237

25000 20000 15000 10000 5000 Force [N] 0 -5000 -10000 -15000 -20000 -25000 0.0 0.5 1.0 1.5 2.0 2.5 Time [ms] Fx -71.32 Fy 1208.37 Fz 0.00 Frms 1210.47 Frms Irms 3.0 3.5 4.0 4.5 5.0 0 5000 10000 15000 Impulse (rms) [N-ms] 20000 25000

150
100
50 Moment [N-m]
-50
-100
ta 0.17
Fmax 20859
t | Fmax 0.45
I | ta+2 9671
Mmax 53.2
t | Mmax 1.28
238
Bibliography
American Academy of Orthopedic Surgeons (1975). Atlas of Orthotics. St. Louis, MO: CV Mosby. Ames, G.E. (1984). Fractures and major nerve injuries in the fractured extremity. In Marvin H. Myers (Ed.), The Multiply Injured Patient With Complex Fractures, pp. . Philadelphia, PA: Lea and Febiger. Anderson, I.B. (1998). The menace of mines. Annals RCPSC, 31(4), 188-191. Argyros, G.J. (1997). Management of primary blast injury. Toxicology, 121, 105-115. Atesalp, A.S., Erler, K., Gur, E., Solakoglu, C. (1999). Below-knee amputations as a result of land-mine injuries: comparison of primary closure versus delayed primary closure. J. Trauma, 47 (4), 724-727. Axelsson, H., Hjelmqvist, H., Medin, A., Persson, J.K., Suneson, A.(2000). Physiological changes in pigs exposed to a blast wave from a detonating highexplosive charge. Mil. Med., 165 (2), 119-126. Boileau Grant, J.C. (1972). Grants Atlas of Anatomy 6th ed. Baltimore, MD: Williams and Wilkens. Bowen, T.E., Bellamy, R.F. (Editors) (1988). Emergency War Surgery, 2nd edition. Washington: US Department of Defense. Carey, M.E. (1996). Analysis of wounds incurred by U.S. army seventh corps personnel treated in corps hospitals during operation Desert Storm, February 20 to March 10, 1991. J. Trauma, 40 (3), S165-S169. Cernak, I., Wang, Z., Jiang, J., Bian, X., Savic, J. (2001) Ultrastructural and functional characteristics of blast injury-induced neurotrauma. J. Trauma, 50 (4), 695-706. Cooper, G.L. (1996). Protection of the lung from blast overpressure by thoracic stress wave decouplers. J. Trauma, 40 (3), S105-S110. Cooper, G.L., Pearce, B.P., Sedman, A.J., Bush, I.S., Oakley, C.W. (1996). Experimental evaluation of a rig to simulate the response of the thorax to blast loading. J. Trauma, 40 (3), S38-S41. Cripps, N.P.J., Cooper, G.J. (1997). Risk of late perforation in intestinal in intestinal contusions caused by explosive blast. British J. of Surgery, 84, 1298-1303. Edlich, R.F., Moghtaler, J.C. (1998). Thermal Burns in Emergency Medicine, 4th ed, St. Louis, MO: Mosby. Rosen, .P, Barkin, R. (Editors).
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Elsayed, N.M. (1997). Toxicology of blast overpressure. Toxicology, 121, 1-15. Gorbunov, N.V., Elsayed, N.M. Kisin, E.R., et al. (1997). Air blast-induced pulmonary oxidative stress: interplay among hemoglobin, antioxidants, and lipid peroxidation. Am. J. Physiol., 272, 320-334. Guy, R.J., Watkins, P.E., Edmondstone, W.M. (2000). Electrocardiographic changes following primary blast injury to the thorax. J. R. Nav. Med. Serv., 86 (3), 125-133. Guy, R.J., Glover, M.A., Cripps, N.P. (2000). Primary blast injury: pathophysiology and implications for treatment. Part III:Injury to the central nervous system and the limbs. J. R. Nav. Med. Serv. , 86 (1), 27-31. Hirshberg, B., Oppenheim-Eden, A., Pizov, R., Sklair-Levi, M., Rivkin, A., et al (1999). Recovery from blast lung injury, one year follow-up. Chest, 116 (6), 16831688. Hull, J.B., Cooper, G.L. (1996). Pattern and mechanism of traumatic amputation by explosive blast. J. Trauma, 40 (3), S198-S205. Irwin, R.L., Lerner, M.R., Bealer, J.F., Mantor, C., Brackett, D.J., Tuggle, D.W. (1999). Shock after blast wave injury is caused by a vagally mediated reflex. J. Trauma, 47 (1), 105-110. Karger, B., Zweihoff, R.F., DuChesne, A. (1999). Injuries from hand grenades in civilian settings. Int. J. Legal Med., 112 (6), 372-375. Kostiuk, J.P. (1981). Amputation Surgery and Rehabilitation, The Toronto Experience. New York: Churchill Livingston. Leibovici, D., Gofrit, O.N., Stein, M., Shapira, S.C., Noga, Y., et al (1996). Blast injuries: bus versus open-air bombings A comparative study of injuries in survivors of open air versus confined space explosions. J. Trauma, 41 (6), 1030 1035. Mayorga, M.A. (1997). The pathology of primary blast overpressure injury. Toxicology, 121: 17-28. Mundie, T.G., Dodd, K.T., Lagutchik, M.S., Morris, J.R., Martin, D. (2000). Effects of blast exposure on exercise performance in sheep. J. Trauma, 48 (6), 1115-1121. Nechaev, E.A., Gritsanov, A.I., Fomin, N.F., Minnullin, I.P. (1995). Mine Blast Trauma, Experience From The War In Afghanistan. Khlunovskaya, G.P., (Translator). St. Petersburg. ODonoghue, D.H. (1976). Treatment of Injuries To Athletes, 3rd ed, Philadelphia: W.B. Saunders.
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Ohnishi, M., Kirkman, E., Guy, R., Watkins, P. (2001). Reflex nature of the cardiorespiratory response to primary thoracic blast injury in the anaesthetised rat. Exp. Physiol, 86 (3), 357-364. Paran, H., Neufeld, D., Schwartz, I., Kidron, D., Susmallian, S., et al (1996). Perforation of the terminal ilium induced by blast injury: delayed diagnosis or delayed perforation. J. Trauma, 40 (3), 472-475. Pizov, R., Oppenheim-Eden, A., Matot, I., Weiss, Y.A., Eidelman, L.A., et al (1999). Blast lung injury from an explosion on a civilian bus. Chest, 115 (1), 165-172. Raich, P.J. (1989). Kinesiology And Applied Anatomy, 7th ed. Philadelphia: Lea and Febriger. Rockwood, C.A., Green, D.P. (1975). Fractures. Philadelphia: J.B. Lippincott Co.. Saljo, A., Bao, F., Haglid, K.G., Hansson, H.A. (2000). Blast exposure causes redistribution of phosphorylated neurofilament subunits in neurons of the adult rat brain. J. Neurotrauma, 17 (8), 719-726. Seminiuk, R. (1996). The devils own device. Equinox, 15 (5), 30-43. Stuhmiller, J.H. (1997). Biologic response to blast overpressure: A summary of modeling. Toxicology, 121, 91-103. Sunderland, S. (1951). A classification of peripheral nerve injuries producing loss of function. Brain, 74, 491. Warwick, R., Williams, P.L. (Eds) (1973). Grays Anatomy 35th ed. Edinburgh: Longman. Wightman, J.M., Gladish, S.L. (2001). Explosions and blast injuries. Annals of Emerg. Med., 37 (6), 664-678. Wolf, D.G., Polacheck, I., Block, C., Sprung, C.L., Muggia-Sullam, M., Wolf, Y.G., Oppenheim-Eden, A, Rivkind, A., Shapiro, M. (2000). High rate of candidemia in patients sustaining injuries in a bomb blast at a marketplace: a possible environmental source. Clin. Infec.t Dis., 31 (3), 712-716. Woodburne, R.T. (1969). Essentials of Human Anatomy, 4th ed. London: Oxford University Press.
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List of symbols/abbreviations/acronyms/initialisms
AIS AP AT BB CB CCMAT CDN CFSL CT DRDCS DSTO FSL GZ HDP ICRC LEAP MESS MTS NISSSA NSN OB Abbreviated Injury Scale Anti-Personnel Anti-Tank Blast Boot Combat Boot Canadian Centre for Mine Action Technologies Canadian CCMAT FSL program Computer Tomography Defence R&D Canada Suffield Defence Science and Technology Organisation Frangible Surrogate Leg Ground Zero Humanitarian Demining Program International Committee of the Red Cross Lower Extremity Assessment Program Mangled Extremity Severity Score Mine Trauma Score Nerve, Ischemia, Soft-tissue, Skeletal, Shock and Age of patient injury score NATO Stock Number OverBoot
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OTF PMA PMN R&D RDX RMS SB STF TNT UPMAH US VS
Object To Film Designator for [former] Yugoslav anti-personnel mines Designator for Russian made anti-personnel mines Research and Development Cyclonite Root Mean Square Spider Boot Source To Film Trinitrotoluene Designator for [former] Yugoslav anti-personnel mine fuses United States Designator for Italian anti-personnel mines
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UNCLASSIFIED SECURITY CLASSIFICATION OF FORM (highest classification of Title, Abstract, Keywords) DOCUMENT CONTROL DATA
(Security classification of title, body of abstract and indexing annotation must be entered when the overall document is classified) 1. ORIGINATOR (the name and address of the organization preparing the document. Organizations for who the document was prepared, e.g. Establishment sponsoring a contractor's report, or tasking agency, are entered in Section 8.) 2. SECURITY CLASSIFICATION (overall security classification of the document, including special warning terms if applicable)
Defence R&D Canada Suffield PO Box 4000, Station Main Medicine Hat, AB T1A 8K6
3.
Unclassified
TITLE (the complete document title as indicated on the title page. Its classification should be indicated by the appropriate abbreviation (S, C or U) in parentheses after the title).
Assessment of Lower Leg Injury from Land Mine Blast Phase 1: Test Results using a Frangible Surrogate Leg with Assorted Protective Footwear and Comparison with Cadaver Test Data (U)
4. AUTHORS (Last name, first name, middle initial. If military, show rank, e.g. Doe, Maj. John E.)
Bergeron, D.M., Coley, G.G., Fall, R.W., Anderson, Col I.B.

5. DATE OF PUBLICATION (month and year of publication of document) 6a. NO. OF PAGES (total containing information, include Annexes, Appendices, etc) 263 6b. NO. OF REFS (total cited in document)
February 2006
7.
15
DESCRIPTIVE NOTES (the category of the document, e.g. technical report, technical note or memorandum. If appropriate, enter the type of report, e.g. interim, progress, summary, annual or final. Give the inclusive dates when a specific reporting period is covered.)
Technical Report
8. SPONSORING ACTIVITY (the name of the department project office or laboratory sponsoring the research and development. Include the address.)
Canadian Centre for Mine Action Technologies

9a. PROJECT OR GRANT NO. (If appropriate, the applicable research and development project or grant number under which the document was written. Please specify whether project or grant.) 9b. CONTRACT NO. (If appropriate, the applicable number under which the document was written.)
10a. ORIGINATOR'S DOCUMENT NUMBER (the official document number by which the document is identified by the originating activity. This number must be unique to this document.)
10b. OTHER DOCUMENT NOs. (Any other numbers which may be assigned this document either by the originator or by the sponsor.)
DRDC Suffield TR 2006-051

11. DOCUMENT AVAILABILITY (any limitations on further dissemination of the document, other than those imposed by security classification) (x) ( ) ( ) ( ) ( ) ( ) Unlimited distribution Distribution limited to defence departments and defence contractors; further distribution only as approved Distribution limited to defence departments and Canadian defence contractors; further distribution only as approved Distribution limited to government departments and agencies; further distribution only as approved Distribution limited to defence departments; further distribution only as approved Other (please specify):
12. DOCUMENT ANNOUNCEMENT (any limitation to the bibliographic announcement of this document. This will normally corresponded to the Document Availability (11). However, where further distribution (beyond the audience specified in 11) is possible, a wider announcement audience may be selected).
Unlimited UNCLASSIFIED SECURITY CLASSIFICATION OF FORM
UNCLASSIFIED SECURITY CLASSIFICATION OF FORM

13. ABSTRACT (a brief and factual summary of the document. It may also appear elsewhere in the body of the document itself. It is highly desirable that the abstract of classified documents be unclassified. Each paragraph of the abstract shall begin with an indication of the security classification of the information in the paragraph (unless the document itself is unclassified) represented as (S), (C) or (U). It is not necessary to include here abstracts in both official languages unless the text is bilingual).
In 1999, the Canadian Centre for Mine Action Technologies (CCMAT) sponsored a series of tests involving the detonation of 25 anti-personnel blast mines against a frangible leg model. The model was fitted with various footwear and additional protective equipment. The aim of these tests was to assess whether this model could be used for routine tests of protective footwear against mine blast. The report describes the frangible leg and compares it to its human counterpart. It then presents an overview of the physics of mine blast and the devastating effects on the human leg. Details of the test setup and procedures are described so that the reader might better interpret the test results. These tests involved medical staff, including two surgeons that had operated on mine blast victims, to examine the frangible legs and determine probable medical outcomes. These results are compared to a database of mine blast injury against human cadavers to identify the strengths and limitations of the frangible leg model. It was found that this frangible leg model has potential to be a good testing tool, provided some modifications are implemented, and further testing be carried out to properly calibrate the response of the modified model against the database of mine injuries.
14.
KEYWORDS, DESCRIPTORS or IDENTIFIERS (technically meaningful terms or short phrases that characterize a document and could be helpful in cataloguing the document. They should be selected so that no security classification is required. Identifies, such as equipment model designation, trade name, military project code name, geographic location may also be included. If possible keywords should be selected from a published thesaurus, e.g. Thesaurus of Engineering and Scientific Terms (TEST) and that thesaurusidentified. If it is not possible to select indexing terms which are Unclassified, the classification of each should be indicated as with the title.)
Canadian Centre for Mine Action Technologies Test and Evaluation Anti personnel landmine Humanitarian demining CCMAT Land mine Blast Frangible surrogate leg Protective footwear Combat boot Wellco Spider boot Lower Extremity Assessment Program Demining LEAP FSL
UNCLASSIFIED SECURITY CLASSIFICATION OF FORM

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Defence Research and Development Canada

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Assessment of Lower Leg Injury from Land Mine Blast Phase 1

Technical Report DRDC Suffield TR 2006-051 February 2006

Assessment of Lower Leg Injury from Land Mine Blast Phase 1

Defence R&D Canada Suffield

Author D.M. Bergeron

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The Mechanics of Standing and Gait ................................................ 19

Circulation in the Lower Limb .......................................................... 21

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2.1.5 2.2 2.2.1 3.

The FSL a Very Simple Model Indeed........................................................ 28

Experimental Setup ........................................................................................ 55

Medical Assessment Procedures .................................................................... 63

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Comparison of FSL Performance Against LEAP Results.............................. 80 5.4.1 5.4.2

Strain Gauge and Load Cell Records ............................................................. 92 5.5.1 5.5.2

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1.1 Scope and Objectives of the CFSL Program

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1.2 Organisation of this report

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Structures of the Human Leg and the FSL

2.1 Clinical Anatomy of the Lower Limb

2.1.1 Organisation of the Anatomy

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Figure 1. Drawing of the foot showing its various componentsI. Anderson

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Figure 2. Overview of the anatomy of a nerveI. Anderson

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Figure 3. Anatomical position showing anterior view of an upright postureI. Anderson

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2.1.2 Lower Limb Anatomy from a Regional Perspective

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Figure 5. Blood vessels about the hip jointI. Anderson

The Tibia and Fibula

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Figure 8. The calcaneus bone (heel bone)I. Anderson

Figure 9. Diagram demonstrating the arches of the footI. Anderson