Surgical removal of an impaled unexploded mortar shell into the chest: Case review from a war-zone

Abstract

Introduction and significance

The surgical removal of unexploded mortar shells is rarely documented in the literature. Since most cases occur within war or conflict regions, reporting such instances is vital for optimizing and enhancing surgical practices, particularly in low-resource settings.

Case presentation

We report the case of a 35-year-old man who sustained an injury from a 60 mm unexploded mortar shell, penetrating the patient's right posterior chest in the right paravertebral region of the 4th thoracic vertebra, causing intrathoracic injuries, multiple rib fractures, and a right pneumothorax. The patient was immediately resuscitated and transferred to the operating room. The projectile was removed without direct contact with metal instruments. A right chest tube was then inserted and the injured area was repaired, resulting in an uneventful postoperative recovery.

Clinical discussion

Unexploded mortar shell injuries are infrequently documented in the literature. These injuries are seen within war and conflict regions, that have limited accessibility or availability of experienced explosive ordnance disposal (EOD) teams, transporting personnel, and equipped and separated operating theaters.

Conclusion

Unexploded ordnance and munitions represent an underrecognized and underreported health risk to patients, healthcare providers, and healthcare facilities. These injuries are commonly encountered within regions that lack experienced transport and EOD staff. The need for the establishment of such experienced teams along with providing adequate training for healthcare providers is necessary.

Highlights

• •Surgical removal of unexploded mortar is scarcely reported in the literature.
• •Limited-resources countries lack experienced EOD and transporting teams which poses a danger to the patients, healthcare providers, and the healthcare facilities.
• •In resource-poor settings, creativity in identifying available knowledge transfer resources is critical, particularly when medical training is inadequate.

1. Introduction

The surgical management of injuries caused by fireworks is complicated due to the significant variations in arsenal design, injury mechanics, and involvement of vital organs [1]. In war zones, various forms of injuries, such as penetrating injuries from metal fragmentation or explosive blasts, are observed [2]. While these injuries typically result from direct artillery impact or explosions, instances of unexploded ordnance and munitions are infrequently documented in the literature [[2], [3], [4]]. Indeed, the management of unexploded munitions presents formidable challenges owing to their multifaceted nature, absence of clinical experience, and resource constraints endemic to the healthcare landscapes wherein these injuries manifest [5].

The presence of impaled unexploded munitions engenders significant hazards during patient evacuation or transfer, posing tangible risks to both healthcare personnel and facilities [3]. Furthermore, managing unexploded impaled munitions in combat zones, with limited experience and resources, can exert discernible influences on clinical decision-making processes, potentially culminating in unfavorable outcomes [5]. Here we present a 35-year-old man who sustained an injury from a 60 mm mortar shell that failed to explode, penetrating the patient's posterior chest in the right paravertebral area of the 4th thoracic vertebra, causing intrathoracic injuries and a right pneumothorax. A senior general surgeon and senior orthopedist performed the surgery in a teaching university hospital. This case report has been reported in line with the SCARE Criteria [6].

2. Case presentation

2.1. Patient information

A 35-year-old male solider with no significant medical history, combatant during the Yemen war (2014–2021) presented to the emergency department about 2 h after being injured by an unexploded mortar shell (Caliber: 60 mm, Length: 470 mm, Weight: 1.7 kg, Fuze: 610 AF). He sustained the injury while in combat. While the mortar shell did not explode, it pierced and passed through the patient's posterior chest along the right midaxillary line and the right paravertebral area of the fourth thoracic vertebra. The head of the shell emerged over the posterior surface of the chest. The patient was managed in the field by pressure dressing, with the placement of a cervical collar, and fluid resuscitation. He was transferred to the closest hospital, about 2 h from the combat zone.

2.2. Clinical findings

Upon the presentation to the emergency department, the patient was hemodynamically stable (blood pressure of 120/70 mmHg, heart rate of 82 beats/min), afebrile (37.3 °C), with oxygen saturation of 89 % on room air. Primary survey showed no evidence of airway compromise, or change in mentation. His clinical examination was pertinent for reduced air entry on the right lung field with paradoxical movement. An object penetrates the patient's posterior chest in the right midaxillary line and the right paravertebral area. There was no active bleeding, however, adjacent lacerations were noted. The remainder of the examination, including abdominal, cardiovascular, and neurological examinations were unremarkable. Urinary catheterization with a 16 Fr catheter revealed 200 mL of clear urine. The initial radiography x-ray revealed three rib fractures, multiple impalement injuries to the chest wall, along with right pneumothorax with no evidence of tension physiology.

2.3. Diagnostic assessment

The FAST scan (Focused Assessment with Sonography in Trauma) showed minimal fluid collection in the abdominal cavity. A plain chest x-ray revealed a right pneumothorax, pleural sliding, and 3rd, 4th, and 5th rib fractures (Fig. 1). Because this was not available, no additional radiological examination, such as computed tomography (CT), was performed.

Fig. 1.

Chest radiography x-ray showing the shell was lodged in the right posterior chest in the right paravertebral region of the 4th thoracic vertebra (arrow).

2.4. Therapeutic interventions

The patient had two large-bore intravenous access secured and received fluid resuscitation with 1000 mL of normal saline via two large-bore intravenous catheters. Furthermore, prophylactic antibiotics (1 g of ceftriaxone and 500 mg of metronidazole intravenously) were initiated, along with tetanus vaccination due to his unknown vaccination history of the patient. There were limited resources with regard to patient transfer into tertiary hospitals, which included the lack of experienced transporting staff and an explosive ordnance disposal (EOD) team. Subsequently, the decision was to manage the patient locally with the aid of experienced nurses who had received prior training in munition handling. As the impaled mortar shell has an explosive nature, the surgical intervention was deemed necessary. After obtaining consent, the patient was immediately taken to the operating room, which was established at a distance from the main surgical and inpatient units.

The patient was positioned in the left lateral decubitus position. Under general anesthesia, a superficial skin incision was made over the object, taking care to avoid direct contact with the underlying device (Fig. 2). Blunt digital dissection was performed all around the mortar shell, and it was subsequently removed (Fig. 3). The wound was then debrided, cleaned, rinsed, and closed. A bleeding-free underwater seal was then achieved and a chest tube was placed in the fifth intercostal space. Intra-operatively, the patient experienced a brief episode of hypotension during the procedure, which was responsive to fluid resuscitation.

Fig. 2.

Intraoperative finding of chest injury: (A) The fins of the shell were lodged in the right posterior chest in the right paravertebral region of the 4th thoracic vertebra, (B) mortar shell removal.

Fig. 3.

The unexploded 60-mm mortar shell after removal.

2.5. Follow-up and outcome

The patient was transferred to the intensive care unit for close monitoring. Due to the risk of contamination and possible anti-microbial resistance, the patient was started empirically on meropenem (500 mg every 8 h) and clindamycin (300 mg every 6 h). Subsequently, on postoperative day 3, the patient was transferred to the surgical floor, and the chest drain was removed on the 5th day post-operatively. He underwent physical therapy and rehabilitation and was discharged home 9 days after surgery with recovered functional and medical status. One month postoperatively, the patient showed a remarkable improvement in his functional status, and a follow-up chest x-ray showed no pneumothorax.

3. Discussion

This case reviews an uncommon form of war-related injuries caused by an impaled mortar shell and documents the patterns of associated injuries. The surgical detonation of live explosives has been documented in the literature since 1942, mostly in connection with military operations [2,7,8]. Unexploded munitions have been reported scarcely in the literature. Nevertheless, they carry a significant risk with a reported fatality rate of 11 %, which reached 21.1 % among children [7,9]. To the best of our knowledge, there have been no documented cases of ordnance explosion during transportation, assembly, or removal [7,8]. Notwithstanding the lack of reported ordnance explosion, all impaled ordnance should presume to be explosive and armed, and thus, cautious practices should be implemented within the first encounter with retained ammunition [5]. Several measures should be initiated upon the earliest encounter with the unexploded munition, which includes cautious disposal and handling [10]. As the military disposal of explosive ordnance requires a high level of caution, composure, training, and teamwork to assure patient and team safety, specialized explosive ordnance disposal (EOD) teams have been implemented in regions like the US [11]. The Explosive Ordnance Disposal (EOD) team must be immediately contacted for assistance in locating, removing, and disposing of the explosive ordnance. The Five Point Protocol (5Cs) is described in military manuals for unexploded ordnance situations [2,8]. These include ensuring the area is “confirmed”, clearing the site, establishing a perimeter, cordoning off the area, checking the area, and exercising “control” over the situation [2,8]. Other tactics include using barricades and wearing body armor. In addition, electrocautery and all other instruments that use heat, vibration, or electricity should be banned [2,[12], [13], [14]]. While the settings of our patient's encounter were within a combat zone, the lack of an EOD team limited a proper initial evaluation and identification of a proper healthcare facility with optimal settings, nevertheless, as the risk of transfer and the critical level of the patient's illness outweighed the assumed benefits, he was managed with aid and recruitment of experienced providers.

Resource-poor environments also lack personal protective equipment (PPE), such as blast-proof barricades or body armor. In a rural area, the hospital may not be large enough to isolate the patient. In this case, it might be a wise decision to care for the patient in a remote location instead of evacuating other patients from the hospital. Particularly if the patient is awaiting a move to a larger facility. Patient transport can also be a challenge in rural areas. It is important to avoid sudden movements. Reducing unnecessary movements could be crucial as the device could be triggered by movement or tampering [2,7]. If a patient transfer is necessary, before entering a car, ensure the patient is adequately grounded to avoid static electricity discharge [7,8].

The surgical removal should be performed within ancillary sites as far as possible from main operative sites, however, with proper access to the necessary surgical and anesthetic equipment [5]. While pre-operative imaging might be necessary, a plain X-ray might be considered the safest utility and it should be sought initially. In our patients, we utilized x-ray imaging along with ultrasonography to assess and evaluate for any possible intra-abdominal bleeding that warrants further exploration. The utilization of ultrasonography seems to be safe as reported by Schlager et al. [15] However, there is limited data on the use of computed tomography, which can provide higher diagnostic accuracy and might aid in surgical planning. While the need for patient re-positioning and the high radiation dosage might carry a high risk for the patients, High et al. reported a case of an impaled mortar shell that underwent computed topography imaging safely [16]. Further studies are warranted to assess the computed topography safety in different forms of unexploded ordnance.

The physical manipulation should be minimized as some types of fuses can be triggered by moving the axis of the device, changing posture, or rotating the device a certain number of times [2,14]. If necessary, resection should also be performed en-block. To reduce the risk of detonation, electric devices, infusers, and defibrillators should be avoided [2]. Alternatively, non-powered manual tools should be utilized [5].

Gunshot wounds to the chest commonly occur in armed conflict or war and carry a high risk of death or physical disability due to damage to vital organs such as the lungs, heart, and major blood vessels. For stable combat patients, minimally invasive procedures may be useful. An individualized treatment approach, such as using the wound canal as an endoscope port after initial surgical wound debridement and antibiotic prophylaxis, was proposed by Lurin et al. [17] In this case, the patient was hemodynamically stable, but we did not have minimally invasive devices and the patient was treated by open surgery with consistent results.

The severity of penetrative chest injury injuries relies on the extent of blood loss and the accompanying organ damage, which can range from minor to life-threatening injuries [18]. Treatment priorities are determined first by life-threatening injuries, followed by those that are most likely to worsen. In our case, the FAST of the abdominal cavity showed mild free fluid which may occur due to chest trauma. Despite suffering a flail chest and lung contusion, our patient was successfully weaned off mechanical ventilation following the procedure.

4. Conclusion

Injuries caused by impaled unexploded mortars are rarely documented. These cases pose a risk to healthcare providers and require reporting to improve understanding and treatment of this unusual and serious type of injury. Early detection of the threat and involvement of explosive ordnance disposal teams are crucial for safe and successful management.

Consent for publication

The written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Patient perspective

Throughout her course of treatment, the patient expressed satisfaction with the care she received.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data collection

Saif A Ghabisha, Mohamed Badheeb Writing of Paper: Taha Al-Mwald and Faisal Ahmed.

Critical revision for intellectual content: Zakaria Mothna and Faisal Ahmed.

Ethical approval

Not required.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Study Concept and Design: Zakaria Mothna, Saleh Al-wageeh and Faisal Ahmed.

Guarantor

Faisal Ahmed is the guarantor of the work and accepts full responsibility.

Research registration number

Not applicable.

Declaration of competing interest

None of the authors have any conflict of interest to declare.

Data availability

The datasets are available from the corresponding author on reasonable request.