MISSILE AND BLAST INJURIES IN NIGERIA – THE SOUTHEAST EXPERIENCE

Abstract

Background

Missile injuries occupy a large segment of injuries treated in Southeast Nigeria, accounting for a significant proportion of morbidity and mortality. However, blast injuries are uncommon in this region. This study became necessary as a result of the rising spate of violence in various parts of Nigeria, particularly in the Northeast and in the Niger Delta regions, as well as the ever-present fear of kidnappers, armed robbers and occasionally, trigger-happy security agents.

Aim

To determine the types of missile and blast injuries in Southeast region, the circumstances that led to them, the management of the patients, and the outcome.

Design of this study

This is a collaborative, retrospective multi-centre study.

Setting:

1. Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State.

2. Imo State University Teaching Hospital, Orlu, Imo State

3. Abia State University Teaching Hospital Aba, Abia State.

4. Federal Medical Centre, Owerri, Imo State.

5. University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, all in the Southeast of Nigeria.

Methodology

Patients who were treated for missile or blast injuries in the last five years in each of the collaborating institutions were studied to determine the pattern of such injuries, causes, management options and outcome.

Results

Four thousand, two hundred and sixteen (4,216) patients were admitted with missile and blast injuries in the collaborating Institutions in a period of five years. Majority of the injuries (4,177{99.1%}) were from gunshots, mainly to the limbs. The 39 (0.9%) cases of blast injuries were from land mines, hand grenades, and the Biafran type of improvised explosive device, popularly known as “Ogbunigwe”. Seven hundred and seventy-two (18.3%) of the patients signed against medical advice and went to traditional bone-setters. Of the remaining 3,444 patients, 3,432 (99.7%) had good outcome. However, there were a total of 12 (0.4%) deaths, four from fulminant sepsis; eight from unknown causes.

Conclusion

Missile injuries account for a significant proportion of injuries treated in the Southeast of Nigeria; only a few were blast injuries. The outcome of management of the affected patients was satisfactory.

Introduction

Missile and blast injuries occur all over the world but the aetiological factors may vary from place to place and between ‘peace time’ and ‘war time’. The distinction between the terms ‘peace time’ and ‘war time’ is only a matter of the quantity of hostilities1.

Gunshot injuries occur when someone is shot by a bullet or other sort of projectile from a firearm. Peace time gunshot injuries occur in a variety of situations – criminal and terrorist incidents (including shots fired by law enforcement agents), attempted suicides as well as unintended firearm ‘accidents’, popularly called ‘accidental discharges’ in Nigeria. The most frequently injured sites are the extremities, particularly the lower limbs2.

In regions of the world where there are wars, terrorism and tribal/religious conflicts, such as the Middle East (Syria, Iraq, Afghanistan, Pakistan etc), or the Northeast region of Nigeria (Chibok, Bama, and Konduga in Borno State, parts of Adamawa State, and parts of Yobe State), blast injuries also occur in addition to missile injuries because of the additional use of bombs, shells, grenades, land mines and Improvised Explosive Devices (IEDs). Some of these injuries can be penetrating or blunt, and can affect different parts of the body such as the limbs, head and neck, thorax, abdomen or pelvis2.

For the past seven years, Nigeria has been grappling with insurgency in the North East region occasioned by the violent attacks, first on the police, then on soldiers and civilians by the Boko Haram terrorist organization3.

Before the coming of the Boko Haram insurgents, the Niger Delta region of Nigeria was the hot-spot for missile and blast injuries caused by the activities of the Movement for the Emancipation of Niger Delta (MEND)4. MEND has been inflicting these injuries on the citizenry, on foreigners of multi-national oil companies (in addition to damaging the facilities and installations of these oil companies as well as those of the Federal Government of Nigeria)4.

In the Southeast, agitators for the sovereign state of Biafra, under the acronym MASSOB (Movement for the Actualization Of the Sovereign State Of Biafra) were also, from time to time and for more than a decade, accused of being associated with violent acts which gave rise to missile injuries5. In the last few years, a splinter group from MASSOB, the Indigenous People Of Biafra (IPOB) emerged and are also towing the same line of agitation for the creation of the State of Biafra6. From time to time, these groups, scattered all over the Southeast, and marginally beyond this region, have had skirmishes amongst themselves, and with the law enforcement agencies, resulting in missile injuries on both sides. These agitators sometimes inflict injuries on people, in addition to the already domiciled and worrisome spate of armed robbery, kidnapping, and hired assassinations.

JUSTIFICATION FOR THIS STUDY

Worried by the apparent rise in the incidence of missile injuries and occasional blast injuries in recent times in the Southeast, we studied the pattern of missile and blast injuries in the Southeast, the management of the patients and the outcome. This study will be useful in comparing similar incidences of missile and blast injuries in future in the Southeast, and in any other region of Nigeria.

Patients and Methods

A total of 4,689 missile injuries were recorded in the five tertiary centres in Southeastern Nigeria between January 2011 and January 2016, a 5-year study period.

Inclusion Criteria: Patients 18 years and above with missile or blast injuries and whose case notes contained the required information; patients less than 18 years and patients with missing medical records were excluded.

Records of all the patients that were admitted with missile or blast injuries for a period of five years (15th January 2011 to 14th January 2016) at the Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi, University of Nigeria Teaching Hospital (UNTH) Ituku-Ozalla, Abia State University Teaching Hospital (ABSUTH) Aba, Imo State University Teaching Hospital (IMSUTH) Orlu and the Federal Medical Centre (FMC) Owerri were obtained from each of these institutions. Relevant data were obtained from the Accident and Emergency Departments, from the surgical wards, from the operating theatres, and from the Medical Records Departments. The following data were extracted from the records and entered in the electronic proforma: age and sex of patient, cause of missile or blast injury, part or parts of the body involved, time between injury and presentation at hospital, treatment given, and outcome. The data were subjected to descriptive analysis using Statistical Package for Social Sciences version 20 Chicago Illinois statistical software.

Results

Out of 4,689 patients managed for missile/blast injuries in the collaborating institutions during the five-year study period, 4,216 (89.9%) folders were retrieved while 473 folders could not be found, giving an attrition rate of 10.1%.

There were 3,805 males and 411 females with a male/female ratio of 9.3 : 1. Their ages ranged from 18 years to 72 years with a mean of 34+1.96 and a peak incidence at 30-40 years bracket (Table 1).

Table 1. Age distribution of the patients.

AGE RANGE	NO. OF PATIENTS
10 – 19	401
20 – 29	935
30 – 39	1,070
40 – 49	952
50 – 59	708
60 – 69	116
70 – 79	34
	4,216

Armed robbery attacks with firearms were recorded in 3,519 (83.5%) cases. Other causes of gunshot wounds included cult group activities in 290 (6.9%) cases and shots from some security agents and some Vigilante groups in 407 (9.6%) cases. Missile injuries to the lower limbs involved the femur in 903 patients (21.4%), the tibia in 614 patients (14.6%), and both the tibia and the fibula in 491 (11.7%) cases. There were 17 (0.4%) cases of pelvic fractures, with injury to the urinary bladder in 14 of them. The remaining 292 (6.9%) patients had soft tissues injuries as shown in Table 2.

Table 2. Anatomical sites affected by missile injuries.

PART OF BODY	NO. OF PATIENTS
LOWER LIMBS	2,800
PELVIS	17
ABDOMEN	702
UPPER LIMBS	946
CHEST	212
SOFT TISSUES	292

There were 39 (0.9%) cases of blast injuries in this study and they affected the lower limbs. Twenty-two (56.4%) of these blast injury patients who had stepped on land mines suffered loss of the offending foot/leg. Only one of the lower limbs was affected in each of these 22 cases. The remaining 17 (43.6%) of the blast injury patients suffered open fractures of the tibia, or both tibia and fibula. There was no isolated fracture of the fibula.

There were 946 (22.4%) upper limb injuries mainly of fractures of the humerus, ulna, radius, and/or the hand.

The 212 (5.0%) patients with chest injuries had rib fractures and haemothorax resulting from gunshot wounds to the left chest wall in 125 (59.0%) of chest these injury cases, to the right chest wall in 73 (34.4%) of chest injury cases, and to both chest walls in 14 (6.6%) of chest injury cases. The abdominal cavity was penetrated in each of the 702 (16.7%) cases of abdominal injuries in this study. The intra-abdominal organs affected included the spleen in 127 (3.0%), the liver in 192 (4.6%), the omentum and the mesentery in 383 (9.1%) cases. No injuries to the intestines or kidneys were recorded (Table 3).

Table 3. Types of missile injuries.

TYPE OF INJURY	NO. OF PATIENTS	%
LOWER LIMB:
Fracture of femur, tibia, tibia + fibula	2,008	47.6
Pelvic fracture	17	0.4
Urinary bladder injury associated with pelvic fracture	14	0.3
UPPER LIMB:
Fracture of humerus, ulnar, radius, hand bones	946	22.4
Only soft tissue injury	292	6.9
Penetrating chest injury	212	5.0
Abdominal injury (spleen, liver, omentum, mesentry)	702	16.7

Out of the 4,216 patients studied, 4,132 (98.0%) presented within the first two hours from time of injury; 83 (2.0%) presented after the first two hours and one patient (0.02%) presented after 11 hours of injury. Sixty-six (1.6%) of the patients who presented to the hospital after the first two hours had first gone to the police to report the incident.

Out of the 2,971(70.5%) patients with fractures of the extremities, 772 (18.3%) opted to be managed by traditional bone-setters. Of the remaining 2,199 (52.2%) patients with fractures, 1154 (27.4%) had internal fixation for closed fractures while 1,045 (24.8%) had external fixators for open tibial fractures. The 22 (0.5%) patients who had stepped on land mines, and whose affected lower limbs were mangled, had amputation of the affected limb. One of the amputees died from severe wound sepsis.

The 14 urinary bladder injuries were associated with pelvic fractures and were repaired at laparotomy. The 212 (5.0%) patients with penetrating chest injuries presented with fractured ribs and haemothorax and had thoracostomy, with good outcome. There were 292 (6.9%) patients with soft tissue injuries. They had surgical debridement and wound dressings before delayed primary wound closure was done, with good outcome. There were 702 (16.7%) patients with penetrating abdominal injuries and they all had exploratory laparotomy. One hundred and twenty-seven patients (3.0%) had splenectomy. Although the Grades of the splenic injuries were not stated, none of the patients with injury to the spleen had spleen conservation surgery. The rest of the patients with abdominal injuries had repair of liver lacerations and omentoplasty (Table 4). There were 11 (0.3%) deaths following laparotomy. These deaths occurred within the first fourteen days post-op. Three of the deaths were from severe sepsis; causes of death of the remaining eight were not recorded. One death occurred on the 11^th day post-op following fulminant sepsis in one of the blast injury patients who had undergone amputation (Table 5). Post-mortem examination was not done on any of the deceased.

Table 4. Treatment and outcome.

TREATMENT GIVEN	NO. OF PATIENTS/%	OUTCOME
Fractures: Internal fixation, external fixator, skeletal traction for pelvic fractures, wiring for small bones of the hands	2,199 (52.2%)	Good
Urinary bladder repair	14 (0.3%)	Good
Debridement of soft tissue injury; wound dressings; delayed primary wound closure	292 (6.9%)	Good
For penetrating chest injury, chest tube thoracostomy	212 (5.0%)	Good
Exploratory laparotomy for abdominal injuries: splenectomy, liver repair, omentoplasty	702 (16.7%)	Good
11 deaths: fulminant sepsis in 3; unknown cause of death in 8.

Table 5. Blast Injuries, treatment and outcome.

INJURY TYPE	NO. OF PATIENTS (%)	TREATMENT	OUTCOME
Fracture of leg and foot bones	17 (0.4%)	Internal/External fixation	Good
Mangled limb = 19 }Traumatic } }amputation } = 3}	22 (0.5%)	Amputation	One death due to sepsis
Total	39 (0.9%)

Discussion

In this study, youths aged 30-40 years and males were mostly involved in missile and blast injuries. In their study on gunshot injuries in Benin City, Akhiwu et al noted a male/female ratio of 10.7:1 and the trunk was more commonly affected contrary to the findings in this study and in the study by Ogunlusi et al in which the extremities, particularly the lower extremities, were most commonly affected7,2. The study by Adotey et al in the Niger Delta region of Nigeria similarly showed more involvement of the extremities in youths in their prime of life8. In their study in Ibadan, Afuwape et al also recorded that more males, in their youthful ages, were affected by gunshot injuries9.

This study showed that majority of the gunshot injuries were inflicted mainly by armed robbers followed closely by gunshots by police affecting commercial bus drivers. These findings were similar to the study by Udosen et al in Calabar in which armed robbers and police inflicted most of the gunshot injuries on the civilian population10. This was also corroborated by Solagberu in Lagos Nigeria and by Abbas et al in Maiduguri, Nigeria11,12.

Urinary bladder injuries were recorded in this study as complications of pelvic fracture, a situation noted by Richard et al in their study13. Penetrating chest trauma could cause a wide variety of cardiac injuries, however, none of the patients in this study had cardiac injuries; a few had fractured ribs with haemothorax14. It is interesting to note that majority of the chest injuries (59.0%) were on the left side, suggesting that the aim of the assailant was to hit the heart and kill the victim. The remaining cases of fractures of the upper and lower limbs were offered internal fixation, with good outcome. Good outcome was also recorded by Anani et al in 2016 in their treatment of fractures of long bones following civilian gunshot injuries15.

The 6.9% cases of soft tissue injuries did well on wound debridement and dressings until full wound healing was achieved. Some of these patients had delayed primary wound closure for full healing. In their series, Ritchie and Harvey as well as Ordog et al recorded good outcome after similar treatment of gunshot soft tissue injuries16,17. Of the 3,444 patients managed in this study, there were 12(0.3%) deaths . There was no record of postmortem examination in any of the deceased. That might be related to the negative attitude of some relatives to postmortem examinations18.

The limitations of this study include the retrospective nature of the study and the hospital record attrition rate.

Conclusions

In conclusion, missile injuries account for a significant proportion of injuries treated in the Southeast region of Nigeria; only a few were blast injuries. The outcome of management of the affected patients was satisfactory.