Military Injuries

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VI.D.0

Lead Author(s): 

Stephen W. Marshall, PhD
Michelle Canham-Chervak, PhD, MPH
Esther O. Dada, MPH
Bruce H. Jones, MD, MPH
This section of the report presents medical surveillance data on injuries affecting Active Duty, nondeployed US Army soldiers. As with civilians, injuries impose a major public health problem in the US Army, impacting more than 300,000 active duty Army soldiers annually and leading to more than 1.0 million medical encounters. Unintentional injuries, a substantial and highly preventable problem, were the leading cause of the 4,053 active duty Army nonbattle deaths from 2005 to 2011 (45%), followed by disease (24%), suicide (23%), and homicide (5%).1

Ongoing analysis of surveillance data from the Defense Medical Surveillance System (DMSS), a central repository of all inpatient and outpatient medical encounters for US military personnel, is a key source of information on military injuries.2 The data presented here were obtained from the Armed Forces Health Surveillance Center, and prepared by the Army Institute of Public Health, Injury Prevention Program. Data on fatalities, hospitalizations, and outpatient visits were obtained and analyzed for all nondeployed US Army soldiers in the Active Component, hereafter referred to as "active duty." The analysis is limited to nondeployed Army since recent standardized medical encounter data are most reliably captured in the nondeployed (garrison) environment.

Fatality data contained in the DMSS originate from two data sources: Washington Headquarters Service and the Armed Forces Institute of Pathology. Hospitalization (inpatient) and outpatient visit data are obtained from DMSS, which draws data from the Military Health System (MHS) Executive Information and Decision Support data systems. Data include treatment received within the MHS, as well as treatment outside the MHS that was paid for by the US military. All data on medical conditions other than injuries are reported according to the 17 major diagnosis code groups as outlined in the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM).3 Injuries resulting in hospitalization and outpatient treatment were identified by ICD-9-CM diagnosis codes from the 800–999 code series for acute (traumatic) injuries and 710–739 code series for injury-related (chronic) musculoskeletal conditions, in concordance with recommendations for monitoring of military injuries.4

Consistent with prior reporting,5,6 injuries and injury-related musculoskeletal conditions are reported in combination in the “injury and musculoskeletal” category. Injury-related musculoskeletal conditions include conditions such as Achilles tendinitis (code 726.71), meniscal tears of the knee (codes 717.0–717.5), non-traumatic rupture of the quadriceps (code 727.65), and tibial stress fracture (code 733.93). Other non-injury conditions in the 710–739 ICD-9 codes series, such as rheumatoid arthritis and arthropathies associated with infection, are captured in the “musculoskeletal, non-injury” category. With the exception of the Relative Burden analysis, a 60-day ”unique hospitalization/outpatient rule” was used in this analysis in order to reduce the effect of follow-up injury visits and potential overestimation of frequencies and rates. The rule states that multiple visits for the same three-digit ICD-9-CM diagnosis within 60 days of the initial visit will be counted only once.  

Causes of injury hospitalizations are coded at the military treatment facility using the coding scheme outlined in the North Atlantic Treaty Organization (NATO) Standardization Agreement (STANAG) No. 2050, ed. 5.7 The coding system is employed for coding all injury hospitalizations, but is required for the first (incident) visit for acute injuries only.8 The STANAG codes are four-digit codes describing the intent/situation of the injury incident, injury cause, and location at which the injury occurred. This report includes injury hospitalizations coded as accidental (a STANAG trauma code, or first digit, of 5–9), which are used in this analysis, and hereafter referred to as unintentional injuries. Outpatient injury cause coding is not yet required in the military health system, although ICD-9 external cause of injury cause codes may be recorded. In this report, data for incident outpatient injury visits with an ICD-9 external cause of injury code are reported.
  • 1. Mortality Surveillance in the US Army, 2005–2011. Army Institute of Public Health; July 2014.
  • 2. Rubertone MV and Brundage JF: The Defense Medical Surveillance System and the Department of Defense serum repository: glimpses of the future of public health surveillance. Am J Public Health 2002;92(12):1900-1904.
  • 3. National Center for Health Statistics. The International Classification of Diseases, ed. 9. Revision, Clinical Modification (ICD-9-CM). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Centers for Medicaid and Medicare Services.
  • 4. DoD Military Injury Metrics Working Group White Paper: Washington, DC: Office of the Assistant Secretary of Defense for Health Affairs, Clinical and Program Policy. 2002.
  • 5. Jones BH, M Canham-Chervak, S Canada, T Mitchener, S Moore. Medical surveillance of injuries in the US military: Descriptive epidemiology and recommendations for improvement. Amer J Prev Med 2010;38(1S):S42-S60.
  • 6. Jones BH, Amoroso PJ, Canham ML, Schmitt JB, Weyandt MB. Chapter 9. Conclusions and recommendations of the DoD injury surveillance and prevention work group. Mil Med 1999;164(8S):1-26.
  • 7. Military Agency for Standardization, North Atlantic Treaty Organization. 2 March 1989. Standardized Classification of Diseases, Injuries, and Causes of Death. 5th ed: STANAG 2050.
  • 8. Amoroso PJ, Bell NS, Smith GS, Senier L, Pickett D. Viewpoint: a comparison of cause-of-injury coding in U.S. military and civilian hospitals. Am J Prev Med 2000;18(3 Suppl):164-173.

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Military Injuries

VI.D.0

This section of the report presents medical surveillance data on injuries affecting Active Duty, nondeployed US Army soldiers. As with civilians, injuries impose a major public health problem in the US Army, impacting more than 300,000 active duty Army soldiers annually and leading to more than 1.0 million medical encounters. Unintentional injuries, a substantial and highly preventable problem, were the leading cause of the 4,053 active duty Army nonbattle deaths from 2005 to 2011 (45%), followed by disease (24%), suicide (23%), and homicide (5%).1

Ongoing analysis of surveillance data from the Defense Medical Surveillance System (DMSS), a central repository of all inpatient and outpatient medical encounters for US military personnel, is a key source of information on military injuries.2 The data presented here were obtained from the Armed Forces Health Surveillance Center, and prepared by the Army Institute of Public Health, Injury Prevention Program. Data on fatalities, hospitalizations, and outpatient visits were obtained and analyzed for all nondeployed US Army soldiers in the Active Component, hereafter referred to as "active duty." The analysis is limited to nondeployed Army since recent standardized medical encounter data are most reliably captured in the nondeployed (garrison) environment.

Fatality data contained in the DMSS originate from two data sources: Washington Headquarters Service and the Armed Forces Institute of Pathology. Hospitalization (inpatient) and outpatient visit data are obtained from DMSS, which draws data from the Military Health System (MHS) Executive Information and Decision Support data systems. Data include treatment received within the MHS, as well as treatment outside the MHS that was paid for by the US military. All data on medical conditions other than injuries are reported according to the 17 major diagnosis code groups as outlined in the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM).3 Injuries resulting in hospitalization and outpatient treatment were identified by ICD-9-CM diagnosis codes from the 800–999 code series for acute (traumatic) injuries and 710–739 code series for injury-related (chronic) musculoskeletal conditions, in concordance with recommendations for monitoring of military injuries.4

Consistent with prior reporting,5,6 injuries and injury-related musculoskeletal conditions are reported in combination in the “injury and musculoskeletal” category. Injury-related musculoskeletal conditions include conditions such as Achilles tendinitis (code 726.71), meniscal tears of the knee (codes 717.0–717.5), non-traumatic rupture of the quadriceps (code 727.65), and tibial stress fracture (code 733.93). Other non-injury conditions in the 710–739 ICD-9 codes series, such as rheumatoid arthritis and arthropathies associated with infection, are captured in the “musculoskeletal, non-injury” category. With the exception of the Relative Burden analysis, a 60-day ”unique hospitalization/outpatient rule” was used in this analysis in order to reduce the effect of follow-up injury visits and potential overestimation of frequencies and rates. The rule states that multiple visits for the same three-digit ICD-9-CM diagnosis within 60 days of the initial visit will be counted only once.  

Causes of injury hospitalizations are coded at the military treatment facility using the coding scheme outlined in the North Atlantic Treaty Organization (NATO) Standardization Agreement (STANAG) No. 2050, ed. 5.7 The coding system is employed for coding all injury hospitalizations, but is required for the first (incident) visit for acute injuries only.8 The STANAG codes are four-digit codes describing the intent/situation of the injury incident, injury cause, and location at which the injury occurred. This report includes injury hospitalizations coded as accidental (a STANAG trauma code, or first digit, of 5–9), which are used in this analysis, and hereafter referred to as unintentional injuries. Outpatient injury cause coding is not yet required in the military health system, although ICD-9 external cause of injury cause codes may be recorded. In this report, data for incident outpatient injury visits with an ICD-9 external cause of injury code are reported.
  • 1. Mortality Surveillance in the US Army, 2005–2011. Army Institute of Public Health; July 2014.
  • 2. Rubertone MV and Brundage JF: The Defense Medical Surveillance System and the Department of Defense serum repository: glimpses of the future of public health surveillance. Am J Public Health 2002;92(12):1900-1904.
  • 3. National Center for Health Statistics. The International Classification of Diseases, ed. 9. Revision, Clinical Modification (ICD-9-CM). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Centers for Medicaid and Medicare Services.
  • 4. DoD Military Injury Metrics Working Group White Paper: Washington, DC: Office of the Assistant Secretary of Defense for Health Affairs, Clinical and Program Policy. 2002.
  • 5. Jones BH, M Canham-Chervak, S Canada, T Mitchener, S Moore. Medical surveillance of injuries in the US military: Descriptive epidemiology and recommendations for improvement. Amer J Prev Med 2010;38(1S):S42-S60.
  • 6. Jones BH, Amoroso PJ, Canham ML, Schmitt JB, Weyandt MB. Chapter 9. Conclusions and recommendations of the DoD injury surveillance and prevention work group. Mil Med 1999;164(8S):1-26.
  • 7. Military Agency for Standardization, North Atlantic Treaty Organization. 2 March 1989. Standardized Classification of Diseases, Injuries, and Causes of Death. 5th ed: STANAG 2050.
  • 8. Amoroso PJ, Bell NS, Smith GS, Senier L, Pickett D. Viewpoint: a comparison of cause-of-injury coding in U.S. military and civilian hospitals. Am J Prev Med 2000;18(3 Suppl):164-173.

Summary Data

VI.D.1

In 2012, there were approximately 370 injury-related deaths, 5,000 injury-related hospitalizations (3,000 acute injuries and 2,000 injury-related musculoskeletal conditions), and 661,000 injury-related outpatient visits (245,000 acute injuries and 415,000 injury-related musculoskeletal conditions).
Injury Pyramid, U.S. Army Active Duty, 2012
Fatalities have been a major focus of injury prevention activities in the past. As illustrated by these data, however, there are far more injury-related hospitalizations and outpatient visits than deaths. These nonfatal outcomes result in significant losses in duty time and manpower for the Army.

In 2012, injuries accounted for approximately 30% of all medical encounters. Injuries were the leading cause of medical encounters and affected more individuals than all other medical conditions, including mental health disorders.
Relative Burden of Injuries and Diseases, U.S. Army Active Duty, 2012
Rates of all injury visits among nondeployed active duty soldiers climbed slightly between 2006 and 2012. During this period, more than half the injury visits were due to lower extremity overuse injuries.
U.S. Army Active Duty Injury and Lower Extremit yOveruse Injury Visit Rates, 2006-2012
In 2012, out of approximately 39,000 incident hospitalizations, three major diagnoses groups accounted for over half of all admissions (56%). The top three reasons for hospitalization were mental disorders (27%), pregnancy-related issues (17%), and injuries and injury-related musculoskeletal conditions (12%).
Injuries vs. Illnesses Resulting in Hospitalization, Top 10 ICD-9 Categories, U.S. Army Active Duty, 2012
A total of 2,511,276 unique outpatient visits were made by active duty Army personnel. Injuries and injury-related musculoskeletal conditions were responsible for 26%, or more than 660,000, of visits.
Injuries vs. Illnesses Resulting in Outpatient Visits, Top 10 ICD-9 Categories, U.S. Army Active Duty, 2012

Acute Injuries and Injury-Related Musculoskeletal Conditions

VI.D.2.0

Acute injuries among active duty, nondeployed US Army soldiers are characterized by the types of injuries incurred, as well as the bodily site of the injuries. Two types of analytical injury matrices are available to further describe acute injuries and injury-related musculoskeletal conditions: (1) the Barell Injury Diagnosis matrix1 and (2) the injury-related musculoskeletal conditions matrix.2 Matrices report ICD-9-CM code frequencies by type of injury and body region. (Reference Table 6D.1 PDF CSV and Table 6D.2 PDF CSV)    

  • 1. Barell V, Aharonson-Daniel L, Fingerhut LA, Mackenzie EJ, Ziv A, Boyko V, Abargel A, Avitzour M, Heruti R: An introduction to the Barell body region by nature of injury diagnosis matrix. Inj Prev 2002;8(2):91-96. USAPHC (Prov) Injury Prevention Report No. 12-HF-0APLa-09 A-2
  • 2.  Hauret KG, Jones BH, Bullock SH, Canham-Chervak M, Canada S: Musculoskeletal injuries: Description of an under-recognized injury problem among military personnel. Am J Prev Med 2010;38(1S):S61-S70.

Types and Sites of Injuries

VI.D.2.1

In 2012, there were 3,093 acute traumatic injuries (coded in the 800–900 ICD-9-CM code series) requiring hospitalization. Leading specific reasons for hospitalizations included fractures of the lower leg and/or ankle (13 %), facial fracture (6%), and fracture of the foot/toes (3%). Comparing all body regions, the lower extremity accounted for 30%, the upper extremity for 19%, and the head for 16%. Within the head region, traumatic brain injury, including skull fracture, accounted for 15%, and other specified head injuries accounted for less than 1%. (Reference Table 6D.1 PDF CSV)

During the same year, US Army active duty, nondeployed soldiers incurred 240,299 acute traumatic injuries (coded in the 800–900 ICD-9-CM code series) for which outpatient care was required. Leading specific reasons for outpatient visits included strains/sprains to the lower leg and/or ankle (9%) and strains/sprains of the shoulder/upper arm (7%). Body regions most affected were lower extremities (38%), upper extremities (26%), and the head and neck region (TBI and other head, face, and neck) (11%). (Reference Table 6D.2 PDF CSV)

Distribution of Acute Injuries by Diagnosis (Barell Matrix), U.S. Army Active Duty Hospitalizations and Outpatient Visits, 2012
Distribution of Acute Injuries by Bodily Location (Barell Matrix), U.S. Army Active Duty Hospitalizations and Outpatient Visits, 2012

Injury-Related Musculoskeletal Conditions

VI.D.2.2

In 2012, there were 1,674 hospitalizations due to injury-related musculoskeletal conditions, roughly one-half the number of acute traumatic injuries requiring hospitalization. The most common types of injury-related musculoskeletal conditions leading to hospital admission were joint derangement (58%), followed by inflammation and pain due to overuse (23%). Joint derangement with neurological involvement accounted for another 12%. The vertebral column (including spine/back) was the most affected by injury-related musculoskeletal conditions (63%), followed by lower extremities (25%) and upper extremities (10%). (Reference Table 6D.3 PDF CSV)

There was nearly twice the number of injury-related musculoskeletal conditions requiring outpatient visits as there were acute traumatic injuries. In 2012, there were a total of 413,466 outpatient visits for injury-related musculoskeletal conditions (710–739 ICD-9-CM series). Most outpatient visits for injury-related musculoskeletal conditions involved inflammation and pain due to overuse (87%). Lower extremities (44%) was the body region most often treated on an outpatient basis, followed by the vertebral column (including spine/back) at (34%), and upper extremities at 19%. The leading specific injury-related musculoskeletal conditions requiring outpatient treatment were inflammation and pain (overuse) to the knee and/or lower leg (20%), inflammation and pain (overuse) to the lumbar spine (18%), inflammation and pain (overuse) to the ankle and/or foot (14%), and inflammation and pain (overuse) to the shoulder (12%). (Reference Table 6D.4 PDF CSV)

Distribution of Injury-related Musculoskeletal Conditions by Diagnosis, U.S. Army Active Duty Hospitalizations and Outpatient Visits, 2012
Distribution of Injury-related Musculoskeletal Conditions by Location, U.S. Army Active Duty Hospitalizations and Outpatient Visits, 2012

Cause of Injuries

VI.D.3

The leading cause of unintentional injury hospitalizations in 2012 was land transport accidents (20%), followed by falls or near-falls (16%). Parachuting and guns/explosives accounted for 8% each. A total of 6% of unintentional injury hospitalizations were due to sports and another 6% were due to heat injury. The top nine causes of unintentional injuries accounted for nearly three-fourths of hospitalizations (74%). Intervention strategies to address many of these issues are available.
 Leading Causes of Unintentional Hospitalizations by Cause, U.S. Army Active Duty, 2012
The leading causes of unintentional injury outpatient visits in 2012 were attributed to overexertion (27%), falls (16%), and injuries due to soldiers being struck by or against objects or other people (16%).
Leading Causes of Unintentional Injury Outpatient Visits by E-Code Groupings, U.S. Army Active Duty, 2012

Key Challenges to Future

VI.D.4

To address a large and complex problem such as injuries in the US Army, a systematic approach is needed.1 This approach should include routine assessment of surveillance data, data-driven and objective priorities, pursuit of detailed risk factor analyses, evaluation of existing prevention strategies, and research to address gaps in intervention and risk factor knowledge. Over the past three decades, contributions to Army injury prevention have been made in each of these areas, including the establishment of deployment injury surveillance capabilities2 and implementation of a data-driven process to define Army injury prevention priorities.3 Epidemiologic analyses and program evaluations have described potential technologies to address motor vehicle crashes among Army personnel4 and the effects of extreme conditioning program elements incorporated into unit physical training.5 Systematic reviews have defined physical training programs to enhance load carriage performance6 and interventions to prevent physical training-related injuries.7 Research efforts have quantified physical-training activities in Army basic training8 and described physical training to improve performance on tactical occupational tasks.9

To maintain progress, continued focus on leading causes of Army injuries such as physical training/exercise, sports, falls, and motor vehicle (land transport) crashes is needed. Collaborations with academia and other government organizations will aid in identifying modifiable causes, risk factors, and effective prevention strategies. Fostering existing and new partnerships between Army leadership, public health, safety, research, health promotion, and other communities will be critical for the success of military injury prevention activities. Given the magnitude and severity of the problem of injuries, effective injury prevention will make a significant contribution to the health and productivity of soldiers and the Army.

  • 1. Jones BH, Canham-Chervak M, Sleet DA: An evidence-based public health approach to injury priorities and prevention recommendations for the U.S. Military. Am J Prev Med 2010 Jan;38(1 Suppl):S1-10.
  • 2. Hauret KG, Taylor BJ, Clemmons NS, Block SR, Jones BH: Frequency and causes of nonbattle injuries air evacuated from Operations Iraqi Freedom and Enduring Freedom, U.S. Army, 2001–2006. Am J Prev Med 2010 Jan;38(1 Suppl):S94-107.
  • 3. Canham-Chervak M, Hooper TI, Brennan FH Jr, Craig SC, Girasek DC, Schaefer RA, Barbour G, Yew KS, Jones BH: A systematic process to prioritize prevention activities sustaining progress toward the reduction of military injuries. Am J Prev Med 2010 Jan;38(1 Suppl):S11-8.
  • 4. Pollack KM, Yee N, Canham-Chervak M, Rossen L, Bachynski KE, Baker SP: Narrative text analysis to identify technologies to prevent motor vehicle crashes: Examples from military vehicles. J Safety Res 2013 Feb;44:45-9
  • 5. Grier T, Canham-Chervak M, McNulty V, Jones BH Extreme conditioning programs and injury risk in a US Army Brigade Combat Team. US Army Med Dep J 2013 Oct-Dec:36-47.
  • 6. Knapik JJ, Harman EA, Steelman RA, Graham BS: A systematic review of the effects of physical training on load carriage performance. J Strength Cond Res 2012 Feb;26(2):585-97.
  • 7. Bullock SH, Jones BH, Gilchrist J, Marshall SW: Prevention of physical training-related injuries recommendations for the military and other active populations based on expedited systematic reviews. Am J Prev Med 2010 Jan;38(1 Suppl):S156-81.
  • 8. Simpson K, Redmond JE, Cohen BS, Hendrickson NR, Spiering BA, Steelman R, Knapik JJ, Sharp MA: Quantification of physical activity performed during US Army Basic Combat Training. US Army Med Dep J 2013 Oct-Dec:55-65
  • 9. Hendrickson NR, Sharp MA, Alemany JA, Walker LA, Harman EA, Spiering BA, Hatfield DL, Yamamoto LM, Maresh CM, Kraemer WJ, Nindl BC: Combined resistance and endurance training improves physical capacity and performance on tactical occupational tasks. Eur J Appl Physiol 2010 Aug;109(6):1197-208.

Acknowledgements

VI.D.6

The material presented here is adapted from the following sources:

Esther Dada-Laseinde, Michelle Canham-Chervak, Bruce H. Jones: U.S. Army Annual Injury Epidemiology Report 2008. USAPHC (PROV) REPORT NO. 12-HF-0APLa-09. U.S. Army Public Health Command (Provisional), 5158 Blackhawk Rd, Aberdeen Proving Ground, Maryland 21010-5403.

Esther Dada, Michelle Canham-Chervak, Bruce H. Jones: U.S. Army Injury Surveillance Summary 2012. U.S. Army Institute of Public Health, Epidemiology and Disease Surveillance Portfolio, Injury Prevention Program.

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