Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    Bastion Classification of Lower Limb Blast Injuries

    Stratifies blast injuries of lower limbs to guide treatment.
    Favorite

    INSTRUCTIONS

    Identify mechanism by the most proximal extent of the injury.

    When to Use
    Pearls/Pitfalls
    Why Use
    • Patients with lower extremity injuries after explosions resulting in complex blast wounds.
    • The constellation of injuries may include blunt or crush injuries, traumatic amputations, and compartment syndrome, as well as associated neurologic, thoracic, gastrointestinal, and genitourinary injuries.
    • The validation study of the Bastion Classification (Jacobs 2014) was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level.
    • Correlates better in blast injuries resulting in traumatic amputations than in segmental injuries.
    • Because not all injuries involve complete traumatic amputation of a limb, this classification is supplemented by the suffix “S” to denote a segmental injury, defined as the presence of potentially viable tissue distal to the most proximal injury.
    • Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs are important in treatment and operative planning, so these are denoted by additional suffixes A-D, respectively.
    • Prehospital application of a tourniquet can effectively obtain hemorrhage control. The study validating the Bastion Classification (Jacobs 2014) had 98 injuries out of 179 (55%) requiring pneumatic tourniquets. A recent study in 2017 by Scerbo et al reports patients who presented without prehospital tourniquets received more transfusions in the first hour of arrival (55% vs 34%, p = 0.02) and had increased mortality from hemorrhagic shock (14% vs 3.0%, p = 0.01).
    • Developed to be a classification system that more comprehensively describes injury pattern of lower extremities after blast injuries.
    • Correlates with treatment need, such as requirement for operative proximal vascular control or amputation level.
    • Helpful in facilitating communication between clinicians and for operative management.
    • Other scores for lower extremity injury severity such as the MESS may not be predictive of functional recovery after limb reconstruction (Ly 2008), though we are not aware of any head-to-head comparison studies including the Bastion Classification.
    Injury confined to foot
    Injury involving lower leg permitting effective below-knee tourniquet application
    Injury involving proximal lower leg or thigh, permitting effective above-knee tourniquet application
    Proximal thigh injury, preventing effective tourniquet application
    Any injury with buttock involvement
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Yes

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Management

    Management depends on the injuries diagnosed. Using the Bastion Classification and suffixes, emergency physicians and trauma surgeons can anticipate the need for additional surgical consultations and the resources required for treatment.

    Formula

    Selection of the appropriate mechanism:

    Mechanism

    Bastion Class

    Injury confined to foot

    1

    Injury involving lower leg permitting effective below-knee tourniquet application

    2

    Injury involving proximal lower leg or thigh, permitting effective above-knee tourniquet application

    3

    Proximal thigh injury, preventing effective tourniquet application

    4

    Any injury with buttock involvement

    5

    Associated segmental injury

    (presence of potentially viable tissue distal to the most proximal injury)

    Suffix S



    Associated intraperitoneal abdominal injury

    Suffix A

    Associated genitalia and perineal injury

    Suffix B

    Associated pelvic ring injury

    Suffix C

    Associated upper limb injury

    Suffix D

    Facts & Figures

    Class

    Recommendation

    Initial debridement and/or amputation

    Method of vascular control

    1

    Debridement ± plaster of paris (PoP) splintage

    None required

    1S

    PoP splintage ± debridement

    At most, tourniquet application

    2

    Most likely low or high transtibial amputation

    Tourniquet at any level; 1 had intraperitoneal iliac vessel control

    2S

    Combination of debridement, PoP splintage, and external-fixation

    At most, tourniquet application

    3

    Most likely through-knee or low transfemoral amputation

    Tourniquet; may require intra- or less commonly extra-peritoneal vessel control

    3S

    Majority required debridement only; also included PoP splintage, external-fixation, or low transfemoral amputation

    Tourniquet at any level; may require extra- or intra-peritoneal iliac vessel control

    4

    Most likely high transfemoral amputation

    Intra-peritoneal iliac vessel control; less likely extra-peritoneal control

    4S

    Majority required debridement only; also included high transtibial or transfemoral amputation

    Tourniquet, femoral vessel or intra-peritoneal iliac vessel control

    5

    Most likely high transfemoral amputation

    Intra-peritoneal iliac vessel control; less likely extra-peritoneal control or tourniquet

    5S

    Debridement only

    Extra-peritoneal vessel control

    Based on data from Jacobs 2014.

    Evidence Appraisal

    A panel of military surgeons, Jacobs et al, developed the Bastion Classification and performed a prospective validation study with 103 patients who sustained 179 lower limb injuries caused by improvised explosive devices (IEDs) in Afghanistan from November 2010 to February 2011.

    The primary aim of the proposed classification was to provide a pragmatic, comprehensive, and clinically relevant system to better facilitate the transfer of information. Currently existing lower limb injury classification systems fail to describe the complete injury pattern or correlate with management. The Internal Committee of the Red Cross classification is broad and does not provide information on the severity of injury. The Mangled Extremity Severity Score (MESS), Gustilo and Anderson, and Muller-AO classifications do not provide information on injury level. Muller-AO also does not take into account soft tissue injury. The secondary aim of the study by Jacobs et al was to facilitate the assessment of interventions. The Bastion Classification did show a predictable association with the level of initial musculoskeletal debridement and/or amputation and the level of vascular control.

    The original study was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level, and thus, this information is not provided in the publication nor conclusions made.

    A recent study in 2013 by Lundy and Hobbs looked at 67 patients with 117 injured limbs caused by dismounted blast exposure. The authors noted that the Bastion Classification appeared to be predictive of initial musculoskeletal treatment but was less useful in predicting the need for proximal vascular control, especially in the most common Class 3 injuries. The original study by Jacobs et al showed Class 3 injuries correlated with a higher rate of intra- or extra-peritoneal iliac vessel control (23% of 83 Class 3 injured limbs without associated abdominal injuries) compared to the study by Lundy et al, which only had 1 patient with a Class 3 injury without associated abdominal injury and 6 (5%) of all injured limbs requiring iliac vessel control. The 2013 study also does not comment on the Bastion Classification and mortality rates.

    Literature

    Other References

    Research PaperScerbo MH, Holcomb JB, Taub E, Gates K, Love JD, Wade CE, Cotton BA. The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock. J Trauma Acute Care Surg. 2017 Dec;83(6):1165-1172.Research PaperCannon JW, Hofmann LJ, Glasgow SC, Potter BK, Rodriguez CJ, Cancio LC, Rasmussen TE, Fries CA, Davis MR, Jezior JR, Mullins RJ, Elster EA. Dismounted Complex Blast Injuries: A Comprehensive Review of the Modern Combat Experience. J Am Coll Surg. 2016 Oct;223(4):652-664.e8.Research PaperCoupland RM, Korver A. Injuries from antipersonnel mines: the experience of the International Committee of the Red Cross. BMJ. 1991 Dec 14;303(6816):15909-12Research PaperGustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. Journal of Trauma 1984 Aug;24(8):742-6.Research PaperMuller ME, Nazarian S, Koch P. The Comprehensive Classification of Fractures of Long Bones. Springer;1987. Research PaperBrown KV, Ramasamy A, McLeod J, et al. Predicting the need for early amputation in ballistic mangled extremity injuries. J Trauma. 2009 Apr;66(4 Suppl):S93-7; discussion S97-8.Research PaperLy TV, Travison TG, Castillo RC, Bosse MJ, Mackenzie EJ. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am. 2008;90(8):1738-43.Research PaperLoja MN, Sammann A, Dubose J, et al. The mangled extremity score and amputation: Time for a revision. J Trauma Acute Care Surg. 2017;82(3):518-523.
    Dr. Neal Jacobs

    About the Creator

    Neal Jacobs, MD, FRCS, is a consultant orthopaedic surgeon at the Salisbury NHS Foundation Trust and New Hall Hospital in Salisbury, UK. He served as a medical officer in the Royal Air Force for over 16 years before retiring with the rank of wing commander in 2015. Dr. Jacobs' work has been published in numerous peer-reviewed publications in the orthopedic medical literature, and he has also co-authored a book chapter.

    To view Dr. Neal Jacobs's publications, visit PubMed

    Content Contributors
    • Jennie Kim, MD
    • Travis Polk, MD, FACS
    About the Creator
    Dr. Neal Jacobs
    Partner Content
    Content Contributors
    • Jennie Kim, MD
    • Travis Polk, MD, FACS