TY - JOUR
AU1 - Derkenne, Clément
AU2 - Lamblin, Antoine
AU3 - Demaison, Xavier
AU4 - Darléguy, Adrien
AB - ABSTRACT The wearing of individual protective elements has revolutionized the typology of war wounds. The benefit/risk ratio is particularly satisfying, but several side effects with minor consequences are described, calling for further ergonomic development from manufacturers of these protective elements. This case report describes a meralgia paresthetica by compression of the lateral cutaneous thigh nerve because of the wearing of bulletproof vest. A symptomatic treatment was introduced, and 2 months after the apparition of the symptoms, the patient's condition has improved, with only a slight hypoesthesia remaining. INTRODUCTION In modern conflicts, 10% of injuries and 20% of casualties reveal chest injuries.1 Primarily protecting the “cardiac box” as well as a large part of the chest, the bulletproof vest (or “frag-jacket”) has led to a reduction of mortality in combat.2 However, this protection is heavy, bulky, and the almost permanent wearing of the jacket in field operations is not without constraints: a reduced mobility during exposure to combat, a logistical load constraint while walking, and related medical complications linked to the wearing of the jacket. OBSERVATION A 30-year-old French soldier, with no medical history, serving in Mali in a Liaison and Operational Support Detachment (Mission Barkhane) consults for a clear hypoesthesia in a very specific area of the thigh (Fig. 1). FIGURE 1. View largeDownload slide Right tight and meralgia paresthetica area. FIGURE 1. View largeDownload slide Right tight and meralgia paresthetica area. This symptom appeared after the patient returned from a 5-day mission; he was wearing a bulletproof vest for about 14 hours a day. Occupying the radio-gunner position, he spent all day, almost without moving, sitting in the front right seat of the Armored Vanguard Vehicle. Medical tests reveal epicritic and protopathic anesthesia in an area, the size of the palm of the hand, below the inguinal ligament, ahead of the greater trochanter on the lower right limb. There was no spinal syndrome, no amyotrophia, at tiered testing, nor any decrease in muscle strength in the thigh muscles or the psoas. There was no pain, and the Lasègue and Leri tests were ineffective. The patellar and Achilles reflexes were symmetrical, the cutaneous plantar reflex in simple retreat. There was no tick bite, no rash. Next to the anterosuperior iliac spine there was a slight clear bruise. Questioned about the trauma causing this cutaneous lesion, the patient referred to a very prolonged compression caused by the lower rim of the frag on the iliac crest. Indeed, after examining the patient with his bulletproof vest, it appeared that when he was seated, it rested on both iliac crests. In the absence of available additional tests, a meralgia paresthetica by compression of the lateral cutaneous thigh nerve was diagnosed. It is not possible to dispose of the triggering factor, and the case does not call for repatriation to France. Simple monitoring was therefore prescribed, and to avoid the sensory disturbance, it was recommended to the fighter to wear body armor when absolutely necessary and avoid maximum nerve compression in the upcoming military operations. A month after his return, the patient's condition had improved, with only a slight hypoesthesia remaining. DISCUSSION Positive Diagnosis of Meralgia Paresthetica In our case, the patient was wearing a Tiger “body armor” made by Paul Boyé Technologies (Labarthe-Sur-Lèze, France); the patient measured 185 cm, weighed 73 kg, and had a 97-cm chest size, so he was equipped with a size-M jacket, as recommended by the manufacturer. Before use, it weighed 13 kg, with all the equipment (6 FAMAS [French assault rifle] chargers and 2 PAMAS [French 9-mm Pistol] chargers) and one first aid kit (19 kg). In standing position, the front plate protects the chest 46 cm from the top of the sternal notch to the navel, stopping 10 cm above the pelvic girdle. When sitting, the patient, sitting upright in the Armored Vanguard Vehicle, saw his head protrude above the upper tape, so he remained slumped during the 5 days of the mission, the frag resting on the iliac crests. The lateral cutaneous nerve of the thigh rises from the lumbar plexus, more specifically the dorsal branches of the second and third lumbar nerves. In 25% of cases, its path protrudes above the iliac crest. Otherwise, it passes through the inguinal ligament, 1 cm within the anterior superior iliac spine. Its posterior branch has a sensory function in the lateral side of the thigh. In the case reported above, it has most likely been pinched, creating an equivalent tunnel syndrome. This clinical phenomenon is not rare. Most common causes include compressing panniculus in obese individuals, tight garments, scar tissue in the proximity of the inguinal ligament, during local or regional surgeries, or in long-distance walkers. Even in combatants, it is relatively not rare, usually because of tight belts. Yet, it is seldom reported that bulletproof vests can be culprits. There are currently only two cases described among American troops serving in Iraq, wearing bulletproof vests for 4 to 6 hours a day for several weeks in a row.3 Treatment with gabapentin, oral nonsteroidal anti-inflammatory drugs, and even topical local anesthetic to reduce dysesthesia were ineffective. The 2 soldiers healed a month after the removal of the protection, as in the case described. There is no consensus concerning the treatment of meralgia paresthetica: physiotherapy, local electrical stimulation, and nervous surgical release. Published articles are very limited. In the latter, the frag was obviously responsible for the injury, and treatment by removal of the jacket was effective.4 Concerning benefits and risks of ballistic protection, one cannot consider not wearing ballistic protective effects, and the risk/benefit ratio is particularly favorable. Benefits first: It has long been difficult to scientifically prove a decline in mortality induced by the usage of a bulletproof vest, this is because of the lack of data. However, Breeze et al. have demonstrated that wearing class IV protection elements has divided by four the number of penetrating injuries in the chest and abdomen and the severity of the wounds on a sample of 174 injured in the Afghanistan conflict.5 An Israeli study comparing military (equipped) and civilians (not fitted) victims of firearm terrorism reported a mortality rate 2.5 times higher in the absence of protection.2 In addition to these benefits on morbidity and mortality, there are positive ergonomic factors to the bulletproof vest, that is, the soft system grip equipment, the ease of extraction from the vehicle along with easy pick and run, thanks to the handles or shoulder straps.6 Risks: nevertheless, recent modern mandates have contributed to fully describe the medical complications of bulletproof vest wear. First of all, frequent back and knee pain, whose allocation to bulletproof vest is also linked to the mechanical and time constraints of marches, sleeping conditions, combat in rough terrain, the weight of armament, haversacks, helmets, night optics, etc. On the other hand, we must not forget the backfire effect of weapons that dissipate the energy absorbed by the protection, causing bruises, fractures, and lung, heart, and liver bruises. We cannot, however, compare the damage caused by the posterior surface of the shield of a bulletproof vest than that caused by the projectile wound in its absence.7 Finally, there is a decrease in mobility during fire action, a major increase in energy expenditure, as well as heat-related thermoregulation problems, so many legitimate accusations are voiced by the military against their shields without however banning their usage.8 Concerning the ergonomics of ballistic protection, if one cannot do without these ballistic elements, we must limit their side effects. They must all meet the STANAG 2920 standard, with a projectile stopping power (maximum 4,000 J). Thus, in French Army, in 2008, the GPB S3 (VTN Industries, Taninges, France) of the Army Police, in use since the conflict in former Yugoslavia, was urgently replaced with IARCs (Eagle Industries, Norfolk, Virginia) models and by MSA Paraclete (Pompano Beach, Florida). Finally, the Paul Boyé Tiger vest was introduced in the Sahel conflict (Paul Boyé Technologies, Labarthe-sur-Lèze, Haute-Garonne, France). The fighters have been upgraded from class III to class IV saving about 3 kg because of the introduction of ceramic plates on the flanks. Numerous ergonomic improvements have also been made: a more adjusted fit to release shoulders, a soft grip material system (Molle: Modular Lightweight Load-carrying Equipment), and the possibility of a very useful quick release in case of injury. Similarly, the straps are evenly lined with high-density foam to protect the deltoids, while an elastic belt straps the jacket close to the body thus improving the weight distribution. CONCLUSION This observation reports a mild and rare complication linked to the wearing of ballistic protection elements. Obviously without questioning their usefulness, it calls for further ergonomic development from manufacturers, which should in the future offer bulletproof vests lighter and customized, adapted to each fighter's body. It also makes the clinician aware of the importance of environmental constraints faced by soldiers in external operations. REFERENCES 1. Borden Institute and Office of the Surgeon General Emergency War Surgery: Fourth United States Revision . Fort Sam Houston, TX: Borden Institute U.S. Army Medical Department Center and School and Falls Church, Virginia: Office of the Surgeon General United States Army, 2013. Available at http://www.cs.amedd.army.mil/borden/FileDownloadpublic.aspx?docid=80035d1a-f208-473d-993b-6debfb17db91; accessed March 2, 2015. 2. Peleg K, Rivkind A, Aharonson-Daniel L Israeli Trauma Group Does body armor protect from firearm injuries? J Am Coll Surg  2006; 202( 4): 643– 8. Google Scholar CrossRef Search ADS PubMed  3. Fargo MV, Konitzer LN Meralgia paresthetica due to body armor wear in U.S. soldiers serving in Iraq: a case report and review of the literature. Mil Med  2007; 172( 6): 663– 5. Google Scholar CrossRef Search ADS PubMed  4. Cheatham SW, Kolber J, Salamh PA Meralgia paresthetica: a review of the literature. Int J Sports Phys Ther  2013; 8( 6): 883– 93. Google Scholar PubMed  5. Breeze J, Allanson-Bailey LS, Hepper AE, Midwinter MJ Demonstrating the effectiveness of body armor: a prospective pilot trial computerised surface wound mapping trial performed at the Role 3 hospital in Afghanistan. J R Army Med Corps  2015; 161( 1): 36– 41. Google Scholar CrossRef Search ADS PubMed  6. Papillault des Charbonneries L, Pessey F, Goutodier G, Rodier M, Lacassagne D Une technique d'extraction d'urgence d'un blessé d'un véhicule de l'avant blindé sous le feu. Médecine Armées  2013; 41( 1): 265– 70. 7. Cannon L Behind armor blunt trauma—an emerging problem. J R Army Med Corps  2001; 147( 1): 87– 96. Google Scholar CrossRef Search ADS PubMed  8. Goforth C, Lisman P, Deuster P The physiological impact of body armor cooling devices in hot environments: a systematic review. Mil Med  2014; 179( 7): 724– 34. Google Scholar CrossRef Search ADS PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - A Heavy Protection
JF - Military Medicine
DO - 10.7205/MILMED-D-15-00191
DA - 2015-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/a-heavy-protection-EHLCJ07ubA
SP - e1287
EP - e1289
VL - 180
IS - 12
DP - DeepDyve
ER -