Embedded Fragments from U.S. Military Personnel—Chemical Analysis and Potential Health Implications

Abstract

Background: The majority of modern war wounds are characterized by high-energy blast injuries containing a wide range of retained foreign materials of a metallic or composite nature. Health effects of retained fragments range from local or systemic toxicities to foreign body reactions or malignancies, and dependent on the chemical composition and corrosiveness of the fragments in vivo. Information obtained by chemical analysis of excised fragments can be used to guide clinical decisions regarding the need for fragment removal, to develop therapeutic interventions, and to better anticipate future medical problems from retained fragment related injuries. In response to this need, a new U.S Department of Defense (DoD) directive has been issued requiring characterization of all removed fragments to provide a database of fragment types occurring in combat injuries. Objectives: The objective of this study is to determine the chemical composition of retained embedded fragments removed from injured military personnel, and to relate results to histological findings in tissue adjacent to fragment material. Methods: We describe an approach for the chemical analysis and characterization of retained fragments and adjacent tissues, and include case examples describing fragments containing depleted uranium (DU), tungsten (W), lead (Pb), and non-metal foreign bodies composed of natural and composite materials. Fragments obtained from four patients with penetrating blast wounds to the limbs were studied employing a wide range of chemical and microscopy techniques. Available adjacent tissues from three of the cases were histologically, microscopically, and chemically examined. The physical and compositional properties of the removed foreign material surfaces were examined with energy dispersive x-ray fluorescence spectrometry (EDXRF), scanning electron microscopy (SEM), laser ablation inductively-coupled plasma mass-spectrometry (LA-ICP-MS), and confocal laser Raman microspectroscopy (CLRM). Quantitative chemical analysis of both fragments and available tissues was conducted employing ICP-MS. Results: Over 800 fragments have been characterized and included as part of the Joint Pathology Center Embedded Fragment Registry. Most fragments were obtained from penetrating wounds sustained to the extremities, particularly soft tissue injuries. The majority of the fragments were primarily composed of a single metal such as iron, copper, or aluminum with traces of antimony, titanium, uranium, and lead. One case demonstrated tungsten in both the fragment and the connected tissue, together with lead. Capsular tissue and fragments from a case from the 1991 Kuwait conflict showed evidence of uranium that was further characterized by uranium isotopic ratios analysis to contain depleted uranium. Conclusions: The present study provides a systematic approach for obtaining a full chemical characterization of retained embedded fragments. Given the vast number of combat casualties with retained fragments, it is expected that fragment analysis will ha...

Biologic monitoring and surveillance results for the department of veterans affairs' depleted uranium cohort: Lessons learned from sustained exposure over two decades

“…Such concern has driven the Department of Veterans Affairs to conduct bio-monitoring on patients who have suffered injuries from improvised explosive devices (IED) during the recent Iraq and Afghanistan conflicts. Through fragment content analysis, a suite of 14 metals has been identified to comprise the most commonly observed metal components of surgically removed fragments from IED injured service members [Centeno et al, 2014]. Because the DU penetrator was not solely composed of DU, but was alloyed with titanium , and due to raised concern regarding the release and potential toxicity of metal ions from DU and non-DU retained fragments as described above, the bio-monitoring battery has been enlarged to include this suite of metals encountered in IED, as well.…”

“…These metals were chosen based on their presence in analyzed embedded fragments [Centeno et al, 2014] and their potential toxicity and carcinogenicity [Gaitens et al, 2010]. Preparation of urine samples and metal analysis by sector field high resolution ICP-MS were conducted as described by Gray .…”

The management of embedded metal fragment patients and the role of chelation Therapy: A workshop of the Department of Veterans Affairs—Walter Reed National Medical Center

“… a Reported by Centeno et al 10 as commonly found in embedded fragments removed from military personnel.…”

“…The infrequency of these events further complicates efforts to identify and remove fragments and to identify and monitor patients at risk 68,69 . While most fragments from combat‐related injuries contain a mixture of metals, iron, copper, and aluminum have been found to be the main components 10 . The presence of lead, tungsten, and DU in embedded fragments is less common 10 .…”

“…Surgical removal of bullets or fragments after the initial injury on the battlefield has been typically limited to those particularly large or easily accessible, those in an intra‐articular or intra‐spinal location and those considered life‐threatening by reason of location near or within vital structures in the body 8 . Also supporting the practice of limited surgical fragment removal has been the long‐held belief that metal fragments embedded in soft tissues were biologically relatively benign and could, therefore, be safely retained in the body over many years 9,10 …”