Injuries Amongst The Bangladesh Armed Forces Personnel During Military Activity Admitted In CMH Dhaka

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1.1 Introduction
 
Injuries in general have a greater impact on the health and readiness of the military than any other category of medical complaint. Physical training and physical fitness are required to accomplish military missions. Many military occupations routinely require a higher level of physical exertion and fitness than most other occupations. During military training, all military personnel must attain and then afterward maintain a much higher level of fitness. The fitness needed to function in an operationa l unit varies by the type of unit but, in general, will be higher in combat arms units than in combat support or combat service support units. In addition to differences between types of units, there are often substantial differences in the personnel within the units. While most military personnel are young and fit, senior non-commissioned officers and officers are generally older, more sedentary, less fit, and may be less healthy¹.
 
The need for fitness and the requisite physical training to maintain mission-readiness, the burden and impact of training injuries, the protective effects of fitness in preventing subsequent injuries result in a complex and dynamic matrix of competing requirements. Understanding this matrix and optimizing the competing requirements is a difficult challenge for military policymakers, planners, commanders, and medical personnel. Nonetheless, only coordinated, well-planned and multifaceted approaches based on an understanding of the many factors involved will have a positive impact on reducing the levels of injuries ².
 
Bangladesh Armed Forces personnel are involved in many kinds of operations, exercises, task and training. The Soldiers from all ranks suffer from injury in terms of mortality or morbidity. Injury in military personnel mainly occurs due to military activities either working place or house holds activities.
 
Common activities are physical training or courses, physical efficiency test, various sports and games; UN adapted training, activities in the field like assault bayonet fighting, unarmed combat, organized drill, parade and basic military training. Among the special activities are operations in counter insurgency, exercise training, working in the aid of civil power etc. Most injuries are not catastrophic or life threatening—result only in limited duty for several days. The high incidence of injuries, however, places a substantial burden on the medical care delivery system and leads to many lost training days.
 
Successful prevention depends on identification of modifiable risk factors. Sound epidemiologic studies can be performed prospectively or retrospectively. Once the risk factors for injury have been identified, targeted and successful modifications can begin to reduce the operational, fiscal, and health impact of these problems. Finally, research and evaluation of injuries and intervention programs must be ongoing to identify the most effective and efficient preventive activities.
 

 
 
 

An injury is the physical damage that results when old of physiological tolerance or a human body is suddenly or briefly subjected to intolerable levels of energy. It can be a bodily lesion resulting from acute exposure to energy in amounts that exceed the threshold or it can be an impairment of function resulting from a lack of one or more vital elements such as air, water, warmth etc.
 
The standard definition of an “injury” as used by WHO is: “Injuries are caused by acute exposure to physical agents such as mechanical energy, heat, electricity, chemicals, and ionizing radiation interacting with the body in amounts or at rates that exceed the threshold of human tolerance.
 
Types of injury
 
Injuries may be categorized in a number of ways. However, for most analysis purposes and for identifying intervention opportunities, it is especially useful to categorize injuries according to the location at which the injury occurs. Commonly used categories are:
a. Road traffic injury: Among all type of injury, road traffic injury are foremost to cause fatal injuries to occupants of motor vehicles and pedestrians as well.
b.Industrial injury: Industrial workers have to remain busy in production processing job for about one third of their active life in workplaces where they come in constant contact with machines and equipment with consequent risk of injury hazards.
c. Household injury: Not all injury occurs on the road or playground or in places of work. Perhaps more common are the injury that take place in known surroundings of our home where we spend most of our time. Inmates of all ages may be involved in domestic injury, but they are all the more serious at the extremes of life causing death and disability.
d. Sport injury: Injury resulting from sports and games are common, in 80% of all such cases upper/ lower limbs are affected and therefore, reduced mortality are generally observed. Thorax and spinal cord may be the frequent outcome of injury in sports⁴.
e. Injury due to military activity: The distribution of the mechanisms of combat injuries is strongly dependent on the branch of military service and how the combat is fought. Injury may occur due to different type of military activity like Operation, exercise (Real military operation and preparation for military operation), playing, physical training (Jumping over 9 feet ditch, drill, fall /crossing over 6 feet wall, 3 km runs, Route march, 4 km walks), physical efficiency test, assault course/bayonet sighting, direct hit by object, crossing monkey rope, carrying log and shell, swimming and daily routine work (driving army vehicle, office work, working in unite for maintenance, house hold activity at home). In military sports are played normally football, volleyball, basketball, hockey and different type of athletics cause different types of injury in the body.
 
Epidemiology and concept of injuries.
 
 In the epidemiology of injury, as in the epidemiology of disease, the factors can be categorized as:
 
Host: The host or the individual affected has been the principal factor of epidemiological studies. Poor vision and uncontrolled convulsive diseases often increase the risk of injuries. Human negligence (e.g. not to use protective attire and equipment), ignorance and complacence on the part of workers may often be the cause of industrial injury. Military activities also cause injury among the Armed Forces Personnel.
 
Environment: Alterations made in the physical environment an increase or reduce the risk of injuries. Road design can decrease or increase the risk of injuries. A road barrier can assist automobiles to come to a safe stop or can become a hazard by piercing an occupant of the automobile. Both physical and psychological environment in factories influence the frequency of industrial accidents. The psycho-social environment is comprised of societal attitudes, laws regulations that control or tolerate events the can lead to injuries.
 
Agent: A large amount of energy quickly transmitted may result in injury. In injuries exposure to these agents occurs at rates greater than the body can tolerate and injury occurs acutely after exposure. The five types of energies that cause injuries are as follows: (1) Mechanical or kinetic energy (automobile crash, fall, sports injuries etc) (2) Thermal energy (burns and scalds); (3) Electrical energy (electrocution) (4) Radiation energy (burns) (5) Chemical energy (Acute brain injury caused by the carbon monoxide interfering with oxygen- carrying capacity of blood).  In Armed Forces mechanical energy is the main causes of injury.
 
Vector: The vectors, in the context of injuries, are the carriers of energy. These factors have influence on the occurrence of injuries. Firearms, which are vectors of kinetic energy. Automobiles are vectors of kinetic energy and automobile design can decrease or increase the risk of injuries.
 
 
 
                                      
                       
 
 
 
 
 

 
 

 
 
 
Figure-1.1: Epidemiology of Injury
 
 
Risk factors for military injuries
Identifying and understanding risk is key to developing effective prevention and treatment strategies for overuse injuries. Successful prevention depends on identification of modifiable risk factors.
 
Intrinsic risk factors:  A number of intrinsic risk factors have been identified among military populations. They include age, sex, anatomy, fitness, flexibility, and smoking.
Extrinsic risk factors:  Several extrinsic factors have also been identified, and these may be even more appropriate areas for intervention efforts than are intrinsic factors. The training itself (the total amount of activity and the scheduling of it), footwear and running surface have all been postulated as being contributors to training injuries. Running more miles and a rapid increase in the level of activity have both been shown to be associated with a higher risk of injury¹.
 
Nature and incidence of injury
Tissue response to injury largely reflects the nature of the damaging mechanism. The pattern of injury throughout the various tissues involved will tend to a degree of uniformity with sonic variation at individual sites as a response to peculiar local factors. The general pattern of injury, however, remains reasonably constant throughout the body. Typical examples of pathological response to trauma in the tissues are repeatedly reproduced at different anatomical sites.
 
Skin injury: A variety of different types of trauma may be noted e.g. laceration, abrasion, hematoma, contusion, bruise, puncture wounds, burns and blisters etc.
 
Muscle injury/muscle tear:   Muscle damage occurs as a result of either external forces (contusion, haematoma or laceration) or more commonly as the result of forces generated within the tissue, i.e. as an intrinsic injury. The injury is then called a strain or tear of which there are three basic types, complete and partial, the latter being either interstitial or intramuscular. The severity of muscle injury will depend very often on the degree of training of the individual.
         
Fig: 1.2- Different types of injuries (from left to right) skin, tendon, muscle and joint injury
 
Tendon injury:          Damage to tendons by direct violence is uncommon. Usually injuries are intrinsic and most are of the overuse type. They are readily classified by their local pathology which is associated with well-defined clinical features.
 
Joint injury:               Joint injuries are common particularly in body-contact events. The range of damage varies from minor sprain to major fracture or dislocation. Most joints are synovial, being reined forced in certain sites by ligaments, and some contain fibro-cartilaginous menisci. Damage may occur to any or all of these structures.
 
Ligament injury:       Damage to ligaments may cause minor tears or complete rupture. Complete rupture leads to mechanical instability.  Tearing even if quite minor may damage the proprioceptive feed back mechanism and lead to stable instability.
 
Bone injury:               Bone injuries are quite common usually as a result of direct violence (sometimes deliberate). Generally fractures sustained in sport differ little from those sustained in other activities.
 
Injury a global burden
 
Injuries constitute a variable epidemic. During 1990s injuries ranked ninth among the leading causes of deaths in the world. It is projected to become second leading cause by the year 2020, next to ischemic heart disease. Injuries are responsible for approximately 9.1 per cent about (5.16 million) of all causes of deaths in the world and about 16 per cent of the disabilities are reported due to injuries. They are also the major cause of death among persons aged 10-24 years. In the developed regions, 57 per cent of male deaths and 43 per cent of female deaths in this age group are due to injuries. About 3.5 million people die of unintentional injuries and about 1.6 million die of intentional injuries. Road traffic accidents claim 1.2 million lives, self inflicted injuries and violence are becoming important causes of loss of lives.
 
Regional scenario and Bangladesh
 
Accidents are definitely on an increase in this South Asian region as well as in Bangladesh. Of the 5.1 million deaths from injuries globally, more than one-fourth are estimated to occur in the South—East Asia Region³. Increasing mechanization in agriculture and industry, induction of semi skilled and unskilled workers in various operations and rapid increase in vehicular traffic have resulted in an increase in morbidity and mortality due to injury. Overcrowding, lack of awareness and poor implementation of essential safety precautions result in an increasing number of accidents. Deaths, disabilities and hospitalization due to injuries continue to have impact of socio-economic loss to individuals, families, society and infrastructure.
 
The magnitude of the problem in the military
 
Among military personnel, injuries cause more deaths (about 50% more) than any other cause. Injuries are implicated in a substantial proportion of disability discharges; nearly 50% of Army medical examination board reviews of personnel assigned to an Army infantry division in 1994 was directly related to injury¹. Evaluation of physical examination board data indicates that many chronic conditions leading to disability may result from service-related injuries. Acute and chronic effects of injuries are a major cause of hospitalization, causing about 30% of Army hospitalizations among active duty personnel in 1992¹. Injuries, particularly training injuries, create an enormous load on outpatient facilities. Among Army and Marine Corps trainees, rates of outpatient visits due to injuries of 20% to 40% per month have been observed, and rates of 20% per month have been reported among trained infantry soldiers. Furthermore, these problems are not unique to the US military; many other countries recognize the impact of injuries on their armed forces.
 

 
 
 
 
 
 
 
 
 
 
 
 

Figure-1.3-No of hospital discharge (major category in USN &Marine Corps) (Source-Diana S, Navy & Marine Public health centre)
 
Injuries at all levels of severity cause a huge drain on military manpower and health care services and inflict enormous direct and indirect costs.
 
Impact of injuries: lost time and financial costs
 
It has been estimated that stress fractures alone among 22,000 Marine Corps trainees in 1 year resulted in 53,000 lost training days and cost more than $16.5 million. Extrapolation from the Marine Corps to all military trainees provides a reasonable estimate of costs related to all training injuries on the order of $100 million annually. The mean number of days lost per injury among Army infantry soldiers for stress fractures was 103, compared to 17 for sprains, 8 for other traumatic injuries, 7 for tendonitis, and 3 each for strains and musculoskeletal pain².
                                                                                    
Commanders and military policymakers need to be vigilant about all aspects of injuries so that they can make broad changes to effect improvements. Research and evaluation of injuries and intervention programs must be ongoing to identify the most effective and efficient preventive activities⁸.
 
1.3       Justification of the study
 
The health, training and lifestyle of the soldiers constitute the pivot of the performance of tomorrow’s Armed Forces. With the increasing demand of national and international military activities the Bangladesh Armed Forces has extended its organizational size and capabilities too. Bangladesh Armed Forces has conducted more than 31 UN peace keeping mission in 25 countries, the highest among the developing countries.
 
The crucial factor for the Armed Forces personnel is their Physical fitness, which is a very important for achieving the individual and national goal. Without physical fitness, modern equipments and technology cannot help to achieve the defined goal. Injury is one of the most single factors that affect the young Armed Forces personnel. Beside this, Armed Forces personnel has to perform some moderate to severe training activities like physical exercise, physical efficiency test, assault bayonet fighting, different games and athletic events etc. Socioeconomic background of our Armed Forces personnel is not well enough to bear the burden of disable life after his retirement.
 
Numerous scientific study related to physical stress were being carried out internationally and nationally to observe the prevalence of injury among the military and non military personnel to reduce the disability. Assuming its importance, several studies were conducted in relations to particular injury in Combined Military Hospital Dhaka. Previously different kinds of study on all types of injuries amongst the Armed Forces personnel were conducted in multifaceted dimension. This study was conducted to find out the all types of injuries amongst the Armed Forces personnel reported to Combined Military Hospital, Dhaka for indoor treatment with an objective that will be helpful in generating some initial data basing in which further research and necessary measures can be taken to prevent such catastrophes.
 
There are multidimensional activities conducted and carried out in the Bangladesh Armed Forces throughout the whole year. Specific pattern of operation, exercise, physical training, sports and other administrative duties are carried out in particular period of time. To get an overall assumption on the injury pattern, it is feasible to conduct a study with a sufficient period of time. For the practical point of view, to achieve such objectives to assess types, causes, treatment module, morbidity and mortality of the military personnel due to injury this descriptive retrospective study design will be able to achieve the desired target.
 
This scientific study in this field would bear immense importance to ascertain the recent pattern of injury and the nature of physical stress involved amongst the young and old Armed Forces personnel of Bangladesh Armed Forces personnel with a view to help Commanders and military policy makers to adopt appropriate rehabilitative and preventive measures to reduce the physical stress as well as consequences of all type of injuries.

1.4       research questions and objectives
 
1.4.1                research questions
 
1.4.1.1             What are the injuries amongst the Bangladesh Armed Forces personnel due to their military activity for which they are admitted in CMH Dhaka?
 
1.4.1.2             What are the causes and morbidity pattern of the injuries amongst the Bangladesh Armed Forces Personnel?
 
1.4.2                General objective
 
To find out the common injuries, causes and morbidity pattern amongst the members of Bangladesh Armed Forces personnel during their military activity.
 
1.4.3         Specific objectives
 
1.4.3.1To identify the socio demographic characteristics of Bangladesh Armed Forces Personnel.
 
1.4.3.2To find out the common types of injuries amongst the Bangladesh Armed Forces Personnel.
 
 
1.4.3.3To explore the causes of injuries amongst the Bangladesh Armed Forces Personnel.
 
1.4.3.4 To ascertain the pattern of morbidity due to injury amongst the Bangladesh Armed Forces Personnel.
 
1.5       Variables
                                         
1.5.1    Key variables:                       
           
1.5.1.1             Injury
                                   
a.         Ankle injury                            b.         Knee injury
                                    c.         Lower leg injury                      d.         Elbow injury
                                    e.         Patella injury                           f.          Foot injury
                                    g.         Neck injury                             h.         Head and facial                                                                                               injury
i.          Shoulder and arm injury         j.          Forearm, wrist           and hand injuries
                                    k.         Spinal injury                            l.          Achilles tendon                                                                                               injury                                                               m.        Pelvis and hip injury               n.            Other injuries
                       
1.5.1.2             Nature of military activity
                                   
a.         Operation / exercise
                                    b.         Games
                                                1)         Foot ball                      5)         Volley ball
                                                2)         Basket ball                  6)         Boxing
                                                3)         Swimming                   7)         Hockey
                                                4)         Athletics                      8)         others
                                    c.         Physical training and test.
                                                1)         Run 3 km.                  4)         Crossing                                                                     horizontal rope.
2)         Walk 16 km.                5)         Swimming.
                                                3)         Crossing 6 feet wall.   6)        Jumping 9                                                        feet ditch.
                                    d.         Administrative duties
 
                                                1)         Driving Army Vehicle   2)     Official duties
                                                3)         Unit maintenance           4)     others
           
1.5.1.3             Morbidity
 
                                    a.         Manifestations of illness
                                    b.         Type of treatment received
                                    c.         Total duration of hospital stay
                                    d.         Duration of suffering
                                    e.         Out come of treatment
                                    f.          Consequences after treatment
                       
1.5.1.4             Socio demographic variables
 
                                    a.         Age
                                    b.         Armed Forces
                                    c.         Arms/ Services
                                    d.         Rank
                                    e.         Marital status
                                    f.          Duration of service
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Fig-1.4-Conceptual frame work
 
 
1.6       Operational definitions
 
1.6.1 Injury:   An injury is the physical damage that results when the physiological tolerance or a human body is suddenly or briefly subjected to intolerable levels of energy which are due to military activity.     
 
1.6.2 Cases:    All male and female serving soldiers of Bangladesh Armed Forces received indoor treatment from CMH Dhaka and diagnosed as a case of injury by concerned surgeons which were due to any type of military activity/duty.
 
1.6.3 Common injury (Due to military activity):        The injuries which frequently occur in the armed forces personnel due to due military activities are the followings.
 
a.         Ankle injury                            b.         Knee injury
c.         Lower leg injury                      d.         Elbow injury
e.         Patella injury                           f.          Foot injury
g.         Neck injury                             h.         Head and facial injury
i.          Shoulder and arm injury         j.          Forearm, wrist and hand injuries
k.         Spinal injury                            l.          Achilles tendon injury            
m.        Pelvis and hip injury               n.         Other injuries
 
1.6.4                Armed Forces:           It includes Bangladesh Army, Navy and Air Force.
 
1.6.5                Arms / Services:         Armed Forces are grouped into fighting, supporting and services group in the Army, Navy and Air force as tabulated below:
Table-1.1L ists of Arms /Services in Bangladesh Armed Forces.
 

 

 
1.6.6 Soldiers: This includes Officers, JCOs, NCOs and all other uniformed personnel serving in the Armed Forces.
 
1.6.7 Ranks:  
a. Commissioned Officers: It includes Second Lieutenant, Lieutenant, Captain, Major, Lieutenant Colonel, Colonel, Brigadier and above of Bangladesh Army (equivalent commissioned rank of Navy and Air Force as specified by Ministry of Defense of Bangladesh).
 
b. Junior Commissioned Officer: It includes Master Warrant Officer, Senior Warrant Officer, Warrant Officer of Army and equivalent rank of Bangladesh Navy and Air Force.
 
c. Non Commissioned Officer and other ranks: It includes Sergeant, Corporal of Army (equivalent rank of Bangladesh Navy and Air Force).
 
d. Other ranks (ORs): It includes, Lance Corporal and Sainik of Army (equivalent rank of Bangladesh Navy and Air Force).
 
1.6.8    Training ground:      It includes the ground utilized for physical training and routine training activities like parade, physical efficiency test. Also includes special training events like assault course/ bayonet fighting, all events of walking, running and firing practice.
 
1.6.9 Sports ground: It includes the ground utilized for games e.g. Football, volleyball, basketball, cricket and athletics etc.
 
1.6.10  Military activity:        Military activities have been performed by the Bangladesh Armed Forces personnel at the present context are divided into following groups.
 
Table-1.2-       Military activity
 

 

 
1.6.11  Duration of suffering: This includes the total duration of period wef the patient being injured until declared fit by the treating surgeons on completion of leave on medical certificate or recommend medical category A from lower medical category.
 
1.6.12  Outcome of treatment: Berney L and Freeman MD⁹ in their book: ‘A long term follows up’ adapted 30 points scoring system for the patients of musculoskeletal injury.
 

 
The progress of the treatment during the stay at CMH Dhaka normally summarized by the concerned physician in his/her comment during discharge. In the study scoring has been determined following the opinion of the treating surgeon as follows which is almost similar in the clinical point of view.
 

 
1.6.13  Disability: Restriction or lack of ability to perform daily activity.
 
1.6.14  Medical category
 
a.         Medical Category ‘A’ (AYE): Armed Forces personnel fit for all kinds of duty anywhere around the globe.
b.         Medical Category ‘B’ (BEE): Armed Forces personnel fit for all kinds of light duty. It is divided into temporary and permanent category.
c.         Medical Category ‘C’ (CEE): Armed Forces personnel fit for only sedentary duty. 
 
1.6.15  MBO (Medically board out): Declared unfit for service due medical reasons.
                                   
LITERATURE REVIEW
 
Injuries at all levels of severity cause a huge drain on military manpower and health care services and inflict enormous direct and indirect costs. The high incidences of injuries place a substantial burden on the medical care delivery system and leads to many lost training days. To combat this catastrophes, many scientific studies were conducted worldwide both in international and native capacity.
 
2.1       Study review of the military injuries
 
2.1.1    Common injuries due to military activities
 
Knapik JJ, Hauret XG and Jones BH¹⁰ revealed by various studies and
enlisted in their book “Recruit Medicine” the following common injuries due to military activities:
 
Sprains: A sprain is a stretch or tear of a ligament. Ligaments are fibrous bands of connective tissue that join the end of one bone with another and provide joint stability. A lateral ankle sprain is the most common sprain in recruit training.
 
Strains: Generally, acute muscle strains result from stretching or tearing a muscle. Acute muscle strains are common in training, occurring most frequently in the muscles of the lower extremities (hamstrings, quadriceps, and the gastrocnernius-soleus muscles), lower back, and shoulder girdle (trapezius and rotator cuff).
 
Blisters and open skin wounds: Blisters and open skin wounds (i.e., abrasions, lacerations, and punctures) are common acute injuries in recruit training. It can become infected if not treated properly. Blisters are friction-related injuries caused by shearing forces that occur between the skin and equipment, such as boots or running shoes.
 
Fractures: In military training, fractures occur less frequently than sprains and strains, but they have a greater impact on training and tend to be more severely debilitating. The most common fracture sites among trainees are the lower leg and ankle. It occurs due to a single forceful event (e.g. falling from obstacle courses and tripping while running).
 
Stress fractures: Stress fractures of the lower extremity are common among military trainees. Stress fractures occur in response to repetitive overloading of bones during activities such as running, walking or marching.
 
Shin splints: “Shin splints,” is a common overuse injury in military training and exercise.
 
Low back pain: Low back pain is a common complaint either associated with or exacerbated by physical activity in recruit training. Low back pain as a result of musculo-skeletal injury can be a symptom of damage to the bony structural elements of the spine (vertebrae, intervertebral discs, ligaments, and facet joints) or to the supporting musculature of the back and abdomen. The major cause of low back pain during recruit training is overuse strain.
 
2.1.2    Injuries related to military training.
 
In their publication at the Borden Institute, Hauret KG, Jones BH and Knapik JJ ¹⁰ broadly classified the military training related injuries as acute (mostly traumatic) injuries and overuse injuries.
 
Acute injury: Acute injuries result from a single, forceful event (e.g. twisting an ankle while running, dislocating a shoulder during unarmed combat training or fracturing a bone in an obstacle course fall). Whenever ligaments, bones, or muscle and tendon units are subjected to significant and major abrupt forces that exceed the body’s inherent capability to absorb and dissipate the energy, structural tissue failure and injury result. The two major types of acute injuries encountered in training are sprains of the ligaments around the joints and strains of the muscles and tendons. Others are fracture bone, dislocation, friction blisters etc.
 
Overuse injury:         Overuse injuries result from smaller, repetitive forces on the structural (bones and ligaments) and force-generating (muscles and tendons) elements of the body. Over time excessive use or repetitive physical strain on tissues can exceed the tissues that decrease the ability to recover and repair it. The cumulative effect of these successive insults causes overuse injuries, which develop over days or weeks and are characterized by pain and inflammation. Trainees who are not physically fit or who were previously inactive are at higher risk for sustaining overuse injuries, compared with their more physically active and fit counterparts. Examples of overuse injuries are shin-splints, plantar fasciitis, and bone stress injuries (e.g. stress fractures), bursitis, tendinitis, metatarsalgia etc.
 
 
2.1.3 Military injuries in sports.
 
Elizabeth Quinn in their publication namely ‘Treatment and Prevention of Common Sports Injuries’ classified the Common sports injuries amongst military as follows.
 
Abrasions: Injuries that result from a fall on a hard surface that causes outer layers of skin to rub off.
Ankle sprain: The most common of all ankle injuries, an ankle sprain occurs when there is a stretching and tearing of ligaments surrounding the ankle joint.
 
Anterior cruciate ligament (ACL) injuries: ACL partial or complete tears can occur when an athlete changes direction rapidly, twists without moving the feet, slows down abruptly, or misses a landing from a jump.
 
Clavicle fracture (Broken Shoulder): A shoulder fracture typically refers to a total or partial break to either the clavicle (collar bone) or the neck of the humerus (arm bone). It generally is from an impact injury, such as a fall or blow to the shoulder¹².
 
Concussion: A concussion is typically caused by a severe head trauma where the brain moves violently within the skull so that brain cells all fire at once, much like a seizure.
 
Delayed-onset muscle soreness: Muscle pain, stiffness or soreness that occurs 24-48 hours after unaccustomed or particularly intense exercise.
 
Hamstring pull, tear or strain: Hamstring injuries are common among runners. The hamstring muscles run down the back of the leg from the pelvis to the lower leg bones, and an injury can range from minor strains to total rupture of the muscle¹³.
 
Knee pain:  Knee pain is extremely common in athletes. In order to treat the cause of the pain, it is important to have an evaluation and proper diagnosis.
 
Muscle Cramps: A cramp is a sudden, tight and intense pain caused by a muscle locked in spasm.
Over training syndrome: Overtraining syndrome frequently occurs in athletes who are training for competition or a specific event and train beyond the body's ability to recover¹⁴.
 
Williams J.P.G⁴ in their book ‘Injury in Sport’ classified some common injury due to sports of Armed Forces Personnel as stated below.
 
Knee injury — meniscus/ cruciate ligament injury: Injury to the menisci due to rotational strain on a flexed weight-bearing knee is extremely common. Damage to either cruciate, particularly when associated with capsular damage, is a potent factor of rotary instability of the knee and pivot shift.
 
Shoulder joint: Shoulder joint injuries are particularly common in sport. They may be the result of overuse, as in racket games such as badminton and tennis, or as a result of throwing and bowling as in cricket. Alternatively they may occur by direct violence. Either in body contact sport, such as rugby union and league football or as the result at a tall.
 
Elbow fractures and dislocations:   Fractures about the elbow, as well as dislocations, of joint mobility, in dislocations and some fractures, require serious attention.
 
Wrist injuries:  Wrist injuries are relatively uncommon, but may be a source of considerable disability. Fractures and sprains are no different from those incurred in normal activities.
 
Spinal injuries: Being well buttressed by the ribs, spinal injuries at this level are unusual except in severe riding and vehicular accidents, in which very heavy loads, often with a rotary component, are applied¹⁵.
 
Lower leg injuries: Lower limb injuries in sport are extremely common, both as a result of direct and indirect violence and of overuse. Apart from basic fractures and soft-tissue injuries, a number of pedal conditions are met in sport which may cause problems.
 
Achilles tendon injuries:  Achilles tendon pain is a problem in sport. Complete rupture is usually intrinsic but the patient often complains that he has been struck on the hack of the leg.
 
Ankle injury: Ankle injury is common in sport, being often associated with unsuitable footwear. It is particularly seen in football and skiing and ranges in severity from fracture dislocation to simple ligament sprain.
 
2.2       Scientific studies on injury
 
2.2.1    International Studies
 
2.2.1.1     General population
 
Cameron P conducted a study to evaluate the frequency, distribution, cause, pattern, and outcome of patients suffering from major trauma in the state of Victoria, England over a year period. The total number of patients admitted into the study was 2,944, and the type of injury was predominantly blunt (87 5%), with only a small percentage of penetrating injuries (64%) & burns (6%) The most common cause of injury was road transport (56%) and falls (22%). There were an unexpectedly low number of patients suffering from major trauma.
 
Messahel F reviewed the trauma admissions to the Surgical Intensive Care Unit (SICU) at King Khalid University Hospital, Riyadh during the period from 30 October 1984 to 29 October 1989. A total of 181 cases constituting 15, 7% of the total surgical admissions to the unit during that period were recognized. The main cause of trauma was road traffic accidents (83.4%). The male to female ratio in this group was 6.3:1.
 
Holmdah L, Orten WP carried out a prospective study over a time period May 1989- May 1992 on 33000 inhabitants of Sweden. They found that yearly incidence of trauma was 14.7% and a third of them occurred within the home. The largest percentage (36%) happened during spare time activities, followed by sports (18%) and on the road (11%). Only 34(0.7%) were severe injuries. Most injuries (67%) occurred in people below the age of 40 and 9% of all those who were injured were admitted to hospital i.e. only 1 in 10 needed admission to hospital.
 
Another prospective study was conducted by Olsen S  to determine the incidence and pattern of injury in young soccer players. The study included 496 boys from the soccer club in Denmark. The soccer players were between the 12 to 18 years. Data on injuries occurring over one year were reviewed. The soccer club had both recreational and elite teams. The players were approximately trained at least for 10 month per year. A total of 312 injuries were sustained by the players. In boys aged 16 to 17 years, the risk of injury to each player was 4 injuries per 1000 hours of play compared with 3.4 in boys aged 12 or 13 years and 3.8 in boys aged 14 or 15 years. Most (70%) of injuries were located in the lower extremities, especially in the knee (26%) and the ankle 23%). Back injuries occurred in 14% of the players. The theoretical risk of injury was one injury every 68 games or one injury every 1.5 years.
 
Contact sports have high rate of injury. Protective equipment regulations are widely used as an intervention to reduce the injury risk. An ecological study of protective equipment and injury in two contact sports was conducted by Marshall WS where injury rates in US collegiate football were compared to New Zealand club Rugby Union. Both sports involved significant body contact and had a high incidence of injury. They found that the overall rate of injury in football games was approximately one third of the rate in rugby. Injury rates were lower in football for all body regions. The most common sites of injury in football was the knee (24% of all injury), followed by the trunk/pelvis/hips region (14%) and ankle (14%). But in Rugby rates of injury in knee was 13%.
 
The Soccer is the most popular team sport worldwide with an estimated 40 million amateur participants. A laboratory and field testing analysis of a preventive intervention was done by Janda HD taken the data of 647368 injuries from the consumer product safety commission through the National Electronic Injury Surveillance system between 1989 and 1992. The distribution of injuries as determined by the consumer product safety commission revealed 71 % of the injuries were sustained by males and 29% by females. Ankle injuries comprised 19.2% of total injuries; knee injuries 12.7%; head and facial injuries 11.3%; lower leg injuries 7.5%.
 
The impact of anaerobic and owner-type strength training on health, however, has been less well investigated. Surakka J had carried out a prospective study to examine the feasibility of a ‘power-type strength training program for middle aged men and women, the impact of training program on perceived health and fitness and on knee and low back symptoms, and the rate of exercise induced injuries. A total 154 voluntary, healthy, sedentary men and women participated in a training program lasting about four months. Musculoskeletal disorders and exercise induced injuries were reported during the training program. Despite other findings, the exercise induced injury rate was 19% in men and 6% in women which was lower than the other study which had shown to be 24% to 40%. The researcher concluded that, participation in a supervised and controlled training program resulted in increased perceived health and fitness. Well structured and carefully planned exercise sessions with sufficient warming up before and stretching after prevented injuries.
 
2.2.1.2 Military Population
 
A study was carried out by S C Singh to detect the effects of poor physical activity, sports participation and prior military training on the incidence of stress fractures amongst the Gentlemen cadets undergoing military training at Indian Military Academy (IMA). 1014 Gentlemen cadets were followed up for a period of 12 weeks, 37 gentle men cadets developed stress fracture during the study period. The incidence of stress fracture was significantly higher in gentlemen without any prior military training (p=0.0009). They were compared with 100 healthy controls drawn from the study population to study the influence of the other mentioned factors. There was no significant association between prior physical activity and stress fractures (OR-0.74, 95% CL = 2.05 to 2.05, p=0.688).
 
A prospective study was carried out by Marshal WS²⁴ on risk factors for a common knee injury among the athletes on 08 April 005 taken the 4800 male and female cadets of Andrews Air Force base during a four year period, beginning at their summer entry into the academies. This study was focused on human movement risk factors involved in injuries to the knee’s anterior cruciate ligament (ACL). The study revealed that most ACL injuries were sports related and most occur when there was no direct physical contact between the athletes and the injury rate to knee ACL injury was up to 8 times higher for women than it was for men, particularly in sports requiring stopping and jumping tasks, as in basketball, soccer and volleyball. Such injuries often require surgery and prolonged rehabilitation.
 
Glomsaker H carried out a wide ranging study of 6488 Norwegian conscripts drawn from the Army, Air Force and Navy. Conscripts were monitored through an initial six-week period of a training for which every injury was recorded. Incidence rate for the Army, Air Force and Navy respectively were 15.3, 13.4, and injuries per 100 conscript months. The sites of majority injuries were the lower limbs (63%). The most common injuries were low back pain; overuse knee injuries; sprains of joint capsules or ligaments etc.
 
Gruhn LM carried out a recent retrospective study of 4,993 archival physiotherapy records at a major military bases in North Queensland, Australia. They investigated the epidemiology of injuries associated with sports and training over 62 month period. The four major body areas treated by physiotherapists were the knee joint (37.0%), lumbar spine (8%), ankle (19.9%) and shoulder (13.8%), which accounted for nearly three-quarters of all admissions. Most were referred without definitive diagnosis (71.1%).
 
A study was conducted by Linenger JM and West LA among US marine recruits undergoing basic training on soft tissue/ musculoskeletal injury between January to April 1990. They found training related injuries occurred at a rate of 19.9 injuries per 100 recruit months. Within the sports medicine clinic, iliotibial band syndrome (22.4%), patellar tendinitis (15.1%), and mechanical low back pain (11.4%) occurred most frequently, with rates per 100 recruit months of 2.1, 1.4 and 1.1 respectively.
 
A study by Sheila D on Sports related knee injuries in Female Athletes revealed that anatomical parameter differ between and within the sexes, the role of sex hormones and dynamic neuromuscular imbalance in female compared with male athletes in hopes of finding the causes for the increased rate of ACL injury. Menisci are shock absorbers of the knee. Traumatic lesions of the menisci are the most commonly produced by rotation as the flexed nee moves towards an extended position. Such injuries are common in people taking part in contact sports and are commonly encountered in soldiers of Armed forces.
 
2.2.2    Study profile South Asia perspectives
 
2.2.2.1 General population
 
Bhatnagar MK reviewed retrospectively the all causalities (1274) admitted to the Afghan surgical Hospital on the Afghanistan-Pakistan border from 22 Feb 1985 to 22 Feb 1987. The causalities ranged in age from 02 to 74 years, 86% were in the 15- 22 year age group. The main causes of injury were fragmentation weapons (50%). Lower extremity injuries were seen 1.6 times more frequently than those of upper extremity. The most commonly injured region was the leg (2 1.4%). followed by the thigh (17.6%), Forearm (9.3%) and knee (8.4%). Only 19 patients (1.5%) presented with paraxial injuries to the scapula, spine, ileum, pelvis, clavicle or axilla. Fractures comprised almost 30% of all injuries seen. The most frequently fractures bones requiring surgery were the tibia and fibula (3L3%), followed by the femur (27.3%), humerus (13.5%) and forearm (12.2%). There were 86 patients (6.7%) with major neurological deficit as a result of their wounds. Foreign bodies e.g. shrapnel, etc, were seen in approximately 6.3% of the injuries, soft tissue infections were present in 13.6% of all cases, the majority in the thigh & leg.  Malunion was a complication in 3.6% of cases; 10% of elbow injuries had mal union requiring surgical correction, the radius & ulna, femur and tibia required surgical correction of a1union in approximately 6% of patients. There were 43 fracture non-unions, 41 of which were long bone diaphyses. Poor range of motion was found in 5 percent of the patients and was most likely to occur with injuries of joints, most frequently the shoulders & knees. Fixed flexion contractures were present in 5% of the patients over all; 22.7 percent of hand injuries and 24.4% of phaangeal injuries resulted in contractures.
 
Study for injury surveillance Sharma SK revealed the following outcomes. A maximum no of 503 cases (25%) were observed to be involving head in the body region followed by lower limbs 499 cases (25%) upper limbs 370 cases (18%). The least no of cases 1% observed to be involving the perineum and genitalia.
 
Table-2.1Injury distribution by site.
 

Source-Sharma SK .
 
A maximum no 688 (39%) were of cut/open wound & 641 no of cases (35%) were observed as other injuries (abrasion, tenderness, bruise, swelling etc). 373 no of cases (21%) were of fracture, least no of cases 85 in no (5%) were haematoma.
 
Table-2. 2       Nature of injury cases
 

 

Source-Sharma SK ³⁰
 
 
2.2.2.2 Military population
 
Pathana PV  conducted study on 50 patients with meniscal tension of the knee admitted to Command Hospital Pune and Military Hospital Kirke Complex during the year 1998-1999. They found that 56% of the cases were in 25-35 year age group. In 80% f the cases military training and contact sports were the mode of injury. The most common modality of injury was military training and contact sports like football, hockey, kabbadi etc were (32%). Others were jumping (18%), running (16%), and slipping (14%). Patients had presented after varying period of delay following the injury. Maximum number of patient (21.42%) reported very late (<2 years), after their initial injury. There was couple of patient who reported within 48 hours of injury. They had various associated complaints like limp (88%), locking of the knee joint (84%), instability (68%), difficulty in climbing staircase (52%) and difficulty in squatting (44%). The right knee was involved most of the patients (30.60%). Medial meniscus was injured in 34 cases 68%) and rest (16.32%) was lateral meniscus.
 
Rhatwar R conducted a prospective study among recruits of three large regimental training centers situated in a particular cantonment of India. The study revealed that the major causes of morbidity were training injuries, including stress fractures. Large majority of training injuries were fractures and joint injuries of the lower extremities. The injury related invalidments were all due to fractures of bones of lower extremities and overall invalidment rate per 1000 was 0.90.
 
Pathana V, Kulshreshtha V conducted study on 50 patients with meniscal lesions of the knee admitted to Command Hospital Pune and Military Hospital Kirke Complex during the year 1998-1999. They found that 56% of the cases were in 25-3 5 year age group. In 80% of the cases military training and contact sports were the mode of injury. The most common modality of injury was military training and contact sports like football, hockey, kabbadi etc were (32%). Others were jumping (18%), running (16%), and slipping (14%). Patient had presented after varying period of delay following the injury. Maximum number of patient (21.42%) reported very late (<2years), after their initial injury. There was couple of patient who reported within 48 hours of injury. They had various associated complaints like limp (88%), locking of the knee joint (84%), instability (68%), difficulty in climbing staircase (52%) and difficulty in squatting (44%). The right knee was involved most of the patients (30.60%). Medial meniscus was injured in 34 cases (68%) and rest (16.32%) is lateral meniscus.
 
2.2.3    National studies
 
2.2.3.1 General population
 
A total 2018 patients were admitted in one of the two casualty units of department of Surgery of Dhaka Medical College Hospital from July 1989 to December 1989 and a study conducted on same place by Hossain A ³³ to see the pattern of injuries and outcome of patients, of which major and minor soft tissue injury with or without bone and joints involvement were 82%. Amongst these soft tissue injuries alone were 40% and the rest 42% were skeletal injury. Other admitted cases were burn 08%, abdominal trauma 05%, and chest injuries 05%.
 
Alam MM made a study of 220 cases of RTA, of them 60 cases had fatal outcome covering a period from January’90 to December’90 in General Hospital, Dinajpur. Almost one third 33.3% cases died within 30 minutes before and after arrival at emergency department. Multiple injuries were the primary cause of death in 43.33% cases and head neck injury in 23.3% cases within 24 hrs of fatal injury. Death due to chest injury occurs in 10% of cases.
 
A prospective study was carried out by Haque RM on 48 cases of knee injury at RIHD during July 1997 to June 1999 to determine the sensitivity, specificity, accuracy, positive and negative predictive value of five common clinical tests for the diagnosis of meniscus tear. Amongst the total number of 48 patient, isolated meniscus injury was 12 (25%), meniscus associated with anterior cruciate ligament injury (ACL) was 14(29.16%), Meniscus and associated with complete ACL tear was 9 (18.76%), ACL injury was alone 8 (16.67%) and chondromalacia was 5 (10.41%).
 
This prospective study was carried out by Alam MM between February 2001 to June 2002, in National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka. In the present series maximum number 20 (55.55%) of patients belonged to age group 18- 30 years. The second peak was between 31 to 40 years. The age ranged from 15-60 years with a mean of 32.16 years young adult patient were more susceptible to this injury. Road traffic accident was the commonest 22 (61.11%) cause of injury followed by fall from height or stairs in 10 (27.78%) and assault in 04 (11.11%) cases.
 
2.2.3.2   Military population
 
A retrospective study by Rahman FS, Islam T, Bhuian A carried out an study on 70 cases of Bangladesh Armed Forces who were admitted in Combined Military Hospital Dhaka with anterior cruciate ligament insufficiency between April 1990 to August 1996 of which 68 patients were serving soldiers. Surgical treatment was undertaken in 62 cases (88.57%) and 8 patients (11.43%) denied operative treatment. Duration of hospital stay ranged from 08 days to 85 days, the average being 34.4 days. The mean follow up period as 26.45 months (longest 48.86 months, shortest 18.60 months). Out of 70 cases 69 were male (98.57%) and one patient was female (1 .43%). The mean age of the patient was 23.67 years and ranged between 14 and 45 years. Among the events causing initial injury, contact and non-contact accounted for 47 cases (67.14%), PET counted for 15 cases (21.43%). Football was the main event causing injury and accounted for 28 cases (40%), volleyball 13 cases (18.57%), and basketball 06 cases (08.57%), among physical efficiency tests (PET) 09 cases were injured by 9 feet ditch 12.86%) and 06 cases by 6 feet wall crossing (08.57%), 08 cases were injured due to other events (11.43%) (e.g. falling/jumping 12.86%, stepping into depression 02.86%, bayonet fighting 04.29% and object striking knee directly 01.43%). The left knee was affected more 41 cases (58.57%) while the right knee was affected in 29 cases (41.43%). Seven (10%) cases had associated medial meniscus injury, of them 05 cases (07.14%) underwent partial meniscotomy and 02 cases (02.86%) denied operative treatment. The study revealed that, out of 48 operated cases 35 (72.08%) cases had been improved by operative treatment while 13 cases (27.08%) showed poor results.
 
A statistical survey was carried out by Hawlader MM at Combined Military Hospital Dhaka between July 1987 and December 1997 among 90 admitted cases of which 88 cases were the serving soldiers of Bangladesh Army. The average age of the patient was 23.67 years. The average duration of hospital stay was 34.4 days. 59% of the patients were admitted for the first times. 62 cases (8.88%) were due to contact and non-contact games of which 38 cases (42.22%) due to football, 15 cases due to volleyball (16.67%) and 09 cases due to basketball (10.00%), 18 cases (19.99%) were due to PET of which 12 cases were injured due to jumping over 9 feet ditches (13.33%), 06 cases were due to crossing over 6 feet wa11 (6.67%), 10 cases of knee injury due to other events (11.11%) where injury due to bayonet fighting (05.56%), falling/jumping from height (2.22%), object striking knee directly (2.22%) were the main associated factors. This study also revealed that left knee was affected more (63.33%) than the right knee (36.66%). Seven cases (10%) had associated with medial meniscus injury. 78% of patients had improved by operative treatment while 22.05% showed poor results.
 
Zaman UIC conducted a retrospective study on 42 serving soldiers of Bangladesh Army at Combined Military Hospital Dhaka with soft tissue injuries of the knee during January 1985 to January 1986 to identify the cause and nature of injury due to performance duties basing on arms and services. He found amongst the arms and services, Infantry (30.95%) were affected most, followed by signals (19.04%) and Engineers (16.67%). Physical efficiency test (PET) or games (e.g. falling/ jumping from the height, slipping at same level etc.) were found to be main causes of injuries (38.09%). games (both contact and non-contact) accounted for the rest one (3.80%). As to the type of injury, it was found that traumatic synovitis (64.29%) was the most common, followed by medial meniscus injury (19.05%). Comparative analysis in that study reveals that the incidence of injury to the (medial meniscus was more than the lateral meniscus (4.76%), that to the medial collateral ligament (4.76%) more than the lateral collateral and that to anterior cruciate ligament (2.38%) more than the posterior cruciate ligament injury.
 
 A retrospective study of 1626 cases of knee injuries was carried out Combined Military Hospital Dhaka by Kabir H, Mortaza G during a six years period (1978 – 1983). Amongst those 729 cases were injuries to menisci. All were male, age group between 18-36 years. The commonest joint injuries among the soldiers were meniscus injury of the knee joint. The ratio of meniscus injury to that of lateral meniscus injury was 5.8 to 1. The right sided injury was about
1.8 times more in occurrence than that of left. The commonest cause of these injuries was 9 feet ditch crossing (46.3%) physical efficiency test of the soldiers. Football game (27.2%), jumping from a wall and falling from a height (26.5%) were the other causes.
 
Haque S conducted a cross-sectional descriptive study on the traumatic cases treated in Orthopedic Centre, CMH, Dhaka with a view to find out certain characteristics of traumatic cases. A total of 148 case Sheets of Trauma-cases admitted from October 99 to December 99 were taken as study cases. Data were collected from the records of their medical history sheets. Trauma cases occupy near about half of the beds (45.12%) in the Orthopedic Centre (148 out of 328 admitted cases). Patients of 15-30 years constitute 41.89% and of 30-45 years constitute 36.49%. It is evident that maximum patients falls within 15 to 45 years, 78.38%. According to occupation and status, Non- Commissioned Officers and below showed the highest number of victims 90 (60.81%), followed by civilians, 43 (29.06%); officers and Junior Commissioned Officers constituted the lowest number -15 (10.13%). 54.05 % cases occurred in units & other in places outside the units. Considering nature of the trauma, accidental fall was found in 39.87% cases (59); sports, training, and technical activities was found in 31.08% (46), road traffic accident in 26.35% (39) and other injury constituted 2.7% (4). Most of the cases were mild to moderate, 126 cases (85.14%) & only 22 cases were found to be severe (14.86%). Lower extremity was affected in 81(49.09%) cases followed by upper extremity in 55 cases (33.34%) and other parts of the body involved in 29 cases (17.57%). 82.43% (122) were treated conservatively & only 17.57(26) required operative manipulation with or without blood transfusion. Average duration of hospital stay was 11.87 (12) days; maximum, 101 cases 68.24%) stayed in hospital up to 10 days.
 
Shahidullah M conducted a study among the serving soldiers reporting sick for knee injury at CMH Dhaka; where he found that 91.3% knee injuries took place at training and sports ground, 61.5% of his respondents sustain injury during training activity. Highest 44.4% Sainik, followed by 13.7% corporal, Lance corporal 11 .4% then sergeant 5.3% and officer 22.4% were suffered from knee injury. He also found that 70.30% knee injury belonged to fighting group and 29.7% from support and service group. In his study that 82.90% patients of knee injuries were treated conservatively and 17.10% needed operatively treatment. Regarding morbidity in his study, where he found that 12.7% suffered for >5 years of disability. Morbidity duration 1-5 year accounted for 42. 4% and <1 year for 449%.
 
A study was carried out by Howlader MAR in Combined Military Hospital (CMH) Dhaka on 900 trauma patients who were treated as indoor cases from July 2ooo to December 2001 for a period of 18 months in which the pattern of injury and their outcome of treatment were evaluated. Among the total 900 patients as many as 825 (91.67%) were male and 75 (8.33%) were female. 551(61.89%) patients were in 3rd and 4th decade. Road traffic accident (RTA) was the main cause of trauma in 612 (68%) patient followed by domestic injury in (255)28.33 % patients. In this study, army patients were the main victim of trauma in 401(44.56%) followed by civil entitled in 213(23.66%) and civil not entitled (CNE) in 103(111.44%) patients. 186(20.67%) patients were brought within 1st hour of injury, 256(28.44%) patients were within 2-6 hours.158 (17.56%) patients were within 25-48 hours and 88(9.77%) patients were brought after 48 hours of injury. In the nature of trauma, musculoskeletal injury were in 776(86.22%) patients, head injury were in 82 9.11%, neurovascular injury were in 29(3.22%) and visceral injury were 13(1.45%) patients. In his study, 120(13.33%) sustained multiple injuries and 56(6.22%) patients involved in mass casualty due to bomb blast, gunshot injury and RTA. In treatment, almost all patient 712(79.11 %) required surgical treatment either as emergency or routine and only 188(20.89%) were treated conservatively. In this series only 3(0.33%) patients died because of secondary complication. Hospital stay 386(42.89%) patients were 1-2 weeks, for 218(24.22%) patients were 3-4 weeks, for 182(20.22%) patients were 5-8 weeks, for 90(10%) patients were 9-12 weeks and for 24 (2.67%) patients were more than 12 weeks.
 
 
Table2.3-Distribution of cases by type of service (n=900).
 

Source– Howlader MAR³⁷
 
 
Table-2. 4-Different types of injury of trauma patient (n=900)
 

Source-Howlader MAR
 
Table-2. 5-Type of treatment given to the patients (n=900).
 

Source-Howlader MAR³⁷
 
Table-2. 6-Times required to stay in hospital (n=900)
 

Source-Howlader MAR
 
 
This study on open Tendo Achilles injury in 40 patients was conducted by Rahman MM  at Combined Military Hospital (CMH), Shaheed Salahuddin cantonment and CMH Dhaka during the period of May 2002 to February 2005. The aim of this study was to evaluate a management protocol in our socioeconomic condition. Commonly affected age group was 26—35 years, male female ratio was 19:1 and right to left ratio was 5: 3.
 
This prospective stud was carried out by Rahman MM at CMH of Shaheed Salahuddin Cantonment Ghatail. Eighty-six (86) young serving male soldiers of 20-35 years age group with moderate ankle sprain were included in this study. The final results were analyzed at the last follow up about 3 to 6 months after injuries. The highest rate of ankle injury was in the age group of 22-25 years 20(50%) (n=40). The highest percentage of injury i.e. 16 patients (40%) occurred during football game and the rest during several sporty and non sporty events. Among active service members, infantry soldiers were leading at the top of incidence followed by members of signals and artillery.
 
 
All the studies revealed that injuries in general and military injuries in particular, are a major cause of morbidity, lost duty time, and financial costs to the military. So keeping in view over this situation, additional study is needed to evaluate the efficiency and effectiveness of modifying other factors.
 
METHODOLOGY
 3.1      Study design
 
A descriptive retrospective study was carried out to explore the injuries amongst the Bangladesh Armed Forces personnel due to military duties who received indoor treatment from Combined Military Hospital Dhaka.
 
3.2       Place of study
 
Combined Military Hospital Dhaka, was selected purposively as the study place to conduct the research. Reasons behind are:
a. Here simple to most complicated injuries from all over the Bangladesh Armed Forces units are treated.
b. It is one of the tertiary level Armed Forces hospital where latest technology and equipments are available.
c. The medical record keeping system is also up-to-date in this hospital.
d. It is nearer to Armed Forces Medical Institute, Dhaka (Location Map is attached as Annexure C to this report).
 
3.3 Period of study
 
The study was conducted from March to June 2010. Detailed work schedule is shown in Annexure-A to this report.
 
 3.4 Study population
 
The study populations were all injured indoor cases treated in Combined Military Hospital Dhaka during the period of January 2009 to December 2009. The study population was all serving uniform personnel, males and females aged between 18 to 54 years. A total of 772 injured cases received indoor treatment in the Orthopedic, surgical, neurosurgery and Officers ward of CMH, Dhaka. These cases were the study population of this study.
 
3.5 Study population selection criteria: Following criteria were considered to select the cases.
 
3.5.1 Inclusion criteria
 
a. Uniformed Armed Forces personnel who received indoor treatment for injury at Combined Military Hospital Dhaka during January 2009 to December 2010.
b. Injury diagnosed by the treating physician or surgeon.
c. Both male and female combat cases.
d. Injury only due to military activities.
 
 3.5.2   Exclusion criteria
 
a.         Injury during leave at home.
b.         Injury due to Personal reasons.
 
 3.6      Sample size
 
On the basis of research design and selection criteria a total 0f 193 cases who received indoor treatment from CMH Dhaka during January 2009-December 2010 were purposively selected as sample size.
 
3.7       Sampling technique
 
In this study injured cases admitted due to military activities were selected purposively. Out of 772 cases every 4^th case was selected as per the admission serial for the purpose of data collection; thereby a total 193 cases had been selected as sample size.
 
 
3.8       Approach for research
 
After approval of research protocol from the respected faculty members of AFMI, permission was obtained from CMH Dhaka through proper channel. Thereafter, the researcher appraised the matter to the commandant and concerned department of CMH Dhaka about the purpose of the research and obtains his blessings to conduct the study.

 

Figure-3.1- Sequence of steps in Research work
 
 
3.9       Pre test
 
Pre test was conducted through reviewing 20 case sheets of the injured uniformed personnel who received indoor treatment from CMH Dhaka in the month of March 2010. Checklist was modified and corrected accordingly.
 
3.10     Data collection procedure
 
Data was collected in every working day as per the schedule by scrutinizing/ reviewing the case sheets of the patients confirming it from hospital documents. In spite of that the patients were contacted over telephone to clarify the necessary information (Usually patient’s contact number is noted on the admission form).
 
 3.11    Data processing and analysis
 
Required checklist filled with data was edited by through checking and rechecking at the end of data collection for omissions or error and was checked at the end of the day for the necessary corrected measure. Additional information if collected during data collection was also noted in paper of the research instrument. The data were entered in computer with the help of soft ware SPSS version 11.5. An analysis plan was developed keeping in mind with the objectives of the study.
 
3.12     Resource requirements and budget
 
For the purpose of data processing and literature review concerned of the AFMI library has extended their cooperation with their resources e.g. computer services, internet browsing, printing, provision of books and journals etc. Monetary support required for this study was provided by the DGMS, MoD, Dhaka cantonment.
 
3.13     Ethical issues
 
Personnel information of the patients, both personnel and military in nature are being used only for research purpose and not otherwise.
 
Limitation of the study
                                   
1.The sample was taken purposively for the study from the cases only admitted in CMH Dhaka, so it may not represent the injuries amongst whole army population.
 
2.The study was conducted amongst the serving uniformed Armed Forces personnel; therefore it does not represent that of the general population.
 
3.The study place is a tertiary level hospital. Complicated cases are received from peripheral Combined Military Hospitals, so complicated cases may have been proportionately higher.
 
4.Data regarding background information, causation or aggravation of injury etc were obtained from medical documents, so some of the portions of the information may be incomplete or not recorded properly in the hospital case sheet.
 
5.The degree of morbidity, medical category or other medical disposals may not give accurate picture as many of the Armed Forces Personnel fail to report or follow up due to transfer, posting or various commitments.
 
Results
This was a descriptive retrospective study conducted among 193 cases who received indoor treatment from Combined Military Hospital Dhaka with different injuries between the periods of January to December 2009. The main objective of the study was to find out the types of injuries among the members of the Armed Forces during military activities.
 
The study populations were all injured cases treated in inpatient department of Combined Military Hospital Dhaka during the above mentioned period. The study populations altogether were 772; all serving uniform personnel aged between 18 to 54 years were included in this study.
 
The documents and case sheets were collected from central admission office and central medical documents stores of CMH Dhaka, NHQ, Medical Directorate and Central medical board of Air force. Required documents/case sheets were scrutinized and the data was collected on working days by reviewing case sheets of the patients using checklists.  The results are summarized below.
 
4.1       Socio demographic characteristics
 
4.1.1    Armed Forces
 
 
Distribution of the Armed Forces personnel is shown in the Pie-chart below. As many as 132(68.4%) were from Army, 34 (17.6%) from Navy and rest 27 (14.0%) personnel from the Bangladesh Air force.
 

 
Figure-4.1-Pie-chart showing the cases according to the Armed Forces (n=193).
 
4.1.2    Arms/Services
 
Table-4.1- Distribution of the cases according to Arms / Services (n=193).
 

 
Among all the cases(n=193) of the military personnel it was seen that the members of the fighting group were 82 (42.5%), support group 50(25.9%) and service group 61 (31.6%) cases.
 
4.1.3    Ranks
 
Table-4.2- Distribution of the Cases according to rank (Equivalent rank of Army, Navy and Air Force) (n=193).

 
Among the cases almost 1/3^rd of the patients were in the rank of Snk 70(36%)  NCOs composed 72(37%), JCOs 13(6.7%). The remaining cases were Officers among which 17(8.85%) Lt/Equivalent, 13(6.7%) Major; only 4(2.1%) were Captain and Lt Col and above respectively. Figure-4.2 below shows the distribution of cases according to rank.
 

Figure-4.2- Bar diagram showing the Cases according to rank (Equivalent rank of   Army, Navy and Air Force) (n=193).
 
4.1.4    Age group
 
Table- 4.3- Distribution of the cases according to age group.
 

 
 
The mean age of the cases were 31.52± 7.54 years and range 18-52 years. About one third 67(34.7%) of the cases were in the age group between 32 -38 years followed by 51 (26.4%), 42 (21.8%) and 24 (12.4%) in the age groups between 25-31, 18-24 and 39-45 years respectively.
 
4.1.5   Marital status
 
 
 
Table- 4.4- Distribution of the cases according to marital status (n=193).
                                                          

 
Among the cases 137 (71.0%) were married and rest of them 56 (29.0%) were unmarried.
 
4.1.6        Sex
 
In this study both the male and female were included and revealed that only 3(1.6%) were female and 190(98.4%) were male.
 
 

 
Figure- 4.3- Pie-chart showing distribution of the cases according to sex category (n=193).
 
4.1.7    Duration of services
 
Table- 4.5- Distribution of the cases according to duration of services (n=193).
 

 
 
It was evident from the study that the mean duration of the service of the cases in the Bangladesh Armed Forces were 12.42±7.218 years. According to duration of service among the 193 cases, 44 (22.8%) served <5 years, 43 (22.3%) between 6-10 years, 32 (16.6%) between 11-15 years, 47 (24.4%) between 16-20 years, 17(8.8%) between 21-25 years and 10 (5.2%) >25 years.
 
4.2       Common injuries
 
4.2.1    Common injuries
 
 
In the present study, knee injury constituted the highest number 43 (22.3%), followed by 33(17.1%) Forearm, wrist and hand injuries, 25(13%) Foot injury, 20(10.4%) Shoulder and arm injury, 13(6.7%) Lower leg injury, 10(13%) ankle and Patella injury each, 8(4.1%) Pelvis and hip injury, 7(3.6%) Spinal injury, 5(2.6%) Head and facial injury, 7(3.7%) were Elbow, Neck, Achilles tendon each and 12(6.2%) other injuries included Bullet, eye, ear, cut, blunt, burn and scald and dental injury etc.

 

Figure- 4.4- Bar diagram shows the type of injury (n=193)
 
 
4.2.2    Types of injury
 
Table- 4.6- Distribution of common injury and their types (n=193).
 

 
 
In the study, it was evident that amongst 41(22.8%) knee injuries, 31(16.1%) belongs to ACL and 11(5.7%) Collateral ligament injuries. Amongst 32(16.6%) Forearm injuries, 16(8.3%) were fracture radius/ulna, 9(4.7%) carpal injuries; in 25(13%) foot injuries 15(7.8%) were toe and 4(2.1%) MT; in the 21(10%) shoulder injuries, 11(5.7%) were fracture clavicle 3(1.6%) dislocation; in the 11(5.7%) ankle injuries 7(3.6%) belongs to sprain and 4(2.1%) belongs to fractures.
 
Table- 4.6- Distribution of common injuries and their types (n=193) Cont…
 

                       
 
4.3       Causes of injury
 
 
4.3.1    Places of injury
 
 
Table-4.7-Distribution of the cases according to place of injury (n=193).
 

 
According to place, where the injuries occurred it revealed that, about one fourth of cases 51 (26.4%) received injury in sports ground, followed by   49 (25.4%) in operation area, 40(20.7%) in training ground, 28 (14.5%) in soldier barrack/ officers mess and 20 (10.4%) in other places, which include the markets, ponds, unit garden and road in between unit and accommodation etc.
 
 
4.3.2    Military activities and injury
 
Table-4.8-Distribution of the cases of injury according to the event of military activities (n=193).
                                                                 

 
 
The above table shows that regarding the injuries due to the military activities; games were the main event that has caused 53 (27.5%) injuries, followed by operation/exercise 50(25.9%), physical training 28 (14.5%) and about one third 62 (32.1%) cases received injury during administrative duties.
 
4.3.3     Games and injury
 
 
Table-4.9-Distribution of the cases of injury according to the event of games (n=193).
 
 

 
It was evident from the study that maximum 24(12.4%) injuries held during playing football followed by Volley ball 13(6.7%) and Basket ball 10(5.25%). Figure-4.5 shows the percentages of distribution of the Cases of injury according to the event of games.
 

 
 
Figure-4.5- Bar diagram shows the cases of injury according to the event of games (n=193).
 
 
4.3.4    Physical training and injury
 
The figure below shows that out of 28 injuries in physical training events PT/drill had maximum 7(3.6%),  followed by Crossing 6 ft wall 5(2.6%), Crossing horizontal rope 4(2.1%), and assault course 3 (1.6%) among others.
 
 

 
Figure-4.6- Bar diagram showing the cases of injury according to the event of Physical training (n=193).
 
 
4.4       Pattern of morbidity
 
 
4.4.1    Duration of patient evacuation
 
Table-4.10-Distribution of the duration of time of evacuation of the cases to hospital (n=193).
 

 
The study revealed that maximum number of causalities 64(33.2%) were evacuated to hospital within 2-6 hours followed by 63(32.6%) within <2 hours and 49(25.4%) within 7-24 hours the of the injury.
 
 
4.4.2    Manifestation of illness
 
Table- 4.11 – Distribution of the cases according to manifestation of illness (n=193).
 

 
 
It was evident that 2/3^rd (115) cases were admitted to CMH with painful movement after the injury.
 
4.4.3    Duration of hospital stay
 
Table-4.12-Distribution of the cases according to duration of hospital stay (n=193).
 

 
The study showed that frequency of duration of hospital stay for different types of injuries was highest (33.7%) in 1-2 weeks, followed by 56(29%) of 3-4 weeks and 41(921.2%) cases stayed of >1-3 months.
 

 
Figure-4.7- Bar diagram showing the cases according to duration of hospital stay (n=193).
 
 
4.4.4    Duration of sufferings
 
Table-4.13-Distribution of the cases according to duration of sufferings (n=193).
                                                              

 
 
The above table shows that amongst the injured, maximum 82(42.5%) cases suffered for 3-6 months followed by 47(24.4%) for 6 months to 1 years, 45(23.3%) for 7-30 days. Distribution of cases according to duration of sufferings is shown in the figure below.
 

 
Figure-4.8-Line chart shows the cases according to duration of sufferings (n=193).
 
4.4.5    Types of treatment received
 
 
The present study reveals that out of 193 injured cases, as many as 113(58.5%) received conservative treatment and remaining 80 (41.5%) cases were provided with operative treatment at CMH, Dhaka.
 
 

 
Figure-4.9-Pie-chart showing the cases according to type of treatment received (n=193).
 
4.4.6    Outcome of treatment
 
The study shows that 118(61.1%) cases had good results followed by excellent in 68(35.2%) cases with the treatment at CMH Dhaka.
 
 
 
 

 
Figure-4.10-Bar diagram showing the cases according to quality of Outcome of treatment (n=193).
 
 
4.4.7    Medical category after treatment
 
Table- 4.14 -Distribution of the cases according to present medical category (n=193).
 

 
 
Table 4.14 shows the medical category of the Armed Forces personnel after the treatment at CMH, Dhaka. Majority 108 (56.0%) belonged to medical category A (AYE) followed by 72 (37.3%) medical category C (CEE) and 2(1%) medical category B (BEE), on the other hand 11(5%) cases were medical board out. Figure- 4.4.6 shows the distribution of the cases according to present medical category.

Figure- 4.11- Pie chart shows the cases according to present medical category (n=193).

 
4.5          Statistical findings
 
4.5.1       Injuries and the Armed Forces
 
Table – 4.15- Distribution of injured cases according to Armed Forces (n=193).
  

 
The above table reveals that 132(68.4%) injury cases held in the Army followed by 34(17.6%) in the Navy and 27(14.0%) in the Air force. The result is statistically Significant, Chi-square Value is 33.92, df=12 and P value<.05. So there are association between frequencies of injuries and different forces.
 
4.5.2    Injuries and the Arms/Services
 
Table – 4.16- Distribution of the injured cases according to Arms/Services (n=193).
 

 
It is evident from the above table that the maximum 82(42.5%) injured cases held in the Fighting arms followed by 50(25.9%) in the Service group and 61(31.6%) in the Support group. There is association between injuries and different arms/services, as the result is statistically Significant, Chi-square Value is 42.49, df=24 and P -value< 0.05
 
4.5.3    Injuries and the duration of services
 
Table – 4.17- Distribution of the injured cases according to duration of services (n=193).
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The above table shows that maximum 47(24.4%) injury occurred in 16-20 years of service group, 1-5 years & 6-10 years age group behind this by a narrow margin having 44(22.8%) & 47(24.4%) respectively, the least amount of injuries held in the cases of the group  > 25 years service. There is association between injuries and the duration of services; because the result is statistically Significant, Chi-square Value is 117.71, df=24 and P value <0.05.
 
4.5.4    Injuries and the place of occurrence
 
Table-4.18-Distribution of types of the injuries according to the place of occurrence (n=193).

 

 
It was revealed that sports ground had maximum injuries among all types, such as knee 15 (34.9%), foot 8(32%), fore arm 6(18.2%) followed by training ground amounting  knee 10(23.3%),foot 5(20%) and forearm 8(24.2%) among other events. The result is statistically just Significant, Chi-square Value is 24.58, df=15 and P value=0.05.
 
 4.5.5      Injuries and the physical training events
 
Table-4.19-Distribution of types of injury according to the physical training events (n=193).
 

 

 
 
The above table shows that in PT/drill event, knee is affected maximum, out of 6 incidents 2(33.3%) occurred in the above item, where patella was affected more in Crossing 6 ft wall 2(100%) and shoulder injuries held more in crossing horizontal rope 3(60%) out of total 5 incidents. The Pearson correlation test is statistically Significant, P value<.05, so there is correlation amongst injuries and events of games in this study.
 
4.5.6       Injuries and the events of games                             
 
Table-4. 20-Distribution of types of injury according to the events of games (n=193).
 

 

 
 
 
The above table shows that out of 15 knee injuries 8(53.3%) occurred in football and 4(26.7%) in basketball, while in foot injury out of 8, 5(62.5%) held in football but in forearm 4(50%) injuries occurred in volleyball among.
 
4.5.7    Injuries and the duration of hospital stay
 
Table-4.21-Distribution of type of injury according to duration of hospital stay (n=193).
 

 

 
It was evident from the study that, in knee injury 15(34.3%) cases stayed in hospital for >1 month<3 months and 14(32.2%5) for 3-4 weeks where as in foot injury 10(40%) cases stayed for <7days and 1-2 weeks each. In forearm injury 14(42.4%) cases stayed for 1-2 weeks and 10(30.3%) for 3-4 weeks. Only one cases of pelvis injury needed to stay for 3-6 months in the hospital.  The result is statistically Significant, Chi-square Value is 25.10, df=12 and P value<.05. So there is association amongst the injuries and the duration of the hospital stay.
 
4.5.8                Injuries and the treatment received by the cases
 
Table- 4.22- Distribution of cases according to type of injury and treatment received (n=193).
 

 

 
 
It is evident from this table that, in case of 43 knee injuries, 28(34.9%%) received conservative treatment and 15(65.1%) treated by operation, while in case of Forearm  injuries 24(72.7%) and 9(27.3%}, Shoulder and arm injury 14(70%) & 6(30%), Foot injury 24(90%) & 1(4%), ankle injury 8(80%) & 2(20%) respectively received the same mode of treatment but in case of Pelvis and hip injury 6(75%) cases got operative and 2(25%) conservative  treatment. In Achilles tendon injury all 3(100%) cases received operative treatment. The result is statistically Significant, Chi-square Value is 16.38, df=3 and P value<.05. This proves the significant association between the treatment pattern and the injuries of this study.
 
 4.5.9     Injuries and the outcome of treatment at CMH, Dhaka
 
Table- 4.23- Distribution of cases according to quality of outcome of treatment at CMH, Dhaka (n=193).
 

 
 
According to the study findings it is revealed that forearm, shoulder and foot injuries treatment showed the excellent results in 18(54.5%), 9(45%) and 15(45.5%) respectively where knee injury treatment showed good result in 38(88.4%) cases and excellent in only 4(9.3%) cases. The result is statistically Significant, Chi-square Value is 16.10, df=3 and P value<.05.
 
DISCUSSION
 
Bangladesh Armed Forces personnel are involved in many kinds of operations, exercises, tasks and training. Soldiers from all ranks, suffer from injury in terms of morbidity or mortality. They are getting injury from either working place or house hold activities.
 
This descriptive retrospective study was conducted at CMH Dhaka during March to June 2010 to identify the socio demographic characteristics, common types of injuries, causes and ascertain the pattern of morbidity amongst the Bangladesh Armed Forces Personnel due to military activities for which they were admitted in CMH Dhaka from January2009-December 2010.
 
The significance of the findings will now be discussed in relation to the objectives of the study and in the light of findings from related research in details:
 
5.1       Socio demographic characteristics
 
Amongst the cases 132(68.4%) Army, 34 (17.6%) Navy and 27 (14.0%) Air force personnel constituted the sample, of which 82 (42.5%) were from the fighting arms, 50(25.9%) from support arms and 61 (31.6%) cases from the service group. In a study conducted by Hawlader MAR^m at CMH Dhaka found that Army patients consists of 44.56%, followed by Navy 10.56% and Air force belongs to 9.78% among others. Another study which conducted by Zaman UIC showed that amongst the injured cases 34% were from fighting arms, 8% from supporting arms and 4% from services arms among others. Shahidullah M  found that 70.30% belongs to fighting group and 29.7% from support and service group. The findings of the present study are almost similar to the above study results. This study reveals that it seems quite obvious that rigorous military training and mobility of particular forces and arms/services are the determinant factor for the number of injuries sustained by its personnel. In Armed Forces; injury is directly proportional to the military activities. It also varies between fighting and services group. The fighting group in Armed Forces received more injury in comparison to support & services group. This may be due to nature of job and tougher training of the fighting group.
 
In the present study it was found that almost half of the cases were in the rank of Snk & LCpl 93(50.25%), Cpl and Sergeant 49(16.4%), JCOs 13(6.7%). The rest of the cases were Officers among which 17(8.8%) Lt/Equivalent, 13(6.7%) Major and 4(2.1%) were Captain and Lt Col and above each. Shahidullah M conducted a study among 205 Armed Forces personnel at CMH Dhaka, where he found that highest 44.4% were Sainik, followed by 13.7% corporal, Lance corporal 11.4% then sergeant 5.3% and officer 22.4% amongst the respondents. This study confers with the present study. As on present statistics; in the Bangladesh Armed forces, majority (3 1.9%) soldiers belong to the rank of Sainik in Army. They sustain more injury than the higher ranking soldier, as the Sainik, under go more physical activities like; training activities, special training events and sports activities in the unit. The association between injuries and the ranks is statistically significant p –value <0.05.
 
In this study the mean age of the cases were 31.52± 7.542 years and range 18-52 years. About one third 67 (34.7%) of the cases were in the age group between 32 -38 years followed by 51 (26.4%), 42 (21.8%) and 24 (12.4%) in the age groups between 25-31, 18-24 and 39-45 years respectively. About 184(95.3%) cases were between 18-45 years of age. Regarding the duration of service, it was evident from the study that the mean duration of the service of the cases in the Bangladesh armed forces were 12.42±7.218 years. Amongst the 193 cases, 44 (22.8%) served <5 years, 43 (22.3%) between 6-10 years, 32 (16.6%) between 11-15 years, 47 (24.4%) between 16-20 years, 17(8.8%) between 21-25 years and 10 (5.2%) >25 years.  Haque S conducted a study in Combined Military Hospital Dhaka amongst 148 trauma cases where he found that maximum trauma cases (78.38%) were between 15-45 years of age. A Similar study was conducted by Hossain MA  in Dhaka Medical College Hospital showed that 86% injured cases were adolescent and adult. Another study was conducted in RIHD by Qavi MI  showed that 58% accident victims were between 21-40 years of age. They found that maximum no of cases were within the first four decades, another study conducted by Rahman MM⁴²on management of knee injury and revealed that age distribution of the patients were between 18-55 years and maximum patients were in the age group of 26-35 years percentage of which was 56.25%. Age has been evaluated as a risk factor for injury in a number of settings, but the findings have not been consistent. In this study the association between duration of service and injuries is statistically significant, p-value<0.05.
 
5.2       Common types of injuries
 
Regarding the injuries in the military personnel, it was revealed in this study that the Knee injuries were highest in number 43 (22.3%), followed by 33(17.1%) Forearm, wrist and hand injuries, 25(13%) Foot injury 20 (10.4%), Shoulder and arm injury, 13 (6.7%) Lower leg injury, 10(13%) ankle and Patella injury each, 8 (4.1%) Pelvis and hip injury, 7(3.6%) Spinal injury, 5(2.6%) Head and facial injury, 7(3.7%) were Elbow injury, Neck injury, Achilles tendon injury each and other injuries included Bullet, bomb and blast injury, injury of the eye, ear, head, cut injury, blunt injury, burn and scald etc. In a study conducted by Hawlader MAR³⁷ and et al on evaluation on trauma management at CMH,Dhaka found that musculoskeletal injury were in 86.22%,he found the following results e.g. Fracture femur (5.78%),Fracture tibia and fibula(7.89%),Fracture radius and ulna(9.66%), Fracture humerus (3.66%),Fracture patella (6.11%), Fracture clavicle (3.11%),Spinal injury(9.11%),Head injury (0.11%), Dislocation shoulder (4.76%), Sprain ankle (7.00%), Knee injury (19.77%), Muscle and tendon injury (1.33%). Almost similar study was conducted by Hauque S⁴⁰ at orthopedic centre in CMH Dhaka showed amongst 165 patient, 9(5.45%) had ankle, 30(18.18%) knee, 4(2.24%) vertebral columns, 55(33.34%) upper extremity, 8 1(49.09%) lower extremity and other part of the body were 24(14.54%) injuries. These studies are not absolutely similar to the present study. This difference may be due to only serving uniform personnel were included in this study. But all these study revealed that musculoskeletal injuries are particularly prevalent in the military population.
 
In the study, it was evident that amongst 41(22.8%) knee injuries, 31(16.1%) belonged to ACL and 11(5.7%) Collateral ligament injuries. Amongst 32(16.6%) Forearm injuries, 16(8.3%) were fracture radius/ulna, 9(4.7%) carpal injuries; in 25(13%) foot injuries 15(7.8%) were toe and 4(2.1%) MT; in the 21(10%) shoulder injuries, 11(5.7%) were fracture clavicle 3(1.6%) dislocation; in the 11(5.7%) ankle injuries 7(3.6%) belonged to sprain and 4(2.1%) belonged to fractures. In a study conducted by Rahman MM⁴²on knee injury at CMH Dhaka showed that 48 out of 70 study cases were ACL injury. Another study by the same researcher on ankle sprain management revealed that 38 cases out of 95 were suffered from ankle sprain. Another study that was carried out by James L, Mark R ⁴⁴ on shoulder injuries of athletes revealed that Fracture clavicle followed by shoulder dislocation are the main shoulder trauma amongst the athletes. A study conducted by Leung F, Chow SP ⁴⁵ on forearm injury found that 56% were the fracture radius and ulna amongst the other injuries of the forearm in their study cases. All this study results confer with the present study findings, little difference may be due to changing pattern of the socio-demographic status and the study population.
 
5.3       Causes of injuries
 
In the Armed Forces maximum soldiers participate in physical training in the training ground, then join their daily routine work; like office work, driving vehicle, assisting patient and carrying goods for their unit. In the afternoon they join sports in the training ground. Special operation or exercises are also done during this period as instructed by the superior authority. It was seen from this study that about one fourth of cases 51 (26.4%) received injury in sports ground, 49 (25.4%) in operation area, 40(20.7%) in training ground, 28 (14.5%) in soldier barrack/ officers mess and 20 (10.4%) in other places. Other places included market, ponds, unit garden and road in between unit and accommodation etc. Shahidullah M⁴¹ conducted a study among the serving soldiers reporting sick for knee injury at CMH Dhaka, where he found that 91.3% knee injuries took place at training and sports ground. Present study finding confers with the study of Shahidullah M⁴¹, It was evident from this study that total domestic injuries (including family accommodation and soldiers barrack / officers mess) contributes 14.5% of total cases. It has shown the similarity with the study of Haque S⁴⁰ at CMH Dhaka where he found that 14.5% of injury happened at domestic level. The association of place of occurrence and the injuries are statistically significant p-value<0.05.
 
In this study military activity has been grouped into operations, sports, physical training and administrative duties. In this study it was shown that the games were the main events of injury that occurred in 53 (27.5%), followed by operation/exercise 50(25.9%) and physical training 28 (14.5%) and during performing daily routine work about one third 62 (32.1%) cases received injury. In this study it was revealed that sports ground having maximum injuries of all types, such as knee 15 (34.9%), foot 8(32%), fore arm 6(18.2%) followed by training ground amounting  knee 10(23.3%),foot 5(20%) and forearm 8(24.2%) among others. Out of 15 knee injuries 8(53.3%) occurred in football and 4(26.7%) in basketball, while in foot injury out of 8, 5(962.5%) held in football but in forearm 4(50%) injuries occurred in volleyball. In the events of physical training, knee is affected maximum in PT/drill event; out of 6 incidents 2(33.3%) occurred in the same item, where patella was affected more in Crossing 6 ft wall 2(100%) and shoulder injuries held more in crossing horizontal rope 3(60%) out of total 5 incidents. The study conducted by Shahidullah M⁴¹ on knee injury at CMII Dhaka, found that 61.5% of his respondents sustain injury during training activity. In another study on basic military training, Linenger JM and West LA²⁷ conducted on musculoskeletal injury among US marine recruits where they found that training related injuries occurred at a rate of 19.9 injuries per 100 recruits per month. These results partially confer with the present study, may be due to socio demographic setting is not same and training facilities were different. In this study the association of military activities and the injuries were found statistically significant p-value<0.05.
 
Among all games and sports football is widely played in our country as well in the Armed Forces, and is responsible for most of the causes of sports injury. This study showed the incidence of injury (n=193) related to Football was maximum 24(12.4%) followed by Volley ball 13(6.7%) and Basket ball 10(5.2%). In a study conducted by Rahman MM⁴² on moderate ankle sprain at CMH, Dhaka showed the incidence of injury related to football was (40%) and basketball/volleyball (15% to 17.5%). Another study carried out by Chan KM et al⁴⁶ in Thailand found that in four of the five sports, the knee 27.27(50.47%) and the ankle 16.78(24.67%) were the commonest sites of injury. It was also the commonest injury condition in volleyball (55.15%), basketball (55.34%), soccer (51.41%) and long-distance running (39.33%). Zaman UIC³⁸ in their study on knee injury in Bangladesh Army found that Football is the sport which accounts for most of the knee injuries (90.0%) sustained in contact and non-contact. Badekas T, Papadakis SA⁴⁷ found that in the all team sports, most injuries affected the lower extremity; 23.8% in soccer, 21.6% in basketball, 16.8% in handball, 7.3% in volleyball. Leonard J, Hutchinson T ⁴⁸ carried out a study on shoulder injury of athletes and revealed that, in particular contact sports, account for 20% shoulder injury/ fractures seen. They also showed a 14% and 17% increase in shoulder injury in professional handball 27% and baseball 26% respectively. In an another study carried out by Rethnam U, Sheeja R, Sinha A⁴⁹ on incidence of skateboard injuries showed that Upper limb injuries specially shoulder and forearm injuries occurred in basketball and volleyball events encountered 28% of total injuries in the above two events. All the study findings are almost similar and the association of events of games and the injuries is statistically significant p-value<0.05.
 
The numerous health benefits of physical training activity have been well documented. These training makes a soldier fit. In this study out of 28 injuries (n=193) in physical training events PT/drill  was having maximum amounting 7(3.6%)  followed by Crossing 6 ft wall 5(2.6%), Crossing horizontal rope 4(2.1%), assault course 3 (1.6%) among others. Shahidullah M⁴¹ conducted a study among the serving Armed Forces personnel on knee injury at CMH Dhaka, where he found that 6 1.5% soldiers were injured during physical activity. In this study it was seen that out of total 50 knee injury, 14(28%) were injured in training ground due to physical activity. Awal MAA⁵⁰ conducted a separate study on knee injury management and showed that in PET the majority was shared by 9 ft ditch (12%), 6 ft wall (8.57%) and bayonet fighting (4.29%). Zaman UIC ³⁷ in their study on knee injury in Bangladesh Army found that Physical efficiency test (PET) is a prominent cause of knee injuries in military personnel (38.09%). Traumas to the knee while crossing the 9 feet ditch (43.75%), another 43.75% of the soldiers sustain injury while crossing the 6 feet wall. These study outcomes showed the similarity with the present study findings. This study also revealed that all those physical training has significant relations with the frequencies of the injuries.
 
The occurrence of injury in the operational area varies from Armed Forces to Armed Forces, type of operational war, nature of physical stress, environment, pre-training exposures to particular that operation, type of armament of opposition / enemy used that operation and protective measure that adopted by the individual etc. It was revealed from this study that injuries related to military operation were 40(20.7%). Haddin B⁵¹ Carried out a study on military injury due to operations, they found that 46% of the musculoskeletal injuries in Jordan Armed Forces were operations related. We know that at present Bangladesh Armed Forces personnel at present are assigned to UN peace keeping mission and counter insurgency operations in Chittagong Hill Tracks, so the number of injured cases in this study is acceptable. The percentages of injured patients may be more in case of bomb blast, bullet, mine injury etc. The physical events and the injuries are significantly associated, p-value<0.05.
 
The other event in this study was administrative duties. It includes normal office work, driving military vehicle, working for maintaining the unit, going to market for unit purpose and day to day activity while stay in military area. In this study it was found that near a 3^rd 62 (32.1%) received injury during daily routing work. Haque S⁴⁰conducted study at CMH Dhaka among the Armed Forces Personnel and civilians revealed that, 41.22% of respondent received injury during daily routine activities. This is because the Armed Forces personnel did not stay at home or barrack in the evening. They remain more committed in military job outside the normal official schedule.
 
5.4       Pattern of morbidity
 
In the present study it was revealed that highest no of causalities were evacuated to hospital within 2-6 hours 64(33.2%) followed by 63(32.6%) within <2 hours and 49(25.4%) in 7-24 hours. Hawlder MAR ³⁷in his study on evaluation trauma management at CMH,Dhka showed  that the majority of patients 20.67% patients were brought within 1st hour of injury, 28.44% patients were within 2-6 hours,17.56%) patients were within 25-48 hours and 9.77% patients were brought after 48 hours of injury. Two study results are almost similar and indicate that the evacuation system is better and well organized in Armed Forces as casualties is one of the important factors in the war strategy and they are well prepared for that.
 
This study showed that the average length of hospital stay (ALS) for different types of injuries were highest between 1-2 weeks (33.7%) followed by 3-4 weeks 56(29%) and then 41(921.2%) cases stayed for >1-3 months. Considering the types of injury it was evident that, in case of knee injury 15(34.3%) cases stayed in hospital for >1 month<3 months and 14(32.2%5) for 3-4 weeks where in foot injury 10(40%) cases stayed for <7days and 1-2 weeks each. In forearm injury 14(42.4%) cases stayed for 1-2 weeks and 10(30.3%) for 3-4 weeks. Only one cases of pelvis injury needed to stay for 3-6 months in the hospital. In a study of Hawlder MAR³⁷ on evaluation trauma management at CMH, Dhaka showed  that the hospital stay of 42.89% patients were 1-2 weeks, for 24.22% patients 3-4 weeks, for 20.22% patients were 5-8 weeks, for10% patients were 9-12 weeks and for 2.67% patients were more than 12 weeks. The association between ALS and the injuries are statistically significant p-value<0.05.
 
Considering the treatment availed by the cases at CMH Dhaka, it was evident that out of 193 injured cases, 113(58.5%) received conservative treatment and remaining 80 (41.5%) got operative treatment. While exploring the types of injuries it is shown that, in 43 knee injury cases, 28(34.9%%) received conservative treatment and 15(65.1%) treated by operation, while in case of Forearm  injuries 24(72.7%) and 9(27.3%), Shoulder and arm injury 14(70%) & 6(30%), Foot injury 24(90%) & 1(4%), ankle injury 8(80%) & 2(20%) respectively received the same mode of treatment but in case of Pelvis and hip injury 6(75%) cases got operative and 2(25%) conservative  treatment. In Achilles tendon injury all 3(100%) cases received operative treatment.  In a study conducted by Haque S ⁴⁰ in CMH Dhaka found that 17.57% patient got operative treatment and 82.43% traumatic cases received conservative treatment. While in the same kind of study of Hawlder MAR³⁷ on evaluation trauma management at CMH, Dhaka showed that almost all patients 712(79.11 %) required surgical treatment either as emergency or routine and only 188(20.89%) were treated conservatively. This results do not confer with this study may be due to that the researcher conducted the study on trauma cases emergency in nature. The association of types of treatment at CMH Dhaka and the injuries is statistically significant p-value<0.05.
 
According to duration of morbidity; this study showed that, out of 193 injury cases maximum 82(42.5) cases suffered for 3-6 months followed by 6 months to 1 years 47(24.4%), 45(23.3%) for 7-30 days. Shahidullah M⁴¹ studied only on knee injury in CMH Dhaka among serving soldiers, where he found that 12.7% suffered for >5 years of disability and More than half 50.7% of the cases required time for cure between 6 months to 1 year, (42.3%) cases suffered for 3-6 months. This study finding shows mild dissimilarity with the present study may be due to that the researcher studied only the knee injury cases. The injuries and the duration of sufferings are statistically significant p-value<o.o5 in this study.
 
The proper management of trauma is rooted in the appreciation of urgency and in the anticipation of life threatening injuries. The study results showed that 118(61.1%) cases had good result by the provided treatments followed by excellent in 68(35.2%) cases and poor in only 7(3.6%) cases. It was revealed that forearm, shoulder and foot injuries treatment showed the excellent results amounting 18(54.5%), 9(45%) and 15(45.5%) respectively where knee injury treatment showed good result in 38(88.4%) cases. In a study by Rahim SF⁵² on femur injury at CMH, Dhaka showed that results were excellent in 21.43% and good in 53.5% cases, where Rahman MM⁴¹ in two separate studies on knee and ankle sprain found the results; dissimilar to the studies mentioned above, those were 33.5% and 37.25% in one study and 70% and 25% excellent & good respectively. In this study the injuries and the outcome of the treatment are statistically significant, p-value<0.05.
 
After the management of the cases, either operatively or conservatively, all the cases are not become fit to carry out the usual military duties for the morbidity and disabilities they suffer from; so in such cases patients are recommended for leave on medical certificate or observed in low medical category as per the case definition and instructions. In this study it was evident that majority 108 (56.0%) has been recommended for medical category A (AYE), followed by 72 (37.3%) medical category C (CEE) and 2(1%) medical category B (BEE). In a study conducted by Rahim SF⁵²at CMH, Dhaka on knee injury found that 33.33% were regarded as medical category A (AYE), 8% medical category B (BEE) and 14% observed under medical category C (CEE). The results of the two studies are almost similar, mild deviation may be due to the difference of the injury pattern of the two studies.
 
The information of this study may do a little to reduce the injury epidemic unless every Soldier and especially every Soldier in a leadership position understands the basics of injury prevention. For prevention of injuries and keeping our future soldier fit in the field of operation, there is no alternative of training.  However, more detailed study is required on overall injury amongst Armed Forces personnel to minimize injury related problems.
 
Conclusion and Recommendation
6.1       Conclusion
 
Injuries cause over five million deaths globally each year and are one of the most challenging global public health issues for the twenty-first century. Injuries in general, have a greater impact on the health and readiness of the military than any other category of medical complaint, are a major cause of morbidity, lost duty time and financial costs to the military. They are also a primary source of crowding in the military outpatient care system. But historically, the injury problem has been neglected, largely because it was viewed as accidents or random events. Bangladesh Armed Forces are also suffering from this occupational health hazards significantly which reduce the professional competency. Putting due attention to combat this crucial issue is a vital for the health management sector of the Bangladesh Armed Forces.
 
This retrospective study was carried out among 193 cases who received indoor treatment from CMH Dhaka to find out the common injuries, types and causes and pattern of morbidity among the Bangladesh Armed Forces personnel. The study revealed that musculoskeletal injuries especially knee, foot, shoulder, forearm, ankle, lower leg and patella injury are prevalent. Bangladesh Armed Forces personnel who are involved in many kinds of operations, exercises, training, sports and task. Study findings also showed the high frequency of morbidity in these regard. It was evident from the study that a significant number of the injuries are life threatening—most result only in limited duty for several days. The high incidence of injuries places a substantial burden on the medical care delivery system and leads to many lost training. This study revealed that more than 50% soldiers stayed in hospital for 3 weeks to 6 months and about 90% patients suffered for 1 month to 1 year, more than one third of the cases were observed low medical category and 6%of the cases needed to leave job through MBO.
 
Public health experts should contribute to the development and evaluation of injury prevention programs and develop the best possible prehospital and hospital care and rehabilitation for injured persons. Careful study and analysis in this regard definitely will explore new dimension to prevent and combat this preventable health burden. Each promising intervention should be investigated and considered for implementation. Commanders and military policy-makers need to be educated about all aspects of training injuries so they can make broad changes to effect improvements.
 
This study may help the concerned authority to take necessary action to reduce the rate which is a simple issue but a complex problem. Finally, research and evaluation of training Vis a Vis injuries and intervention programs must be ongoing process to identify effective and efficient preventive activities.
 
6.2       Recommendations
 
On the basis of findings and discussion of the study following recommendations are put forward for the policy markers, public health specialist and future researchers intending to take necessary measures and to do research in this field:
 

 
 
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