Musculoskeletal Injuries at the Chinese Peacekeeping Level II Hospital in Wau, South Sudan, 2018-2022

ABSTRACT

Introduction

Musculoskeletal injuries (MSIs) are common among U.N. military personnel and cause a substantial toll, but little is known about the actual risks and changes of MSIs. The Chinese level II hospital (CHN L2H) was the highest-level hospital in the Western Sector of the U.N. Mission in South Sudan (UNMISS). This study reviewed and analyzed the MSIs managed by the CHN L2H in UNMISS.

Methods

Medical records of MSIs in CHN L2H from September 2018 to July 2022 were identified. We analyzed all the MSIs and treatment procedures.

Results

A total of 857 patients from more than 40 countries were included (86.8% men, average age of 37.83 years), consisting of 457 troop-contributing country, 231 U.N. local, and 169 U.N. international personnel. The most common injury was lumbar muscle strain (14.2%). Sports-related mechanism (29.2%) was the most frequent cause of MSIs. The most significant proportions of anatomical regions were the lumbar spine (22.52%), hand (13.77%), and foot (10.97%). No-steroid anti-inflammatory drugs (43.99%), physical therapy (20.54%), and immobilization (11.32%) were the most used treatments.

Conclusions

MSIs are common diseases in the CHN L2H in the Western Sector of UNMISS. The universality and complexity of MSIs demonstrate the urgent need to improve prevention, treatment, and rehabilitation.

INTRODUCTION

Musculoskeletal injuries (MSIs) refer to damage to the skeletal and muscular systems because of strenuous activity and include damage to skeletal muscles, bones, tendons, joints, ligaments, and other soft tissues.¹ Musculoskeletal injuries constitute a substantial toll on populations. Military personnel have a high risk of MSIs because of exposure to intense physical demands in their working or living environments,² but fewer studies focused on MSIs of U.N. peacekeeping personnel. Musculoskeletal injuries are the most frequent diseases in U.N. peacekeeping mission areas, where peacekeepers confront a high risk of terror attacks and a dangerous environment.³ Musculoskeletal injuries lead to more outpatient medical encounters, inpatient hospital stays, and surgical cases than any other diseases and 50% of all military disability cases in U.S. Military personnel.⁴ Chronic disability and dysfunction exacted by MSIs were direct and indirect physical and financial burdens for the U.N. and peacekeepers.⁵

Musculoskeletal injuries can be divided into combat-related MSIs and non-combat-related MSIs.⁶ Combat-related MSIs usually result in severe injuries requiring critical care capabilities and extensive rehabilitation, leading to disability and dysfunction. Non-combat-related MSIs are far more frequent and account for 90% of all injuries to military personnel. Musculoskeletal injuries of U.N. peacekeepers vary in different mission regions and time. There are increased concerns about the MSIs of U.N. peacekeepers, but little is known about actual risks and any changes in this over time.

The U.N. Missions in South Sudan (UNMISS) is initially established in 2011 and is composed of 14,222 military personnel, 1,446 police, and 2,228 civilian workers, as well as small contingents of experts, staff officers, and volunteers. China sends military medical teams yearly to the Chinese level II hospital (CHN L2H) in the Western Sector of UNMISS. The CHN L2H locates in Wau city of South Sudan, and it provides medical services for approximately 4000 U.N. personnel from 60 countries, including military personnel and local and international staff. The CHN L2H consists of four outpatient clinics (surgical, internal, dental, and infectious disease clinics), three emergency department bays, one operating theater table, three intensive care unit beds, 20 ward beds, and three separate isolation wards. The medical staff consists of consultants in general medicine, emergency medicine, intensive care medicine, general surgery, orthopedics, gynecologists and obstetricians, ENT surgery, ophthalmologist, radiology, ultrasonic medicine, anesthetics, and public health and a general duties medical officer. The CHN L2H is equipped with a digital X-ray machine, a mobile X-ray machine, a mobile ultrasound apparatus, and a laboratory for routine imaging examinations, laboratory examinations, and multiplex Polymerase Chain Reaction machine for diagnosis of infectious diseases. The CHN L2H can treat 20 patients for 7-day hospitalization, receive up to 40 outpatients, and perform three anesthesia surgeries daily.

We aim to estimate the MSIs of the U.N. peacekeepers in the West Sector of UNMISS. This study adds knowledge on trends, factors, and risks of MSIs in peacekeepers and provides clinical experience for U.N. medical staff.

METHODS

It was a retrospective review of MSIs in the CHN L2H in the Western Sector of UNMISS from September 2018 to July 2022. We retrospectively collected details of MSI clinical episodes of date of attendance, national origin, gender, age, diagnosis, mechanisms of diseases, and disposal from electronic medical records in CHN L2H. Then, we analyzed diagnoses and treatments subdivided by MSI categories and treatment procedures. Musculoskeletal injury categories include contusions, fractures, dislocations, sprains, closed head injuries, abrasions, muscle pulls, lacerations, or other injuries, and chronic musculoskeletal conditions such as sciatica, bursitis, and tendonitis. Treatment procedures include non-steroid anti-inflammatory drugs (NSAIDs), physical therapy, immobilization, antibiotics, debridement and suturing, dressing change, mass resection, traction, spine surgery, and transfer to higher hospitals. Multiple procedures in one patient’s anatomic area were counted as one treatment and recorded as the primary procedure.

RESULTS

We analyzed 857 patients in the CHN L2H from September 2018 to July 2022. The basic demographic characteristics are presented in Table I. Patients were from more than 40 different countries and consisted of troop-contributing country (TCC) personnel (n = 457) (mostly from China and Bangladesh), U.N. local staff personnel (n = 231), and U.N. international staff personnel (n = 169). 86.8% of patients were men (n = 744), while 13.2% were women (n = 113), and the mean age was 37.83 years (8-63 years).

Mechanisms of MSIs are shown in Table II. Sports-related mechanism was the most common and accounted for 29.2%, followed by work-related (28.6%), chronic degeneration (20.3%), road traffic (13.2%), inflammation and infection (6.1%), weapons and mines (1%), and others (1.6%). The distribution of diseases’ anatomical regions is summarized in Table III. The top three proportions of anatomical regions were the lumbar spine (22.52%), hand (13.77%), and foot (10.97%). Treatment procedures are presented in Table IV. NSAIDs (43.99%), physical therapy (20.54%), and immobilization (11.32%) were the most commonly performed treatments. 5.95% of patients were transferred to higher hospitals for further diagnosis and treatment.

The top 10 MSIs are listed in Supplementary Fig. S1. The most common category was lumbar muscle strain (122, 14.2%), followed by hand trauma (66, 7.7%), soft tissue injuries (knee: 57, 6.7%; foot: 47, 5.5%; ankle: 42, 4.9; shoulder: 28, 3.3% and elbow: 19, 2.2%), spinal diseases (cervical spondylosis: 52, 6% and lumbar disc herniation: 38, 4.4%), and paronychia (28, 3.3%).

DISCUSSION

We found that MSIs were very common among the U.N. peacekeepers in the West Sector of UNMISS and elicited three main findings. First, sports-related, work-related, and chronic degeneration injuries were the most frequent injuries and accounted for almost 80% of all the patients. Second, soft tissue injuries were the most common category, although the lumbar spine was the most frequent anatomical region. Third, more than 60% of patients were treated with NSAIDs or physical therapy, and 5.95% were transferred to higher hospitals because of a lack of examination facilities and surgical instruments.

Some studies described MSIs of U.N. personnel in different mission regions. A survey of U.N. forces deployed to Namibia for approximately 1 year (1989) showed that orthopedic and rheumatologic diseases were the fourth most frequent diseases, which accounted for 5.2% of a population of 7,114 persons.⁷ Another study of U.N. peacekeepers deployed in Haiti from June to October 1995 described that orthopedic injuries (1.9%) were the most common of outpatient diagnostic categories and orthopedic patients (including back and neck strain) (8.5%) were the fifth category of inpatient diagnostic categories.⁸ Studies of the UK Military Level II Hospital (L2H) in Bentiu of South Sudan showed that MSIs were the second most common category in the emergency department and the largest diagnostic group for aeromedical evacuation.^9,10 Musculoskeletal injuries have become a threat to U.N. personnel in most of the U.N. mission regions.

According to the U.N. standard operating procedure, all the L2Hs in different peacekeeping areas (South Sudan, Mali, Congo, and Lebanon) have the same missions and medical facilities. Diseases and medical care capacity differ depending on the security situation, skill training, and experience of medical staff and hospital management. Two studies described the orthopedic activities of U.N. personnel in the CHN L2H in Mali.^3,11 The difference between CHN L2H in Mali and South Sudan exhibited the following characteristics: First, MSI categories were influenced by the security situation of mission areas. Terror attacks were a significant threat and resulted in the highest injuries to U.N. peacekeepers in Mali. The signing of the Revitalized Peace Agreement in 2018 and a transitional government of national unity significantly reduced violence and terror attacks in South Sudan. As a result, combat-related injuries were the most common injuries in Mali, whereas sports-related, work-related, and chronic degeneration injuries were the most frequent MSIs in South Sudan. Second, medical care services varied in different U.N. L2Hs. The main treatments of CHN L2H in South Sudan were conservative (NSAIDs, physical therapy, and immobilization). Most fracture and severe MSI patients were transferred to higher hospitals because of a lack of examination facilities, surgical instruments, and external or internal fixators. External and internal fixations of fracture patients accounted for almost 26% of the surgeries in CHN L2H in Mali. The L2H should provide treatment that includes hemostasis, limiting wound contamination, and stabilization of bone segments before evacuation based on U.N. standard operating procedure, which aims to stabilize the wounded according to the principles of damage control surgery, but the medical care services and demands are diverse in different mission areas.

Most MSIs of U.S. Military service members are related to participation in sports exercises and physical training.^12–14 The TCC military persons are the major personnel engaged in U.N. peacekeepers. They have a high rate of sports-related or training-related MSIs managed in CHN L2H in South Sudan. At the same time, U.N. local and U.N. international personnel had a high risk of work-related and chronic degeneration MSIs. The differences between TCC and U.N. local/international personnel were because of age, gender, and occupation. First, the TCC patients are younger and more than 95% are men, whereas the U.N. local/international patients are older and more than 30% are women. Second, TCC personnel frequently participate in physical fitness training and sports activities, resulting in training or sports-related injuries, similar to U.S. soldiers.^15–17 Most U.N. local and international personnel did administrative and clerical duties. As a result, the disease spectrum of MSIs varies in TCC, U.N. local, and U.N. international personnel, and U.N. medical staff should take different actions to prevent and treat the MSIs of them. Moreover, as the most frequent MSIs, the prevention of sports-, training-, and work-related MSIs should be identified as a top priority for injury prevention in the U.N. personnel in South Sudan.¹⁸

According to our study, the main treatments for MSIs in CHN L2H in South Sudan were conservative (NSAIDs, physical therapy, and immobilization). Most patients recovered well with the treatments in CHN L2H, but there were still some shortcomings. First, rehabilitation therapy is critical in modern MSIs multimodality therapy and helps patients recover more quickly. The rehabilitation therapies in the CHN L2H were electromagnetic therapy, infrared therapy, and traditional Chinese medicine (acupuncture, cupping, and massage). We usually treat MSI patients with simple treatments. Individual-based treatments should be made according to the different MSI types, reasons, and individual differences in the future. Second, surgical instruments and emergency programs for fracture surgeries or severe patients are necessary for CHN L2H. Third, most sports-related and military training injuries can be prevented with education and prevention.^18,19 However, there are no health education curricula for MSIs and necessary precautions in the U.N. base of Wau. The U.N. and CHN L2Hs should work together to protect U.N. personnel from MSIs through education, training, and prevention measures.

This study had several limitations. First, this was a retrospective review of MSIs in U.N. personnel. A prospective study is ideal, but a retrospective study could be acceptable if a sufficient number of prospective studies have not been conducted yet. Second, some medical records of MSIs were lost in the electronic medical records system in CHN L2H for various reasons. We could not get the medical records in MSIs level I clinics in the West Sector of UNMISS. So, this study could not reflect the panorama of all the MSIs in this mission region. Third, CHN L2H is located in the West Sector, and we mainly focused on the medical service for personnel in this area. We could conduct cooperative research with other hospitals in UNMISS in the future to get more comprehensive data.

CONCLUSION

We focus on MSIs in the CHN L2H in Wau, South Sudan. This study highlights the importance of the physical burdens of MSIs and the long-term effects of MSIs on reducing U.N. personnel’s time on active duty. Thus, the UN should improve the prevention, treatment, and rehabilitation to mitigate the burden of MSIs among U.N. personnel to achieve the best possible functional outcomes while decreasing early and long-term damage and costs. On the one hand, the UN should assess the level of physical fitness, improve the training equipment, and adjust the amount and level of intensity of training to prevent MSIs among U.N. personnel. On the other hand, the UN should train the medical staff in standardized treatment and rehabilitation of MSIs and improve the medical facility (especially the rehabilitation equipment) to ensure MSI treatment and therapy capabilities at all U.N. peacekeeping hospitals.

ACKNOWLEDGMENTS

Special thanks to all the medical staff in the CHN L2H in Wau, South Sudan.

SUPPLEMENTARY MATERIAL

SUPPLEMENTARY MATERIAL is available at Military Medicine online.

FUNDING

The study was funded by Nature Science Foundation of Hubei Province (grant no. 2022CFB878) and Hubei Key Laboratory of Central Nervous System Tumor and Intervention (ZZYKF202209).

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

The data that support the findings of this study are available on request from the corresponding author. All data are freely accessible.

CLINICAL TRIAL REGISTRATION NUMBER

None declared.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

No human subjects were involved in this study. It does not contain any personal and/or medical information about an identifiable living individual. The Ethics Committee of the General Hospital of Central Theatre Command agreed to this research. The Medical Section, Division of Mission Support of UNMISS approved the study.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INSTITUTIONAL CLEARANCE

Institutional clearance approved.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

C.S. is the first author. C.S. and C.X. collected and analyzed the data. C.S. and F.X. drafted the manuscript. C.X. and F.X. are the study guarantors. All authors have read and approved the final manuscript.

REFERENCES

Author notes