AN INSTRUCTIONAL REVIEW OF MILITARY HAND TRAUMA: LEARNING FROM PAST EXPERIENCE AND EMBRACING EMERGING CONCEPTS

Abstract

Objectives: To review the changing pattern of orthopaedic injury encountered by deployed troops with regard to the importance of hand trauma.

Methods: A literature review of orthopaedic practice in recent conflict. The search period extended from 1990–2007. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded according to Levels of Evidence.

Results: 210 published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. The evidence is overall level 5 with the majority of papers comprising reviews, individual sub-unit experiences, historical perspectives and individual database analyses.

The evolving importance of extremity trauma is clear from the quantity of its reporting. The paucity of life threatening cavity trauma is highlighted. Casualty survival off the battlefield is increasing perhaps due to the impact of personal protective equipment. The combination of changing ballistics and increasing survivability leads to an apparent increase in limb threatening and complex hand trauma being encountered by military surgeons.

Despite being rarely reported in isolation, the proportion of complex hand trauma is broadening with an increase in open fractures and mutilated soft tissue injuries resultant from high and low energy transfer ballistics.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Sporting activities and inappropriate use of equipment are responsible for soft tissue and bony injury with considerable morbidity.

The literature was analysed with regard to the classification of hand trauma. Articles relating to recent conflicts were notable for their lack of classification of these injuries.

The bulk of papers retrieved concerning military hand trauma management were published prior to the conflicts of the last decade. It is within these papers that classification and treatment priorities including the nature of debridement and fracture stabilisation are discussed and highlighted as core knowledge.

Conclusion: The nature of injuries sustained by troops in conflict is evolving. Changing survivability is resulting in increasingly complex hand trauma presenting to military surgeons.

Despite a culture of ensuring that today’s trauma surgeons learn from mistakes made by their predecessors, in the field of hand trauma this is not the case.

A comprehensive review of changing orthopaedic conflict related injury patterns with special regard to hand trauma and the key learning points from historical literature are highlighted. Proposals for improving management are discussed with regard to improved training opportunities and dialogue between military trauma surgeons.