There are well-established guidelines for musculoskeletal and connective tissue disorders in the assessment of potential recruits. There have been no critical appraisals of the application of these guidelines since their recent revision. The aim of this study was to examine whether common presenting conditions are covered by the guidelines and whether there was adherence by the assessor to the recommended outcome. We reviewed 110 potential recruits presenting to an Orthopaedic Consultant. There were a number of conditions not covered and a few occasions when the decision seemed contrary to the guidelines. In particular we think more consideration is needed of congenital deformities.

Introduction SLAP (superior labrum anterior and posterior) lesions are a recognised cause of shoulder pain and instability. They can occur following a direct blow, (biceps) traction and compression injuries, and are commonly seen in overhead athletes. Military personnel are physically active and often subjected to trauma. We assessed the incidence of SLAP lesions within a military population presenting with shoulder symptoms.

Methods A retrospective review, of all shoulder arthroscopies performed by a single surgeon between June 2003 and December 2004 at a district general hospital serving both a military and civilian population, was undertaken. The presentation and incidence of SLAP lesions were recorded for both military and civilian patients.

Results 178 arthroscopies were performed on 70 (39.3%) military and 108 (60.7%) civilian patients. The average age was 42.3 (range 17–75), 50 females and 128 males were included. Indications for arthroscopy included pain (75.3%), instability (15.7%), pain and instability (7.9%), or “other symptoms” (1.1%). 39 SLAP lesions (22%) were found and grouped according to the Snyder classification – 20.5% type 1, 69.3% type 2, 5.1% type 3, 5.1% type 4. Patients with a history of trauma or symptoms of instability were more likely to have a SLAP lesion (p< 0.05). The incidence of SLAP lesions in the military patients was 38.6% compared to 11.1% in civilian patients (p< 0.05). After allowing for the increased incidence of trauma and instability in the military, SLAP lesions were still more common in the military patients (p< 0.05).

Conclusions There is a higher than average incidence of SLAP lesions in military patients compared to civilian patients. They tend to present with a history of trauma, as well as symptoms of pain and instability. Given the high incidence in military personnel, this diagnosis should be considered in military patients presenting with shoulder symptoms, and there should be a low threshold for shoulder arthroscopy.

Background: Ballistic fractures produce a significant burden on medical facilities in war. Workload from the recent conflict was documented in order to guide future medical needs.

Method: All data on ballistic fractures was collected prospectively. Wounds were scored using the Red Cross Wound Classification and the Red Cross Fracture Classification.

Results: During the first two weeks of the conflict, 202 Field Hospital was the sole British hospital in the region. Thereafter, until the end of the conflict, it became the tertiary referral hospital for cases requiring orthopaedic and plastic surgery opinions. Thirty-nine patients, with 50 ballistic fractures, had their initial surgery performed by British military surgeons. Fifty-two percent (26/50) were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. Four children sustained five fractures. Thirty per cent of wounds became infected. Thirteen limbs were amputated; seven were traumatic amputations. The relationship between those fractures with adverse outcomes and their fracture and wound scores will be discussed.

Conclusion: War is changing; modern conflicts appear likely to be fought in urban or remote environments, producing different wounding patterns and placing civilians in the line of fire. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts.

Stability of the elbow joint is provided primarily by the integrity of the ulno humeral articulation. Secondary contributions to stability are provided by the radio-capitelar joint and the medial collateral ligament complex. Lesser contributions are provided by the lateral ligament and the joint capsule.

A dislocation which is complicated by an injury to one of these main stabilising structures will have a greater risk of instability and recurrent dislocation. Poor outcomes have been noted to occur with both coronoid fractures and significant radial head fractures. There is a group of patients with a more severe injury within this spectrum who have a pattern of injury which leads to gross instability. This “unhappy triad” is a dislocation where there is an associated coronoid fracture, a radial head fracture and complete disruption of the medial collateral ligament complex.

These severe injuries tend to present to a specialist after significant delay with recurrent dislocation following failure of initial management. Three cases will be presented to illustrate the anatomical considerations and management strategies for this pattern of injury by immediate reconstruction, hinged external fixation or elbow replacement.

Forward surgical teams have been employed in many recent conflicts. However, as in the Gulf War, they have not usually been sited further forward than the Field Ambulance level. During recent operations in Northwest Pakistan and Afghanistan, two Special Forces Field Surgical Teams were forward deployed to isolated and remote desert areas to provide a completely independent surgical facility, backed up only by a small guard force.

Advanced resuscitation and damage control surgery including major vessel ligation, wound debridement and skeletal stabilization was undertaken. These operations all took place within a two resuscitation bay, two table surgical complex set up within a C-130 Hercules aircraft. This allowed for an extremely mobile response to any perceived threats approaching the complex. A small laboratory with a ruggedised ‘Thermopol’ blood refrigeration unit was also carried. This allowed for the forward provision of 50 units of mixed blood type. This facility was found to be life saving.

Following surgical stabilization, these patients were then casevaced by a separate pre-positioned, aeromed pre-fitted C-130 aircraft to a Deployed Operating Base Hospital in Oman. Here, further stabilization surgery, skeletal fixation and wound care was carried out. Twenty-four hours later, all casualties were in a teaching hospital in the UK where final definitive surgery took place.

The management and care of these patients at all of the above stages is presented and discussed with some appropriate lessons for future operations

Forward surgical teams have been employed in many recent conflicts. However, as in the Gulf War, they have not usually been sited further forward than the Field Ambulance level. During recent operations in Northwest Pakistan and Afghanistan, two Special Forces Field Surgical Teams were forward deployed to isolated and remote desert areas to provide a completely independent surgical facility, backed up only by a small guard force.

Advanced resuscitation and damage control surgery including major vessel ligation, wound debridement and skeletal stabilisation was undertaken. These operations all took place within a two resuscitation bay, two table surgical complex set up within a C-130 Hercules aircraft. This allowed for an extremely mobile response to any perceived threats approaching the complex. A small laboratory with a ruggedised ‘Thermopol’ blood refrigeration unit was also carried. This allowed for the forward provision of 50 units of mixed blood type. This facility was found to be life saving.

Following surgical stabilisation, these patients were then casevaced by a separate pre-positioned, aeromed pre-fitted C-130 aircraft to a Deployed Operating Base Hospital in Oman. Here, further stabilisation surgery, skeletal fixation and wound care was carried out. Twenty-four hours later, all casualties were in a teaching hospital in the UK where final definitive surgery took place.

The management and care of these patients at all of the above stages is presented and discussed with some appropriate lessons for future operations.