Introduction: Children are inevitably casualties in wars. They are treated variously by local doctors and foreign surgeons working for military and Non-Governmental Organisations. The basic principles of surgical treatment of war wounds are the same as for adults, but there are specific differences in injury pattern and the response to injury that must be borne in mind. Method: Casualties under sixteen years age with extremity trauma caused by missiles or blast admitted to a British military field hospital during the latest Gulf War were evaluated. The date, time and method of wounding were recorded and ICRC Wound Scores calculated. The details of surgical treatment prior to admission, and further surgical management described. Case studies were used to illustrate particular considerations relevant to paediatric trauma. Results: The records for sixteen wounded children were available for analysis. Their ages ranged from three to fifteen years. The method of injury falls into three phases, gun-shot wounds during the mobile attack, shell fragment wounds during the seige of urban areas and blast/fragment injuries from small munitions from the period following active fighting. Blast/fragment wounds typically affected multiple body areas. Half the patients had received surgical treatment before reaching the hospital, either at civilian hospitals, forward military surgical units or both. None of this surgery was strictly “life or limb-saving”. Amputations performed prior to admission were in the proximal tibia and followed the long posterior flap pattern appropriate to an adult amputation for vascular disease regardless of the level of injury. Several had primary closure of war wounds. After admission, four patients required plastic surgical procedures, two had ophthalmic surgery, one had a laparotomy and one had a facial reconstruction procedure in addition to surgery for extremity trauma. One child with fragment wounds was undergoing treatment for acute lymphoblastic leukaemia. Conclusion: A military hospital must be prepared to treat children during war-time. Multi-system injury patterns are common and require multidisciplinary care. When possible children should be transferred to a facility with specialist care available for primary surgery. The effects of injury and treatment on future growth should be given more consideration

During the second Lebanon war, between 12/07/06 to 14/08/06, 241 war injuries were admitted to Rambam Medical Center emergency room: 202 soldiers and 39 citizens. (Post traumatic stress disorders victims were not included). Majority of the injured soldiers (98%) were mobilized by the Israeli Air Force helicopters. More then 40 helicopters had landed in the hospital heliport during the war. Distribution of injuries according to the injury type:. 110 patients (44% of all injured) had Orthopedic injuries (including hand injuries). 76 patients (31% of all injured) had Orthopedic injuries combined with other injuries. Not orthopedic injury – 63 patients (25%) Majority of all wounded (75%) had suffered from an orthopedic injury. Distributions of soldier’s injuries among soldiers were similar to the above :. 81 soldiers (41%) Orthopedic injuries (including hand injuries). 64 soldiers (33%) Orthopedic injuries combined with other injuries. 50 soldiers (26 %) Not orthopedic injury. About 75 % of the injured soldiers suffered from orthopedic injuries. Vast majority of the injuries were shrapnel injuries, which were divided to 3 levels:. Mild soft tissue damage due to few or superficial shrapnel injury – 107 (49%) soldiers. Moderate soft tissue injuries due to multiple shrapnel injuries – 54 (25%) soldiers. Severe soft tissue injuries had muscular and neurovascular damage. Organs injury distribution:. 24 Patients total of 54 fractures, 24 of those had been long bone fractures. 17 Patients had sustained a Major vascular injury. 20 Patients had sustained a nerves injury. Amputation – 5 soldiers were underwent completion of traumatic lower limb amputation. One soldiers had bilateral below knee amputation, 1 above knee amputation and 3 unilateral below knee amputation. Two hundred and three orthopedic surgery interventions were done by Orthopedics’ B’ department in Rambam Medical Hospital, during the Second Lebanon War

Over the centuries there has been a pattern of order developing from chaos in the behaviour of nations. The 20th century has demonstrated major conflict between nations, and Defence Health has supported the core activity of the Australian Defence Force (ADF), which has been the aim of military medicine generally in all world defence forces. Preventative medicine and mass casualty treatment, as well as the maintenance of health and return to duty from minor injuries, has been a success for all traditional military medical structures. It has been known that if the civilian population is supportive of the military effort, this is a significant advantage. The military medical assets directed in this manner to the local civilians builds bridges for lasting peace. In 1989 the world changed, with the Cold War won and leaving the United States as the only super power. From that time, conflict has tended to be intrastate rather than between sovereign states, with a rise in communal or ethnic conflict. This situation is probably not going to change in the foreseeable future as there are no longer client states being controlled by super powers. Since that time the Australian Defence Force has been involved in the treatment of indigenous Australian citizens, UN humanitarian missions and disaster relief. In fact the military medical assets of the ADF have been busier in the last 30 years in Military Operations Other Than War than in war itself. The original concept of the Forward Surgical Teams developed in Adelaide was modular, encompassing a General surgeon, an Orthopaedic surgeon, an Intensive Care specialist and an Anaesthetist, and thus they were able to cover trauma sustained by most combat casualties. This module was man-liftable and able to be deployed by aircraft, by vehicle and also on board ship, augmenting existing medical facilities according to need. This module in its varying forms has stood the Australian Forces well in Rwanda, Bougainville, East Timor, PNG, disaster relief and Aboriginal health missions. It may be that further health modules can be developed, such as a Burns module, a Paediatric module and a Primary Care module, building on the increasing medical knowledge base, sub-specialisation and advancing technology. These building blocks can come together to form significant hospitals if necessary. The ADF has provided first-world medicine and third-world medicine, producing a dichotomy in requirement for medical skills and technology, depending on circumstances. Being busy enhanced our logistical support systems and organisational skills. Medical experience was gained, and the foundation for lasting peace and building communities was established. If war is considered the greatest social disease left then the pathology of war is in history. The diagnosis is easy but the treatment and prevention difficult. Early in an emergency the military medical assets of any defence force are able to be deployed under difficult living conditions, and can provide health care for those who have survived the disaster whether it be man-made or natural

During the second Gulf War in 2003, the Primary Casualty Receiving facility onboard R.F.A. Argus treated thirty six patients with injuries sustained in the conflict, including thirty Iraqi enemy prisoners of war and displaced persons. Their injuries and operative management are reported. Eighteen casualties sustained fragmentation injuries, six casualties sustained gunshot wounds and seven casualties suffered a combination of both. In addition to penetrating missile injuries five casualties from road traffic accidents were treated. All wounds were managed following the established principles of war surgery. The extremities were involved in twenty eight patients (78%) including nine open, multifragmented long bone fractures which were managed with external skeletal fixators. Two laparotomies and one thoracotomy were performed. The average duration of surgery was one hundred and thirty two minutes with the longest procedure lasting for six hours and ten minutes. This was the first time that the Primary Casualty Receiving Facility had been used to surgically manage war casualties and it fulfilled this role to good effect

Cluster bombs are an inhuman weaponary, intended, among other things, for mass kiling of humans. The use of modern weaponary can cause very serious damage of all structures in injured extremity. During the war on teritory of Yugoslavia in 1999. at our clinic for orthopaedic and tramatology Ð Clinical Center Nis, we have treated 120 injured patients. The youngest injured patient was 17 the oldest 77. In evaluated group the patients of third and forth decade of life have been dominated. Multiple injuries were the most often (caused by cluste bombs). All victims got hard wounds of lesia type due to injuring by a great number of sharpnelñs. The hospital treatment complexity of these wounds is pointed out. Such treatment is caused by a number of simultaneous wounds of many sistems in organisam. We have treated war wounds with fractures of extremity with the Ç Mitkovic È external þxator (using convergent method of pin applications), living the wounds open and performing necessary debridments.AT and antibiotic therapy was administrated. Surgical treatment of war wounds, external þxation, living the wounds open and performing necessary debridments, adequate drug therapy, are essential in achieving good results in this patients. To take care of casualties is a complex task requesting the teamwork of orthopaedists, common surgeries and plastic surgery specialists

Aims: To evaluate the clinical outcome of the treatment of severe high-energy war injuries to limbs using circular external þxation frames. Metods: 43 patients after war injuries with 57 high-energy fractures were treated. According to Gustilo and Anderson all fractures were open grade 3B and 3C. There was other major organ trauma in 52,8% of patients. On admission, the fractured bones were stabilized with an AO tubular external þxation frame followed by thorough extensive soft tissue debridement, vascular reconstruction if needed. After 5 to 7 days the tubular þxator is exchanged for a circular frame that allows receiving stability, sufþcient for full weight bearing by minimal invasive þxation and freeing the previously bridged joints, in order to preserve their range of movement. Closed reduction of fractures was performed in most patients by successful implementation of ligamentotaxis and use thin wires with olives. In patients with high-energy Ç ßoating joint È injuries the circular devices were connected by hinges to permit early initiation of joint motions and functional treatment. In patients with upper limb injuries a separate bone þxation was used to allow early ßexion/ extension and pronation/supination motions. Results: In all patients the circular external þxation was the deþnitive treatment. Bone grafting was not necessary in any patient because of compression-distraction possibility. Fracture union was achieved at median time of 8 months (range 3 60). Throughout the period of fracture healing the patients were ambulatory, living at home. Conclusion: The circular þxation frame allows perform successful skeletal stabilization and functional restoration of limbs in patients with extensive bone and soft tissue loss, even in limbs of the risk

Introduction and aims. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have used 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fascio-cutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

Introduction. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have using 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fasciocutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

Objective The aim of this study was to prospectively study the effectiveness of external fixation for war injuries during the recent Gulf conflict. Patients and Methods We studied all patients seen at 202 Field Hospital, which received the majority of patients who had external fixators applied by the British Armed Forces. Results Fifteen patients had external fixators applied with follow-up available for 14 (15 external fixators). Of the 15, 13 (87%) required early revision or removal due to complications of the injury or the fixator. Seven required early removal at a mean of 9.1 days (range 1–19). Six required early revision at a mean of 5.9 days (range 1–22). Instability was a problem with 10 fixators (67%). Seven fixators were revised and 3 were removed. Pin loosening was noted with 5 fixators (33%) involving twelve pins. The cause was multifactorial, but was related to injury severity and frame design. A significant pin track infection developed at 14 pin sites (3 fixators – 20%). All 3 fixators were removed after a mean of 15.5 days (range 14–19). Only 2 fixators did not require early removal or revision. Conclusion We have demonstrated a high early failure rate with the use of external fixation and would caution against its universal acceptance. For many fractures plaster or skeletal traction provide an alternative option. When external fixation is required, stability must be achieved. Even with this there is likely to be a high complication rate due to pin track infection and loosening, and amputation must still be considered as a possible outcome for military injuries

A randomised controlled trial was conducted using a rabbit model of a complex contaminated extremity war wound. Compared to saline soaked gauze dressings Inadine (iodine) and Acticoat (nanocrystalline silver) had significantly lower levels of Staphylococcus aureus after 7 days while Activon Tulle (Manuka honey) had significantly higher levels. Molecular level analysis of the wound was conducted. Plasma cytokines of interest were assayed using ELISA and levels of expression of relevant tissue genes measured using PCR following RNA extraction. Appreciable levels of Interleukins 4 and 6 and Tumour Necrosis Factor-α were identified in plasma with significantly higher levels of IL-4 and TNFα detected in the Activon Tulle group. In tissue TNFα, Matrix metalloproteinase-3 and the ratio of Matrix metalloproteinase-9 to Tissue Inhibitor of Matrix metalloproteinase-1 were significantly higher in tissue injured limbs than the uninjured limbs with no significant differences between groups. Interpretation of these results is challenging. IL-4 has been associated with transition from pathological inflammation to repair and TNFα with impaired healing. However, Activon Tulle had significantly higher levels of S. aureus and we found no differences in observational, histology, haematology or tissue gene expression outcomes over 7 days which would correlate with these molecular biology results

A 7-day randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercially available dressings. The Flexor Carpi Ulnaris of anaesthetised rabbits was exposed to high-energy trauma using a computer-controlled jig and inoculated with 10. 6. Staphylococcus aureus 3 hours prior to application of dressing. Quantitative microbiological assessment demonstrated reduced bacterial counts in INADINE (Iodine) and ACTICOAT (Nanocrystalline Silver) groups and an increase in ACTIVON TULLE (Manuka Honey) group (2-way ANOVA p<0.05). Clinical observations were made throughout the study. Haematology and plasma cytokines were analysed at intervals. Post-mortem histopathology included subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy (SEM). There were no bacteraemias, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. There were no significant differences in animal behaviour, weight change, maximum body temperature or white blood cell count elevation nor in pathology severity in muscle or lymph nodes (Kruskal-Wallis). There was no evidence of bacterial penetration or biofilm formation on SEM. Interleukin-4 and Tumour Necrosis Factor α levels were significantly higher in the ACTIVON TULLE group (1-way ANOVA p<0.05). This time-limited study demonstrated a statistically significant reduction in Staphylococcus aureus counts in wounds dressed with INADINE and ACTICOAT and an increase in wounds dressed with ACTIVON TULLE. There was no evidence that any of these dressings cause harm but nor have we established any definite clinical advantage associated with the use of the dressings tested in this study

A randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercial dressings. The Flexor Carpi Ulnaris of anaesthetised New Zealand rabbits was exposed to high-energy trauma using computer-controlled jig and inoculated with 10. 6. Staphylococcus aureus 3 hours prior to application of dressing. After 7 days the animals were culled. Quantitative microbiological assessment of post-mortem specimens demonstrated statistically significantly reduced S aureus counts in groups treated with iodine or silver based dressings (2-way ANOVA p< 0.05). Clinical observations and haematology were performed during the study. Histopathological assessment of post-mortem muscle specimens included image analysis of digitally scanned haematoxylin and eosin stained tissue sections and subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy to determine the presence of bacteria and biofilm formation within the injured muscle. Non-parametric data were compared using Kruskal-Wallis. There were no bacteraemias, significantly raised white cell counts, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. All injured muscle specimens showed evidence of haemorrhage, inflammatory cell infiltration and fibrosis. All ipsilateral axillary lymph nodes were activated. There were no significant differences in the amount of muscle loss, size of the activated lymph nodes or in subjective semi-quantitative scoring criteria for muscle injury or lymph node activation. There was no evidence of bacterial penetration or biofilm formation. This study demonstrated statistically significant reductions in Staphylococcus aureus counts associated with iodine and silver dressings, and no evidence that these dressings cause harm. This was a time-limited study which was primarily powered to detect reduction in bacterial counts; however, there was no significant variation in secondary outcome measures of local or systemic infection over 7 days

Introduction: Within the period from 1992. to 1996. (War in Bosnia) we performed 528 amputations. At the Chopart level in 45 (8.5%) patients and at the Syme level by 7 (1.3%) patients.

Etiology: In more than 90 % patients the injury was caused by mine.

Method: Open method, primary suture or primary delayed suture. We had 6 reamput actions and 15 corrections.

Result: The Chopart stump inclines to deformation (we can often use only a part of calcaneus and talus). Achille’s tendon pulls the heel in increased supination and this is disturbing when leaning onto it and when placing the prosthesis. We achieved good results with the Baumgartner procedure: lengthening of Achille’s tendon, transfer of tendon m. tibialis anterior and tibio=tal=calcaneal arthrodesis. In cases with infection or if there remains only half of the calcaneus and talus, we prefer Syme level.

Conclusion: The patient with CH stump was properly followed and kept under control. We prefer Baumgartner procedure as prevention of deformation. In some cases the better result are achieved with the Syme level (it remains only part of calcaneus and talus)

Introduction. Over the past 30 years multiple wars and embargos have reduced healthcare resources, infrastructure, and staff in Iraq. Subsequently, there are a lack of physiotherapists to provide rehabilitation after an anterior cruciate ligament reconstruction (ACLR). The implementation of home-based rehabilitation programmes may provide a potential solution to this problem. This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone. Methods. A cohort observational study of patients aged ≥ 16 years with an ACL rupture who underwent an ACLR under a single surgeon. This was performed arthroscopically using a hamstring autograft (2 portal technique). Patients completed a home-based rehabilitation programme of appropriate simplicity for the home setting. The programme consisted of stretching, range of motion and strengthening exercises based on criterion rehabilitation progressions. A full description of the programme is provided at: . https://ngmvcharity.co.uk/. . Demographics, mechanisms of injury, operative findings, and outcome data (Lysholm, Tegner Activity Scale (TAS), and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics. Results. The cohort consisted of 545 patients (547 knees), 99.6% were male with a mean age of 27.8 years (SD 6.18 years). The mean time from diagnosis to surgery was 40.6 months (SD 40.3). Despite data attrition Lysholm scores improved over the 15-month follow-up period, matched data showed the most improvement occurred within the first 2 months post-operatively. A peak score of 90 was observed at nine months. Post-operative TAS results showed an improvement in level of function but did not reach pre-injury levels by the final follow-up. At final follow-up, six (1.1%) patients required an ACLR revision. Conclusion. Patients who completed a home-based rehabilitation programme in Kurdistan had low revision rates and improved Lysholm scores 15 months post-operatively. To optimise resources, further research should investigate the efficacy of home-based rehabilitation for trauma and elective surgery in low- to middle-income countries and the developed world

Ballistic fractures are devastating injuries often necessitating reconstructive surgery or amputation. Complications following surgery are common, particularly in the austere environment of war. Workload from the recent conflict was documented in order to guide future medical need. All data on ballistic fractures was collected prospectively. Fractures were scored using the Red Cross Fracture Classification. 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 were treated by British military surgeons. Patients were predominantly Iraqi (20 enemy prisoners of war and 15 civilians); 4 children sustained five fractures. Fifty percent were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. A total of 30 per cent of wounds became infected, 12 per cent were deep infection necessitating surgical drainage. Thirteen limbs were amputated; seven were traumatic amputations. Ballistic fractures remain a challenge for surgeons in times of war. There is a continued need to relearn the principles of war surgery in order to minimise complications and restore function. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts

Background War wounds produce a significant burden on medical facilities in war. Workload from the recent conflict was documented in order to guide medical needs in future conflicts. Method Data on war injuries was collected prospectively. In addition, all patients sustaining penetrating injuries that received their treatment at our hospital had their wounds scored using the Red Cross wound classification. This information was supplemented with a review of all patients admitted during the study period. Results During the first two weeks of the conflict, the sole British field hospital in the region received 482 casualties. One hundred and four were battle injuries of which nine were burns. Seventy-nine casualties had their initial surgery performed by British military surgeons and form the study group. Twenty-nine casualties (37%) sustained gunshot wounds, 49 casualties (62%) suffered wounds due to fragmentation weapons and one casualty detonated an anti personnel mine. Sixty-four casualties (81%) sustained limb injuries. These 79 patients had a total of 123 wounds that were scored using the Red Cross wound classification. Twenty-seven of the wounded (34%) were non-combatants; of these, eight were children. Median delay from point of wounding to definitive care for coalition forces was 6 hours (range 1 to 11.5 hours) compared to 12 hours (range 1 hour to 7 days) for Iraqi casualties. Four patients (5%) died; all had sustained gunshot wounds. Conclusion War continues to demand that a full spectrum of hospital specialists be available to treat our own personnel and the Defence Medical Services are increasingly likely to be called to provide humanitarian assistance to wounded non-combatants. Military medical skills, training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts

Introduction A retrospective analysis of aeromedical evacuation of casualties from OP TELIC contrasting the demand for evacuation and nature of injury during both war fighting and peace enforcement missions. The study was performed to address a perception of clinicians working within the operational theatre that service personnel outside of times of conflict were being evacuated with increasingly trivial or chronic injuries compared with those evacuated when war fighting was occurring. Methods A comprehensive record of patients evacuated was retrospectively studied. Consecutive cases were classified by diagnosis. The period of study was 1. st. March 2003 to 30. th. June 2004. Results In the sixteen month period a total of one thousand nine hundred and twenty four patients were evacuated by air to the United Kingdom. In the first three months (immediately before, during and post conflict) eight hundred and thirty patients were evacuated, an average of 280 per month. Of these, 2.8% were as a result of battle. During the conflict phase, an average of 60 patients a month were evacuated due to a chronic orthopaedic condition. This is in contrast to an average of 10 a month in the post conflict phase. In the three months following the conflict (incorporating the Iraqi summer) four hundred and seventy one troops were evacuated - an average of 157 per month. Of these, heat illness accounted for 28%. In the following ten months 621 troops were evacuated, averaging 62 per month. During the post conflict period, Battle injuries accounted for 5.6% of those evacuated, which is double that seen during conflict. Chronic general surgery maintained a similar percentage of total sent home throughout both phases. Other specialities were more sporadic with no particular pattern other than a decrease in raw figures compared to the war fighting phase. Conclusion This pattern of aeromedical evacuation in a modern major deployment illustrates the paucity of battle injury at the time of fighting in relation to non battle injury. It also highlights the impact of chronic injury on a deployed force, especially injury related to back pain. The study has shown that contrary to perception by the clinicians in theatre, there was no obvious increase in evacuation of troops as a result of chronic or minor injuries in the post conflict period. Heat illness clearly places an important predictable strain on this method of evacuation

We live in troubled times. Increased opposition reliance on explosive devices, the widespread use of individual and vehicular body armour, and the improved survival of combat casualties have created many complex musculoskeletal injuries in the wars in Iraq and Afghanistan. Explosive mechanisms of injury account for 75% of all musculoskeletal combat casualties. Throughout all the echelons of care medical staff practice consistent treatment strategies of damage control orthopaedics including tourniquets, antibiotics, external fixation, selective amputations and vacuum-assisted closure. Complications, particularly infection and heterotopic ossification, remain frequent, and re-operations are common. Meanwhile, non-combat musculoskeletal casualties are three times more frequent than those derived from combat and account for nearly 50% of all musculoskeletal casualties requiring evacuation from the combat zone

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection. . Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination. . While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared

Heterotopic ossification (HO) is perhaps the single most significant obstacle to independence, functional mobility, and return to duty for combat-injured veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Recent research into the cause(s) of HO has been driven by a markedly higher prevalence seen in these wounded warriors than encountered in previous wars or following civilian trauma. To that end, research in both civilian and military laboratories continues to shed light onto the complex mechanisms behind HO formation, including systemic and wound specific factors, cell lineage, and neurogenic inflammation. Of particular interest, non-invasive in vivo testing using Raman spectroscopy may become a feasible modality for early detection, and a wound-specific model designed to detect the early gene transcript signatures associated with HO is being tested. Through a combined effort, the goals of early detection, risk stratification, and development of novel systemic and local prophylaxis may soon be attainable.