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 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

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.

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

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

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

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

Crown copyright 2009. Published with the (permission of the Defence Science and Technology Laboratory on behalf of the Controller of HMSO. Introduction. The optimum strategy for the care of war wounds is yet to be established. A need exists to model complex extremity injury, allowing investigation of wound management options. Aim. To develop a model of militarily relevant extremity wounding. Study Design. Laboratory study with New Zealand White Rabbits. Methods. Phase 1. Development of injury. Following induction of general anaesthesia, a muscle belly on the flexor aspect of the forelimb of the rabbit was exposed. This was achieved by creating a fascial tunnel under the belly of flexor carpi ulnaris (FCU). Utilising a custom built drop test rig a high energy, short duration impact was delivered. To replicate casualty evacuation timelines, the animal was maintained under anaesthesia for three hours and recovered. The wound was dressed with saline soaked gauze and supportive bandaging. 48 hrs later, the animal was culled and the muscle harvested for histological analysis. Analgesia was administered once a day. Animals were checked by experienced staff at least twice a day and body temperature recorded by a subcutaneous transponder. Phase 2. Contamination of muscle injury. Sequential animals had inoculums of 1×102/100μl, 1×106/100μl and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered from anaesthetic and monitored as per phase 1. Delivery was evaluated by droplet spread and via injection by fine bore needle into the muscle belly. At the 48 hour point, the animals were culled, dressings removed, the muscle harvested and auxiliary lymph nodes sampled. Quantitative microbiological analysis was performed to determine colony forming unit counts (CFU) at 24 hours post-collection. Results. Phase 1. Six animals were exposed to a loading of 0.5kg. Histological analysis demonstrated a consistent injury pattern with 20% of the muscle belly becoming necrotic. Following discussion with subject matter experts this was found to be representative of the nature of injury from ballistic limb trauma and was adopted as standard. Phase 2. Twenty-two animals were exposed to the standardised injury and then inoculated at the prescribed challenge doses and delivery methods. A challenge dose of 1×106/100μl S. aureus delivered by droplet provided the greatest consistency. A group of six animals with an average challenge dose of 3.3×106/100μl yielded growth at 48hrs on average of 9.2×106 CFU. There were no adverse effects on animal welfare throughout, with body temperatures within normal limits at all times. Discussion. The use of rabbits in the investigation of musculoskeletal injury and infection is well established. No study to date however has addressed high energy complex soft tissue wounding, contamination and its optimum management. Considering the current burden of such wounds the need for this question to be answered in a research setting is transparent. This model enables a significant, reproducible, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management options including wound coverage and fracture fixation