Failure of fracture healing is a significant problem, resulting in considerable morbidity and financial costs to the NHS. It is also a major complication of ballistic injuries.

We reviewed our experience in the management of non-union by revision of fracture fixation and use of Bone Morphogenic Protein at Ministry of Defence Hospital Unit Frimley Park. Bone Morphogenic Proteins have been identified as promoting osteogenesis and have been used to stimulate bone growth in fracture revision surgery and spinal surgery. BMP’s are a subgroup of the TGF-β family and consist of at least 20 different subtypes of which BMP 2 and BMP 7 are commercially available. Current preparations include a solution for application to a gel matrix and as a powder for reconstitution to a paste for implantation to the fracture site. Costs per graft are in the region of £2,000.

BMPs have been used at Frimley Park since 2005 in the management of 12 patients with established non-union. These included fractures of 4 femurs, 5 humerai, 2 clavicles and 1 metatarsal. Early results are encouraging and support continued use of BMP’s in fracture revision surgery for established non-union.

Non-union remains a difficult problem and even with this treatment there was a significant failure rate, often associated with failure of fixation.

Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate following high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The purpose of this study was to assess the validity of Mangled Extremity Severity Score (MESS), the only verified score, in a population of military patients with ballistic mangled extremity injuries.

52 military patients with 58 limbs who had ballistic mangled extremity injuries were identified, 13 of whom required amputation. Using both the trauma audit and the hospital notes, demographics were assessed. Patients were retrospectively evaluated with the MESS system for lower extremity trauma.

The MESS would not help in the decision-making. However, we were able to develop an algorithm for management, in particular the need for early amputation.

The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have developed an algorithm to provide guidelines for management.

Extremity injuries on the battlefield are commonly secondary to high energy mechanisms. These cause significant injury to soft tissue and bone and are contaminated. Evacuation to medical care can be difficult in the operational environment and may delay the time to initial surgery. There is already substantial literature on the complications of such injuries but this is the first report from UK forces. Our aim was to assess the complications, but specifically infections, in relation to delay in surgery and also the method of fracture stabilisation.

Military patients who had ballistic mangled extremity injuries were identified from the database (courtesy of ADMEM). Using both the trauma audit and the hospital notes, demographics were assessed. The injuries sustained (including the fractured bones), time to theatre, associated injuries, method of stabilisation at Role 3, definitive fixation and complications were noted.

81 patients were identified with 95 limbs injured (68 lower limb, 27 upper limb). The most commonly fractured bones were the tibia, radius/ulna, femur and humerus. Primary stabilisation was either ExFix (53%) or plaster (44%). Of those stabilised by ExFix, the definitive stabilisation was mainly by either a nail (44%) or plate (17%). Those stabilised by plaster mainly stayed in plaster. 72% of patients developed at least one complication, the most common of which was superficial infections. Other complications were deep infections, delayed union, haematomas, neuropathic pain and flap failures. The main organisms involved were Acinetobacter, Bacillus and Pseudomonas. There was no association between delay to theatre and decision to amputate. There was an association between the use of plaster for definitive stabilisation and superficial infection and plates for definitive stabilisation and deep infections. There was no association between time delay to theatre and infections.

This provides the first report of complications from extremity injuries secondary to ballistic missile devices in UK forces. It allows for comparison with reports from other sources on similar injuries and helps to guide further management of patients. In particular it agrees with recent civilian data that initial surgery does not have to be carried out as soon as possible, which has implications for military planning.

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.

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.

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.

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.