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.

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.

We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.