The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma. The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East

Background. Low back pain is a common condition amongst Armed Services personnel and can have significant impact upon their ability to undertake military duties, including being deployed into austere environments. Methods and results. This was a qualitative study of 16 military physiotherapists exploring their attitudes and beliefs towards management of low back pain. Semi-structured interviews were conducted and transcribed. The transcripts were analysed using a method of thematic content analysis. Six themes were identified; military culture, occupational issues, continuing professional development, clinical reasoning, need for a cure and labelling the patient. The highly challenging occupational demands placed on military patients appeared to prompt physiotherapists to request radiological investigations at an earlier stage than recommended in current guidelines. Justification for early investigation was considered to be both in the patients' and the Armed Services best interests, for the patient to initiate treatment with minimum delay whilst also decreasing the number of personnel unable to deploy for medical reasons. Conclusion. Obtaining investigative procedures at an early stage of the patients' management was justified by reference to the highly demanding physical duties undertaken by service personnel. The military physiotherapists' were very well informed about occupational demands placed on their patients; in this instance results from radiological investigations were used to inform not only the clinical management but more significantly the occupational management. The military physiotherapists regard for the significance of occupational factors sets them apart from those in civilian practice where management is predominantly based on clinical features alone

The aim of the study was to investigate the attitudes and beliefs of military physiotherapists utilising the ‘Health care providers beliefs attitudes and impairments scale’ devised by Rainville et al (1994). The scale is a valid and reliable tool which indicates the likelihood of advice given to patients with a low back pain is either pro active or fear avoidant. The scale has been utilised amongst health care professionals and has shown a high degree of correlation with patient vignettes. A high score on the HC- PAIRS, is indicative of that advice given to patients is generally fear avoidant and cautious. Conversely, a low score supports current research and indicates that pro-active advice is more likely to be given to the patient. The HC PAIRS questionnaire was distributed to all 90 military physiotherapists currently serving in a clinical role. The questionnaire was accompanied by a letter explaining that the nature of the study and requesting the questionnaire be completed and that the biographical information of gender, rank, age range, years military service, years physiotherapy experience, qualification to practice as a physiotherapist and highest academic qualification obtained be recorded. A total of 83 returns were received. Statistical analysis was undertaken using the SPSS (version 14) statistical package. Results indicated a mean score of 50.86(SD 10.189). Military service equated to a mean of 8.86 years (SD 9.153), whilst physiotherapy experience gave a mean of 8.87 years (SD 6.327). Further statistical analysis was undertaken to establish whether there was a correlation between any of the biographical data collected and of the HC-PAIRS score. No correlation of statistical significance was identified in any of the categories. The results obtained from the military physiotherapists are very similar to those obtained in similar studies utilising civilian physiotherapists, moderately fear avoidant. Attitudes and beliefs would appear to be developed very early in the physiotherapist’s career, exposure to both clinical experience and military culture would appear to have minimal impact on these beliefs. This has important implications when changes to traditional management strategies are being considered and implemented. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

This paper describes how advances in three-dimensional printing may benefit the military trauma patient, both deployed on operations and in the firm base. Use of rapid prototype manufacturing to produce a 3D representation of complex fractures that can be held and rotated will aid surgical planning within multidisciplinary teams. Patient-clinician interaction can also be aided using these graspable models. The education of military surgeons could improve with the subsequent accurate, inexpensive models for anatomy and surgical technique instruction. The developing sphere of additive manufacturing (3D printing functional end-use components) lends itself to further advantages for the military orthopaedic surgeon. Military trauma patients could benefit from advances in direct metal laser sintering which enable the manufacture of complex surfaces and porous structures on bio-metallic implants not possible using conventional manufacturing. “Bio-printing” of tissues mimicking anatomical structures has potential for military trauma patients with bone defects. Deployed surgeons operating on less familiar fracture sites could benefit from three-dimensionally printing patient-specific medical devices. These can make operating technically easier, reducing radiation exposure and operating time. Further ahead, it may be possible to contemporaneously 3D print medical devices unavailable from the logistics chain whilst operating in the deployed environment

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

In the young and highly active population of military patients, femoroacetabular impingement can be a source of serious disability as well as a threat to their career. This morbidity can be treated with hip arthroscopy with debridement of cam lesion, and excision or repair of a corresponding labral tear. We report on the long term outcomes (>1 year) of 26 military cases who underwent hip arthroscopy for femoroacetabular impingement, in a single surgeon's series. Twenty two patients (four bilateral cases) underwent hip arthroscopy as a day case procedure during the period February 2013 to October 2014. Non-Arthritic Hip Scores (NAHS) were obtained from patients pre-operatively, at two months, four months and at least one year post-operatively. There was a significant improvement in NAHS at two months (75.6)(p<0.05), four months (85.1)(p<0.001) and one year (84.8)(p<0.001), compared to pre-operative NAHS (65.8). There was no significant change in NAHS beyond four months. Only three out of the 22 patients were medically discharged secondary to persistent hip symptoms. Hip arthroscopy for femoroacetabular impingement is an effective, viable procedure for military patients. Mobility, pain and function is significantly improved after surgery. This improvement is sustained in the long term up to and beyond one year

Amputation is one of the most feared injuries in service personnel, particularly a worry that it will mean the end of their military career. The aim of this study was to determine the outcome, in relation to military service in UK military amputees. UK service personnel who sustain an amputation undergo rehabilitation and prosthetic limb fitting at the Defence Medical Rehabilitation Centre Headley Court. This includes a realistic assessment of their employment capabilities, and they are graded by a Functional Activity Assessment (FAA). FAA ranges from 1 (fully fit) to 5 (unfit all duties). In addition the Short Form-36 Health Survey (SF-36) is completed on initial admission and at follow-up. We reviewed this information to determine the outcome of military amputees. We identified 53 casualties who had sustained amputations. 8 had sustained an upper limb amputation, 41 a lower limb amputation, and 4 had sustained both an upper and lower limb amputation. 9 patients (including 1 Reservist) have left the forces by medical discharge, with the remaining 44 continuing to serve. 32 of the 44 have returned to work, albeit at a lower level. 49 patients have FAA grades and are at least 6 months post-injury. No patients were graded as FAA 1, 8 as FAA 2 (Fit for Trade and fit for restricted General or Military Duties), 18 as FAA 3 (Unfit for Trade but fit for restricted General or Military Duties), 18 as FAA 4 (Unfit for all but Sedentary Duties) and 5 as FAA 5. All bilateral and triple amputees were FAA 4 or 5. Other injuries such as blindness, severe brain injury or mental health issues also increased the FAA. Of the 32 patients who have returned to work, 8 are FAA 2, 12 are FAA 3, 11 are FAA 4, and 1 has not been graded. SF-36 data was available in 40 patients, available as paired scores for 34. The mean time between SF-36 scoring was 6.7 months (range 0.2 – 17.4). The mean SF-36 scores for Physical Component Summary (PCS) increased from 34.40 (SD 9.3) to 42.06 (SD 11.1), with Mental Component Summary (MCS) 52.01 (SD12.9) remaining similar at 52.92 (SD 12.0). Pre- and post-rehabilitation PCS scores improved with rehabilitation (p=0.0003). MCS scores were similar in these patients to the normal population, 50 (SD 10). No differences could be found within the unilateral lower limb amputation group regarding amputation level (trans-tibial, through-knee disarticulation, trans-femoral) and SF-36 scoring. Furthermore due to the low numbers, no conclusion could be made comparing the unilateral lower limb amputation group with the bilateral lower limb group, the unilateral lower limb plus upper limb, the bilateral lower limb and upper limb (trilateral), and the isolated upper limb groups. This study is the first to report the outcomes, with regards to return to work, of the UK military amputee population injured in Afghanistan and Iraq. There is an almost even distribution of FAA score between 2, 3, and 4 for those back at work. Level of amputation and SF-36 scores do not seem to correlate, partly due to other injuries sustained that confound the patients’ perception of their health. SF-36 PCS scores increase significantly with rehabilitation, whilst MCS remain similar to the normal population

Hip osteoarthritis is uncommon in active military personnel but can be extremely debilitating. Previously in such cases total hip replacement was usually delayed as long as possible. The two main reasons for such reluctance were that these persons would be graded P7 Permanent after total hip replacement and that the amount of physical activity an active military person does would lead to early loosening of implant and revision surgery. Resurfacing Arthroplasty has allowed us to take an earlier and more interventional approach in younger active patients. We describe our early results of 18 hip resurfacing operations in active serving military personnel. Average age was 48 years. All 18 were done in MDHU Northallerton by one in-service orthopaedic consultant in 2004 and 2005. There were no serious complications; average length of stay was 5.5 days. Specifically there were no fractured necks of femur and there were no early signs of component loosening. Final grading after six months was P3. Hence we now recommend that in selected active military personnel where anatomy permits early hip resurfacing should be considered rather than a conventional hip replacement

It has been shown that extremity injuries form a large proportion of the operative surgical workload in conflict situations. Injuries to the hands are an important subgroup and hand surgery has a long association with military surgery. While most hand injuries do not require surgical intervention, those that do, require that military surgeons should be well versed in the principles of hand surgery. The concepts of staging and/or damage control surgery are well applied to this region. The nature of military medical support necessarily changes in the transition from war fighting to a post-conflict phase. We examine the activity in the sole British Military Hospital serving a multi-national divisional area in Iraq over 2004. During this post conflict phase, the spectrum of hand trauma is characterised. The overwhelming majority of hand trauma resulted in soft tissue injury. There was a clear predisposition to hand trauma for males, manual workers, combat soldiers and engineers/mechanics. X-ray imaging is heavily used in this environment. Even where soldiers are returned to duty they are often restricted in the duties that they can perform. The results of this study reinforce the relevance of basic principles of hand trauma management, particularly in challenging environments. These knowledge and skill requirements should be emphasised for the war surgeon and the emergency physician. Hand surgery is an evolving speciality that continues to find clear and direct applications for the military surgeon

Military patients have high functional requirements of the upper limb and may have lower pre-operative PROM scores than civilian patients i.e. their function is high when benchmarked, but still insufficient to perform their military role thereby mandating surgery. Our aim was to compare the pre-operative Oxford Shoulder Instability Scores in military and civilian patients undergoing shoulder stabilisation surgery. We undertook a prospective, blinded cohort-controlled study (OCEBM Level 3b). The null hypothesis was that there was no difference in the Oxford Shoulder Instability Scores between military and civilian groups. A power calculation showed that 40 patients were required in each group to give 95% power with 5% significance. A clinical database (iParrot, ByResults Ltd., Oxford, UK) was interrogated for consecutive patients undergoing shoulder stabilisation surgery at a single centre. The senior author - blinded to the outcome score - matched patients according to age, gender and diagnosis. Statistical analysis showed the data to be normally distributed so a paired samples t-test was used to compare the two groups. 110 patients were required to provide a matched cohort of 80 patients. There were 70 males and 10 females. Age at the time of surgery was 16-19yrs (n=6); 20-24yrs (n=28); 25-29 (n=16); 30-34(n=12); 35-49(n=12); 40-44(n=6). 72 patients (90%) had polar group one and 8 patients (10%) had polar group two instability. The mean Oxford Shoulder Instability Score in the civilian group was 17 and the in military group was 18. There was no statistical difference between the two groups (p=0.395). This study supports the use the Oxford Shoulder Instability Score to assess military patients with shoulder instability

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

Objectives. The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function. Methods. Follow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery. Results. In 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months). The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351). Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001). Conclusions. At five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes. Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2

Military patients have high functional requirements of the upper limb and may have lower pre-operative PROM scores than civilian patients i.e. their function is high when benchmarked, but still insufficient to perform their military role thereby mandating surgery. Our aim was to compare the pre-operative Oxford Shoulder Instability Scores in military and civilian patients undergoing shoulder stabilisation surgery. We undertook a prospective, blinded cohort-controlled study (OCEBM Level 3b). The null hypothesis was that there was no difference in the Oxford Shoulder Instability Scores between military and civilian groups. A power calculation showed that 40 patients were required in each group to give 95% power with 5% significance. A clinical database (iParrot, ByResults Ltd., Oxford, UK) was interrogated for consecutive patients undergoing shoulder stabilisation surgery at a single centre. The senior author - blinded to the outcome score - matched patients according to age, gender and diagnosis. Statistical analysis showed the data to be normally distributed so a paired samples t-test was used to compare the two groups. 110 patients were required to provide a matched cohort of 80 patients. There were 70 males and 10 females. Age at the time of surgery was 16–19 yrs (n=6); 20–24yrs (n=28); 25–29 (n=16); 30–34 (n=12); 35–39 (n=12); 40–44 (n=6). 72 patients (90%) had polar group one and 8 patients (10%) had polar group two instability. The mean Oxford Shoulder Instability Score in the civilian group was 17 and the in military group was 18. There was no statistical difference between the two groups (p=0.395). This study supports the use the Oxford Shoulder Instability Score to assess military patients with shoulder instability

A retrospective review of 57 military patients undergoing ankle arthroscopy between 1999 and 2011 was performed. A case-note review of medical records was undertaken pertaining to military role, ankle injury sustained, mechanism, presenting symptoms and their duration. Arthroscopic findings were compared to findings on radiographs and MRI scans. At first presentation 23 patients had features of arthritis on radiographs. We found MRI was both highly sensitive (97.7%) and specific (93.4%) in detecting osteochondral defects (OCD). 16 of the patients had evidence of osteochondral injury. All OCDs picked up on MRI were confirmed at arthroscopy. Ankle injury may not be a benign injury in military personnel, with over half of these young patients having radiological features of osteoarthritis at presentation. We found MRI an effective tool for identifying occult injuries not seen on radiographs. Lateral ligament injury with associated gutter scarring can be successfully treated with arthroscopic debridement. This suggests pseudoinstability rather than a true mechanical instability as the main cause for patient's symptoms in this cohort

Introduction. Femoroacetabular impingement (FAI) is a relatively recent recognised condition and a potential cause of anterior hip pain in the young military adult population. Both Cam and Pincer type FAI may lead to inflammation, labral tears, and or damage to the smooth articular cartilage of the acetabulum leading potentially to early osteoarthritis of the hip. Open Surgical hip dislocation using the Ganz Trochanteric Flip approach is an accepted technique allowing osteoplasty of the femoral neck and acetabular rim combined with labral repair if required. We present our results of this technique used in military personnel. Methods. All Military personnel who underwent FAI surgery in our unit since August 2006 were included in the study. Functional outcome was measured using the Oxford hip and McCarthy non-arthritic hip scores pre and post-operatively. Results: 13 hips in 11 patients with an average age of 36 years (21–45) underwent surgical hip dislocation for treatment of FAI. Average time of downgrading prior to surgery was 9.3(3-18) months. 6 out of the 11 patients have been upgraded to P2. Average time to upgrading was 6.8(3-17) months. There were no infections, dislocations, or neurovascular complications. Mean Oxford Hip Score improved from 22.8(range 8–38) to 39.5(11–48) and mean McCarthy hip score from 49.6(33.75–80) to 79.2(36.25–100) with an average follow up of 19.4 months (range 4– 42 months). Discussion. The early results of surgical hip dislocation in military personnel are encouraging. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis

The study used a qualitative methodology to explore the attitudes and beliefs of military physiotherapists and how these influenced the management of military patients presenting with chronic low back pain. Semi-structured interviews were undertaken with a sample of 16 military physiotherapists; the transcripts were analysed using a method of thematic content analysis. Analysis of semi-structured interviews undertaken resulted in the identification of six themes. These were: military culture, occupational issues, continuing professional development, clinical reasoning, need for cure and labelling the patient. The importance of understanding the occupational demands on their patients was considered highly significant by all of the military physiotherapists interviewed. However, there appeared generally poor knowledge of the biopsychosocial model in the management of low back pain and over-reliance on the medical model. Three-quarters of the military physiotherapists interviewed expressed frustration in their management of patients with low back pain. Similarly, the military physiotherapists displayed a poor awareness of current evidence-based clinical guidelines for the management of low back pain. The themes military culture and occupational issues were significant in influencing the military physiotherapist's clinical management. The highly physical and arduous nature of military occupations resulted in investigative procedures being requested at an earlier stage than is recommended in the current evidence-based guidelines. Justification for early investigations was provided on the basis of the unique occupational factors combined with requirement to optimise the number of military personnel able to deploy operationally. It was concluded that the management of low back pain in military personnel could be improved by increasing awareness of the current evidence-based guidelines. This would benefit both patients and the Armed Services, by reducing the disability caused by low back pain and increasing the number of operationally deployable service personnel

Musculoskeletal injuries are one of the leading causes for morbidity within military personnel on operations and are the leading cause for aeromedical evacuation of British military personnel from Afghanistan for Disease and Non-Battle Injury. The objective of this study was to improve our knowledge relating to these injuries. This prospective cohort study included all British military personnel presenting with musculoskeletal injuries to primary healthcare in Camp Bastion and the rehabilitation team working in British bases forwards of Bastion, Afghanistan. Injury report forms were completed by medical officers and physiotherapists. Data was collected over two separate two week periods during the first and second half of the tour. 273 injury forms were completed in total. Most injured body parts were back (23%), knee (17%), shoulder (13%) and ankle (13%). 53% were attributed to training, 25% were due to overuse and 37% were old injuries. Leading cause for musculoskeletal injuries sustained on operations was training, not sport. Further studies are required to clarify what training factors are attributing to injuries which will enable design and implementation of prevention strategies

High-energy firearms do not necessarily produce ‘high-energy’ Gun Shot Wounds (GSWs). The aim of this study was to characterise the gun shot injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound. The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 Jan 2009 and 31 Dec 2013: only UK personnel were included. There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Of the 325 survivors with full records, 236 had GSWs to the limbs and pelvis. ‘Through and through’ wounds were strongly associated with less requirement for debridement (p<0.0001). Fractures were associated with a requirement for a greater number of wound debridements (p=0.00022) GSW with intact, retained bullets and those involving bullet fragmentation, required similar numbers of wound debridements (p=0.53744). This study characterises the GSWs sustained by UK Military personnel over 5-years of warfare. More complex wounds as indicated by the requirement for repeated debridements are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured

Femoral neck stress fractures (FNSF) are uncommon, representing around 5% of all stress fractures. In military personnel, FNSF represents one of the severest complications of military training, which can result in medical discharge. Clinical examination findings are frequently non-specific and plain radiography may be inconclusive leading to missed or late diagnosis of FNSF. This paper highlights the significance of FNSF’s in military personnel and alerts physicians to the potential diagnosis. We identified all military recruits, aged 17 to 26, who attended the Infantry Training Centre (Catterick, UK), over a four-year period from the 1. st. July 2002 to 30. th. June 2006, who suffered a FNSF. The medical records, plain radiographs, bone scans and MRI’s of the recruits were retrospectively reviewed. Of 250 stress fractures, 20 were of the femoral neck; representing 8% of all stress fractures and an overall FNSF rate of 12 in 10,000 military recruits. FNSF’s were most prevalent amongst Parachute Regiment recruits (1 in 250, p< 0.05). Onset of symptoms was most commonly between 13–16 weeks from the start of training. The majority (17/20, 85%) of FNSF’s were undisplaced, these were all treated conservatively. Three FNSF’s were displaced on presentation and were treated surgically. Overall, the medical discharge rate was 40% (8/20). FNSF’s are uncommon and the diagnosis remains a challenge to clinicians and requires a high index of suspicion in young athletic individuals. In such individuals early referral for MRI is recommended, to aid prompt diagnosis and treatment, to prevent serious sequelae. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

Back pain is extremely common in soldiers undergoing training. 1. There is no data worldwide with regards to incidence, prevalence and impact of back pain in a deployed military population. This study was undertaken to evaluate these issues. 1000 back pain questionnaire were distributed over a period of four days at the main military base in Basrah in February 2009 in different locations. The filling out was anonymous and completely voluntary. UK military personnel. Information was obtained about age, BMI, length of service, rank, incidence, prevalence, onset, admission rate, treatment, aero-medical evacuation, operational effectiveness, pain killers and VAS. 768 (77%, 26% of population at risk) questionnaires were returned Prevalence of back pain was 33.4% (257). A greater prevalence occurred in the combat arms (41.7%, p=0.01) and those of over 12 years service (44%, p=0.004). No statistical difference was found with rank, or BMI. 74 people (9.6%) had developed new onset back pain since deploying. Recurrent pain occurred in 38.9% of the whole sample. VAS showed a normal distribution. 35% of those affected were discharging their duty with mild difficulty but around 6% were having great difficulty. 25% were on regular analgesics. Back pain constituted 23% (137/583) of the physiotherapy dept caseload, 6.6%, (25/378) of ward admissions and 0.04% (5/119) of aero-med patients. Back pain is a major problem among deployed personnel. However with adequate resources the vast majority can be managed in the field thus reducing attrition rates. 2. and maintaining operational effectiveness. Further studies should be undertaken to assess if back pain persists after deployment