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

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

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

Aim. To review current military orthopaedic experience and establish if there exists a consensus of opinion in how and if to perform fasciotomy of the foot and to guide other clinicians. Method. A questionnaire was sent to 10 DMS orthopaedic consultants to identify their experience with foot compartment syndrome and performing fasciotomies. Results. 50% had performed a foot fasciotomy (average 2, range 1-6) over an average of 6.2 years as consultant and an average of 7.3 months deployed. Most commonly two dorsal and a medial incision were used to decompress the foot, while one advocated not decompressing and accepting the contractures, a view consistent with some civilian literature. Discussion. The debate surrounding decompression stems from the rarity of the condition, the lack of consensus regarding the anatomy of the foot compartments and whether to accept the inevitable contractures by not decompressing. Given that foot compartment syndrome may not be seen during civilian training, then there is a requirement for guidance for the deploying military surgeon. Conclusion. DMS clinicians need to remain vigilant to compartment syndrome of the foot and especially in cases of crush or blast injury or of multiple fractures. If diagnosed or even if an impending compartment syndrome is suspected then the foot should be decompressed and the deployed orthopaedic surgeon should be capable of performing it

Hand fasciotomy is a rarely performed procedure which should be considered by military surgeons, and performed where necessary. Maximising hand function is vital in all military patients, but is even more significant in those who have lost multiple limbs and require maximal function from remaining hands, which are commonly injured too. It is vital that compartments are decompressed expediently to minimize muscle ischaemia. Cases were identified from the JTTR from March 2003. Data were collected prospectively from Aug 2009 to Feb 2010. Patient notes were analysed and the following recorded –demographics, mechanism of injury (MOI), associated injuries, echelon of care at which fasciotomy was performed, indication recorded by operating surgeon, and specialty of operating surgeon. 9 patients were identified, median age was 23, MOI was IED in 8/9 and mine in 1/9/. All were multiply injured. 4/9 (44%) were performed at R3 and 5/9 (56%) at R4. All fasciotomies at R4 were performed at the first debridement, intrinsic muscles were found to be necrotic in 1 case. At R3 3/4 were performed by orthopaedic surgeons and 1/4 by a plastic surgeon, at R4 all were performed by hand surgeons, either orthopaedic or plastic. All fasciotomies performed at R4 were at the first debridement, and 1 revealed necrotic intrinsic muscles. This implies that some of these patients may have benefited from earlier procedures. In upper limb injury where it is not possible to passively flex the metacarpophalangeal joints to 90 degrees, decompressing the hand should be considered

Hand injuries are common in military personnel deployed on Operations. We present an analysis of 6 years of isolated hand injuries from Afghanistan or Iraq. The AEROMED database was interrogated for all casualties with isolated hand injuries requiring repatriation between April 2003 and 2009. We excluded cases not returned to Royal Centre for Defence Medicine (RCDM). Of the 414 identified in the study period, 207 were not transferred to RCDM, 12 were incorrectly coded and 41 notes were unavailable. The remaining 154 notes were reviewed. 69% were from Iraq; only 14 % were battle injuries. 35% were crush injuries, 20% falls, 17% lacerations, 6% sport, 5% gun-shot wounds and 4% blast. Injuries sustained were closed fractures (43%), open fractures (10%), simple wounds (17%), closed soft tissue injuries (8%) tendon division (7%), nerve division (3%), nerve/tendon division (3%) complex hand injuries (4%). 112 (73%) of the casualties required surgery. Of these 44 (40%) had surgery only in RCDM, 32 (28%) were operated on only in deployed medical facilities and 36 (32%) required surgery before and after repatriation. All 4 isolated nerve injuries were repaired at RCDM; 2 of the 4 cases with tendon and nerve transection were repaired before repatriation. Of the 10 tendon repairs performed prior to repatriation 5 were subsequently revised at RCDM. This description of 6 years of isolated hand injuries in military personnel allows future planning to be focused on likely injuries and raises the issue of poor outcomes in tendon repairs performed on deployment

CECS is an exercised induced condition that causes pain, typically in the lower limbs, and is relieved by rest. It is often seen in military personnel significantly restricting their duties. Conservative treatment is rarely successful and patients often require surgical decompression by fasciotomy or fasciectomy. All IMP (intramuscular pressure) tests (n=286) carried out between December 2007 and October 2010 on patients with suspected CECS in the anterior compartment of the lower leg were reviewed. The treatment and outcomes of those referred for surgery were analysed. Pre- and post-surgery military medical grading for leg function was extracted from the medical records system. Independent t-tests compared differences between patients that had surgery or did not. The Wilcoxon signed-rank test compared grades before and after surgery. According to the diagnostic criterion, 80% of patients undergoing IMP testing had CECS. Of these, 179 (68%) patients underwent surgery, 17 (9%) of these were for recurrent symptoms. Almost all decompressions were bilateral (95%). The majority of operations (121) were fasciectomies of the anterior compartment only and were performed by 2 surgeons. The remaining operations (58) were performed by 6 surgeons and were fasciotomies of both anterior and lateral compartments. The mean time from testing to surgery was 24 (median 11) weeks. There were 23 (13%) complications other than recurrence including 16 wound infections, 6 seromas and 1 haematoma. Pre- and post-surgery grading was available for 67% of patients. These patients had significantly better leg function after surgery (Z=−3.67, p<0.001). Of these, 47% improved, 38% showed no improvement and 15% had a poorer outcome had. Those who had a fasciectomy were significantly more likely to improve than those who had a fasciotomy (p=0.023, rho=−1.96). Our results demonstrate that patients generally improve lower limb function following surgical decompression. However, 53% showed no improvement or deteriorated in their medical grading. In addition, there is a high diagnosis rate for CECS following IMP measurement. This may reflect the poor validity of the diagnostic criterion or this could be due to good clinical selection for testing. Furthermore, fasciectomy shows a greater correlation with improved outcome than fasciotomy. There is a need to develop more accurate diagnostic criteria and to evaluate the benefits of standardising surgical technique

We present the British Military's experience of treating devastating lower limb injuries in personnel returning from Iraq and Afghanistan. We evaluate current surgical practice of attempting to maximise stump length through sequential debridement, rather that early amputation outside the zone of injury. Following an observation that the frequency of sequential amputation had appeared to increase during spring 2009, it was speculated that there may be factors which would predict which patients would require a more aggressive early amputation. The Joint Theatre Trauma Registry was interrogated for all cases of amputation between Apr 06 and Sep 09. The following data were collected: demographics, mechanism of injury, requirement for massive transfusion, use of combat applied tourniquet, number of stump debridements and echelon of care performed at, all microbiology and final level of amputation. A regression analysis was performed to establish correlation between each data-set and final level of amputation. 95 cases were identified; 21 were either digits or upper limbs and excluded. Clinical notes of the remaining 74 cases were requested, of which 48 were available representing a total of 66 lower limb stumps. No significant relationships were established between sequential amputation and any of the variables we examined. It was not possible to identify factors with predictive value with respect to which patients would benefit from a more aggressive early amputation approach. These results support current practice by demonstrating that attempts to balance maximal stump length with sufficient debridement to eradicate infected tissue, does not expose patients to unnecessary operative “hits”

Surgical planning is the first step in operative fracture management. Complex situations are often faced which pose difficulties on both technical and logistic fronts. Surgical planning is the first step in operative fracture management. The degree of planning that is required is therefore determined by a number of factors including: the nature of the injury mechanism and its concomitant physiological insult, complexity of the fracture and region, expertise of the surgical team and equipment limitations. This paper explores a novel planning process in orthopaedic trauma surgery based upon British Military Doctrine. The seven questions of surgical planning represent a novel method that draws inspiration from the combat estimate process. It benefits from a global approach that encompasses logistic as well as surgical constraints. This, in turn, allows the surgical team to form an understanding of the nature of the fracture in order to develop, document and deliver a surgical plan. This has benefits for the operating surgeon, operating room practitioners and trainees alike and ultimately can result in improved patient care

Aim To develop a militarily relevant complex extremity wounding model. Study Design Controlled laboratory study with New Zealand White Rabbits. Method Phase One: Injury Development. Under general anaesthesia, the flexor carpi ulnaris of the right forelimb was exposed and high energy, short duration impact delivered via drop test rig. Anaesthesia was maintained for three hours, the animal was recovered and saline soaked gauze and supportive bandaging applied. 48 hrs later, the animal was culled and muscle harvested for histological analysis. Analgesia was administered daily, animals checked by experienced staff at least twice daily and temperatures recorded by subcutaneous transponder. Phase Two: Contamination. Sequential groups of animals had inoculums of 1×102, 1×106 and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered as phase one. At 48 hours, animals were culled, muscle harvested and axillary lymph nodes sampled. Quantitative microbiological analysis was performed on the muscle. Results: Six animals given a loading of 0.5kg yielded consistent injury with 20% of the muscle becoming necrotic. Representative of injury from ballistic trauma, this was adopted as standard. Twenty-two subsequent animals were exposed to the injury and inoculated with the challenge doses. 1×106/100μl S.aureus provided the greatest consistency in recovered yield. There were no adverse effects on animal welfare and body temperatures were always within normal limits. Discussion. This model enables a consistent, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management including wound coverage and fracture fixation

Freezing cold injuries (Frostnip and Frostbite) (FCI) have become uncommon in UK military personnel relative to non-freezing cold injuries (NFCI, ‘trench foot’). However if unidentified or inappropriately treated they may lead to avoidable medical downgrading or discharge. JSP 539 recommends delay or avoidance of surgical debridement where possible. An anonymised retrospective audit was performed of FMED7 medical reports of cases seen in the Institute of Naval Medicine Cold Injury Clinic (CIC) between July 2002 and January 2014 inclusive. In all 149 FCI cases were identified, 71 affected hands only of which 34 were bilateral, and 58 affected feet only, 34 of those being bilateral. A total of 17 patients had injured both hands and feet, with 10 bilateral. Royal Marines accounted for half of these cases, with the Army making up a further third, and the Royal Navy and RAF making up the remainder. Most FCI were found to have occurred in Norway, with Marine ranks being most commonly affected. Ten cases underwent surgery: aspiration of blisters, debridement of tissue, or amputation. Seven of these procedures took place prematurely, which appeared detrimental to recovery. No patients required fasciotomy. FCI are uncommon, but in arctic conditions their risk rises dramatically. The best treatment is conservative where possible following JSP 539 guidelines and consultation with CIC should occur at the earliest possibility. The Potential benefits of surgery must be weighed against problems of injured tissue healing and expert opinion should be obtained

This is a retrospective study of survivors of recent conflicts with an open fracture of the femur. We analysed the records of 48 patients (48 fractures) and assessed the outcome. The median follow up for 47 patients (98%) was 37 months (interquartile range 19 to 53); 31 (66%) achieved union; 16 (34%) had a revision procedure, two of which were transfemoral amputation (4%).

The New Injury Severity Score, the method of fixation, infection and the requirement for soft-tissue cover were not associated with a poor outcome. The degree of bone loss was strongly associated with a poor outcome (p = 0.00204). A total of four patients developed an infection; two with S. aureus, one with E. coli and one with A. baumannii.

This study shows that, compared with historical experience, outcomes after open fractures of the femur sustained on the battlefield are good, with no mortality and low rates of infection and late amputation. The degree of bone loss is closely associated with a poor outcome.

Cite this article: Bone Joint J 2015;97-B:842–6.

Aims

The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS).

Introduction. This is the first study to illustrate spinal fracture distribution and the impact of different injury mechanisms on the spinal column during contemporary warfare. Methods Retrospective analysis of Computed Tomography (CT) spinal images entered onto the Centre for Defence Imaging (CDI) database, 2005-2009. Isolated spinous and transverse process fractures were excluded to allow focus on cases with implications for immediate management and prospective disability burden. Fractures were classified by anatomical level and stability with validated systems.

Clinical data regarding mechanism of injury and associated non-spinal injuries for each patient was recorded. Statistical analysis was performed by Fisher's Exact test. Results 57 cases (128 fractures) were analysed. Ballistic (79%) and non-ballistic (21%) mechanisms contribute to vertebral fracture and spinal instability at all regions of the spinal column. There is a low incidence of cervical spine fracture, with these injuries predominantly occurring due to gunshot wounding. There is a high incidence of lumbar spine fractures which are significantly more likely to be caused by explosive devices than gunshot wounds (p<0.05). 66% of thoracolumbar spine fractures caused by explosive devices were unstable, the majority being of a burst configuration. Associated non-spinal injuries occurred in 60% of patients.

There is a strong relationship between spinal injuries caused by explosive devices and lower limb fractures Conclusion Explosive devices account for significant injury to both combatants and civilians in current conflict. Injuries to the spine by explosions account for greater numbers, associated morbidity and increasing complexity than other means of injury.

The aim of this study was to report the pattern of severe open diaphyseal tibial fractures sustained by military personnel, and their orthopaedic–plastic surgical management.The United Kingdom Military Trauma Registry was searched for all such fractures sustained between 2006 and 2010. Data were gathered on demographics, injury, management and preliminary outcome, with 49 patients with 57 severe open tibial fractures identified for in-depth study. The median total number of orthopaedic and plastic surgical procedures per limb was three (2 to 8). Follow-up for 12 months was complete in 52 tibiae (91%), and half the fractures (n = 26) either had united or in the opinion of the treating surgeon were progressing towards union. The relationship between healing without further intervention was examined for multiple variables. Neither the New Injury Severity Score, the method of internal fixation, the requirement for vascularised soft-tissue cover nor the degree of bone loss was associated with poor bony healing. Infection occurred in 12 of 52 tibiae (23%) and was associated with poor bony healing (p = 0.008). This series characterises the complex orthopaedic–plastic surgical management of severe open tibial fractures sustained in combat and defines the importance of aggressive prevention of infection. Cite this article: Bone Joint J 2013;95-B:101–5

The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma

The aim of this study was to establish medium term outcomes in military casualties following severe open tibia fractures. Cases from a previously published series were contacted and assessed with the SF-36 outcome tool. Their results were then compared to a similar study of military trans-tibial amputees. Of the original data set of 49 patients, 30 patients were followed up and completed an SF-36 (61%) with a median follow-up of 4 years (49 months, IQR 397–63). Ten of the 30 required revision surgery, 3 of which involved conversion from initial fixation to a circular frame. Twenty-two of the 30 patients recovered sufficiently to complete a military basic fitness test. The median physical component of SF-36 in the tibia fracture group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in the amputation or fracture group reporting pain (p= 0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). We present the patient reported outcomes following combat open tibia fracture and show that they are similar to those achieved after trans-tibial amputation

Counter-insurgency warfare in recent military operations has been epitomised by the use of Improvised Explosive Devices (IED) against coalition troops. Emerging patterns of skeletal fractures, limb amputations and organ injuries, which are caused by these weapons have been described over recent years. This paper describes a retrospective case series of knee dislocations caused by IEDs in recent conflict. Data was obtained about military personnel from 2006 to 2011, who had sustained a knee dislocation while serving in Afghanistan from a prospectively gathered database, the Joint Theatre Trauma Registry (JTTR), maintained by the Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine. The diagnosis of knee dislocation and its associated skeletal injuries was assessed by review of all relevant plain radiographs, computed tomography scans and magnetic resonance images. The mechanism of injury, incidence of vascular injuries and other skeletal injuries was recorded. During the study period, 23 casualties sustained a knee dislocation caused by an IED. Four casualties had an associated popliteal vascular injury. Eleven injuries were caused in enclosed spaces, and 10 injuries caused by IEDs out in the open. Anterior dislocations were common in the group caused in enclosed spaces. 19/20 patients had at least one other skeletal fracture. Knee dislocations represent an uncommon but important diagnosis in modern warfare. Urgent and careful assessment for any associated vascular injuries or other skeletal injuries may help ensure timely treatment and promote future recovery. Mitigation against knee dislocation may be possible in the enclosed environment because of the predictable pattern of injury

This is a case series of prospectively gathered data characterising the injuries, surgical treatment and outcomes of consecutive British service personnel who underwent a unilateral lower limb amputation following combat injury. Patients with primary, unilateral loss of the lower limb sustained between March 2004 and March 2010 were identified from the United Kingdom Military Trauma Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire. A total of 48 patients were identified: 21 had a trans-tibial amputation, nine had a knee disarticulation and 18 had an amputation at the trans-femoral level. The median New Injury Severity Score was 24 (mean 27.4 (9 to 75)) and the median number of procedures per residual limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were completed by 39 patients (81%) at a mean follow-up of 40 months (25 to 75). The physical component of the SF-36 varied significantly between different levels of amputation (p = 0.01). Mental component scores did not vary between amputation levels (p = 0.114). Pain (p = 0.332), use of prosthesis (p = 0.503), rate of re-admission (p = 0.228) and mobility (p = 0.087) did not vary between amputation levels. These findings illustrate the significant impact of these injuries and the considerable surgical burden associated with their treatment. Quality of life is improved with a longer residual limb, and these results support surgical attempts to maximise residual limb length. Cite this article: Bone Joint J 2013;95-B:224–9

The aim of this study was to characterise severe open tibial shaft fractures sustained by UK military personnel over 10-years of combat and to determine the infection rate and factors that influence it. The UK military Joint Theatre Trauma Registry was searched and X-rays, clinical notes and microbiological records were reviewed for all patients. One hundred GA III open tibia fractures in 89 patients were identified. Three fractures were not followed up for 12-months and were therefore excluded. Twenty-two (23%) of the remaining 97 tibial fractures were complicated by infection requiring surgical treatment, with S. aureus being the causative agent in 13/22 infected fractures (59%). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer or smoking status were significantly associated with infection. Bone loss was significantly associated with subsequent infection (p<0.0001). Most infection in combat open tibia fractures is caused by familiar organisms i.e. S. aureus. The use of external fixators to temporarily stabilise fractures is not associated with an increased risk of subsequent infection. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was