Introduction

Civilian fractures have been extensively studied with in an attempt to develop classification systems, which guide optimal fracture management, predict outcome or facilitate communication. More recently, biomechanical analyses have been applied in order to suggest mechanism of injury after the traumatic insult, and predict injuries as a result of a mechanism of injury, with particular application to the field so forensics. However, little work has been carried out on military fractures, and the application of civilian fracture classification systems are fraught with error. Explosive injuries have been sub-divided into primary, secondary and tertiary effects. The aim of this study was to 1. determine which effects of the explosion are responsible for combat casualty extremity bone injury in 2 distinct environments; a) in the open and b) enclosed space (either in vehicle or in cover) 2. determine whether patterns of combat casualty bone injury differed between environments Invariably, this has implications for injury classification and the development of appropriate mitigation strategies.

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis.

Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C).

We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01).

Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

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We reviewed the clinical details and radiographs of 52 patients with ballistic fractures of the femur admitted to the International Committee of the Red Cross Hospital in Kenya (Lopiding), who had sustained injuries in neighbouring Sudan. In all cases there had been a significant delay in the initial surgery (> 24 hours), and all patients were managed without stabilisation of the fracture by internal or external fixation.

Of the 52 patients, three required an amputation for persisting infection of the fracture site despite multiple debridements. A further patient was treated by an excision arthroplasty of the hip, but this was carried out at the initial operation as a part of the required debridement.

All of the remaining 48 fractures healed. Four patients needed permanent shoe adaptation because of limb shortening of functional significance.

Although we do not advocate delaying treatment or using traction instead of internal or external fixation, we have demonstrated that open femoral fractures can heal despite limited resources.

Objective The aim of this study was to prospectively study the effectiveness of external fixation for war injuries during the recent Gulf conflict.

Patients and Methods We studied all patients seen at 202 Field Hospital, which received the majority of patients who had external fixators applied by the British Armed Forces.

Results Fifteen patients had external fixators applied with follow-up available for 14 (15 external fixators). Of the 15, 13 (87%) required early revision or removal due to complications of the injury or the fixator. Seven required early removal at a mean of 9.1 days (range 1–19). Six required early revision at a mean of 5.9 days (range 1–22).

Instability was a problem with 10 fixators (67%). Seven fixators were revised and 3 were removed. Pin loosening was noted with 5 fixators (33%) involving twelve pins. The cause was multifactorial, but was related to injury severity and frame design.

A significant pin track infection developed at 14 pin sites (3 fixators – 20%). All 3 fixators were removed after a mean of 15.5 days (range 14–19).

Only 2 fixators did not require early removal or revision.

Conclusion We have demonstrated a high early failure rate with the use of external fixation and would caution against its universal acceptance. For many fractures plaster or skeletal traction provide an alternative option. When external fixation is required, stability must be achieved. Even with this there is likely to be a high complication rate due to pin track infection and loosening, and amputation must still be considered as a possible outcome for military injuries.

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.

A retrospective review of all patients presenting to the multinational integrated medical unit at Sipovo in Bosnia-Herzegovina during the period 1 June 2000 to 30 November 2000 was carried out. During this 6-month period, 203 new patients presented to the orthopaedic surgeon; these patients form the basis of this study. Of the 203 patients, 54 (26.6%) presented with chronic problems, but of these 18 (33.3%) had been exacerbated by sporting activities during the tour. The remaining 149 (73.4%) presented with acute problems, and of these sports injury was the most common cause. Traffic accidents, military training injuries, non-specific trauma (falls, crush injures etc) and acute orthopaedic problems such as sciatica accounted for the remainder of the causes. These data are presented in table 1.

Football was again the most common cause of injury accounting for 34.4% of all sporting injuries, and the lower limb, particularly the ankle, was the most common site of injury. The wisdom of allowing this sport, during operational tours, must be questioned. Only 5 (8.2%) of the patients presenting with sports injuries were discharged straight back to full duties. The majority (70.5%) received light duties (mean 14.4 days), but 13 patients (21.3%) required admission to hospital of which 9 were subsequently evacuated out of theatre.

The total number of patients used for this review was 203 of which 13 were trauma from traffic accidents, 61 were sporting injuries, 7 from military training, 52 were non specific trauma, 11, the cause was not recorded, 5 were acute non traumatic orthopedic problems, 18 were chronic and exacerbated by sport and 36 were not related to sport at all.