UK personnel have been deployed in Afghanistan since 2001 and over this time a wealth of experience in contemporary war surgery has been developed. Of particular note in the latter Herrick operations the injury pattern suffered by personnel is largely blast wounds, primarily from improvised explosive devices. With the development of improved body armour, previously unsurvivable blasts now result in a large number of traumatic amputations, predominantly affecting the lower limb. Faced with this, deployed medical personnel in the Role 3 facility, Camp Bastion, have developed, by a process of evolution, a standard process for timely management of these injuries.

We present a documented schema and photographic record of the ‘Bastion’ process of management of traumatic amputation through the resuscitation department, radiology, theatres and post-operatively. In resuscitation the priority is control of catastrophic haemorrhage with exchange of CAT tourniquets to Pneumatic tourniquets. While undergoing a CT, time can be used to complete documentation. In theatre a process of social debridement & wash then sterile prep followed by formal debridement allows rapid management of the amputated limbs.

This work provides a record of current best practice that generates maximum efficiency of personnel and time developed over a large number of procedures. This allows reflection both now in relation to continuing Herrick operations and when military medical services are faced with a future conflict and an inevitable change in injury patterns.

During two sequential deployments to Afghanistan, it was noticed that an inordinately high number of patients with bilateral lower limb injuries that resulted in amputations at Camp Bastion itself, had associated upper limb injuries. It was decided to study the incidence and distribution of the same. Permission was granted to conduct this study as it would throw a light on the pattern of injuries and allow a further study of the impact of this on rehabilitation.

This was both a retrospective as well as a prospective study. Of the 221 cases, 68 were recorded and data collected prospectively whereas the data for the rest was gathered using the patients' scanned records from Camp Bastion, their radiology reports and clinical photographs (from the Joint Theatre Trauma Registry).

A total of 221 patients were studied as described above. They included UK, NATO, US, ANA, ANP, EF and Afghan civilians (June 2009 - January 2011). There were 59 fatalities from these 221 cases. That data pertaining to these cases was discarded. Of the surviving 162 cases, 31 cases had no upper limb involvement. A number of these individuals were subjected to an IED attack when mounted, although dismounted injuries still accounted for the vast majority. 131 individuals had upper limb involvement of some sort or the other. The injuries were classified into anatomical distribution as well and the type of trauma (amputations, composite soft tissue, fractures, vascular, nerves etc). The predominance of the injuries was on the distal portion of the upper limb (i.e involving the digits, hands and forearm (digits and hands – 66 patients, wrist and forearm in 69 patients, elbow and arm in 42 patients). The most common form of involvement was a composite tissue injury (involving skin, muscle and vessels/nerves) in 85 patients. 27 patients ended up as triple amputees by the time they left the Camp Bastion Role 3 Hospital.

From the pattern and severity of injuries it is obvious that dismounted individuals presented with a very severe spectrum of injuries. The predominance of the left upper limb being involved is in keeping with a dismounted right-handed soldier out on patrol with the left upper limb extended along the barrel of the rifle or his weapon. Using various cases (clinical photographs as well as radiographs) the spectrum of injuries is explained and a case is made for truly differentiating the debridement and radical treatment of upper limb versus lower limb trauma during initial surgery.