Recruits undergoing arduous training at Commando Training Centre Royal Marines (CTCRM) carry a higher risk of femoral neck stress fractures than many other military populations. This injury has serious sequelae and requires urgent operative fixation if it is displaced. Existing literature advocates a low threshold for imaging patients where this injury is suspected, due to the prognostic advantage conferred by early intervention. CTCRM uses a locally produced scoring system based on history and clinical assessment, to guide the requirement for imaging. Since 2015 access to MRI has been possible through a fast track provider. Between 2012 and 2015, 3522 Royal Marine Recruits entered training. Over the period, 95 MRI scans of the hip were performed, of which 12 utilised private pathways. 13 stress fractures of the femoral neck were identified; 23% (n=3) were displaced and required fixation. The overall incidence rate for this injury is therefore 37 per 10,000, with a displaced incidence rate of 9 per 10,000. We compare these data with previous studies, discuss the use and efficacy of the scoring tool, and assess the benefit conferred by the local private MRI agreement.

Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and

15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons.

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.