Extremity injury and complications such as wound infection remain a significant problem for the military. This study investigates the anti-microbial efficacy of four dressings used in militarily relevant complex extremity injury.

Under general anaesthesia, the flexor carpi ulnaris of 24 New Zealand White rabbits was exposed to a high-energy impact and then inoculated with 10⁶ colony forming units of Staphylococcus aureus. Dressings: gauze soaked in saline, Chlorhexidine, Betadine or Acticoat¯, were randomised and applied 3 hours post injury, to replicate casualty evacuation. Once recovered, animals were checked at least twice daily and body temperature recorded. Analgesia was administered once a day. At 48hrs animals were culled, the muscle harvested and analyzed by a blinded investigator. Group sizes of 6 were required to detect a statistically significant effect of a mean one log reduction in bacterial counts at 48 hours.

No dressing gave a significant reduction in bacterial counts at 48 hours. A paired t-test of contamination versus recovered dose gave p values of 0.903, 0.648, 0.396 and 0.336 for saline, Acticoat¯, chlorhexidine and iodine respectively. Contamination dose between groups compared using ANOVA showed no significant difference (p=0.566). Recovered bacterial loads between groups revealed no significant difference (p=0.280).

This study indicates that over a 48 hour period, dressings with reported anti-bacterial properties offer no advantage over saline soaked gauze in reducing the bacterial burden in a contaminated soft tissue injury. Future work will extend the study temporally and introduce multiple contaminants.

Anti-vehicle mines (AV) and Improvised Explosive Devices (IEDs) remain the most prevalent threat to Coalition troops operating in Iraq and Afghanistan. Detonation of these devices results in rapid deflection of the vehicle floor resulting in severe injuries to calcaneus. Anecdotally referred to as a ‘deck-slap’ injury, there have been no studies evaluating the pattern of injury or the effect of these potentially devastating injuries since World War II. Therefore the aim of this study is to determine the pattern of injury, medical management and functional outcome of UK Service Personnel sustaining calcaneal injuries from under-vehicle explosions.

From Jan 2006 – Dec 2008, utilising a prospectively collected trauma registry (Joint Theatre Trauma Registry, JTTR), the records of all UK Service Personnel sustaining a fractured calcaneus from a vehicle explosion were identified for in depth review. For each patient, demographic data, New Injury Severity Score (NISS), and associated injuries were recorded. In addition, the pattern of calcaneal fracture, the method of stabilisation, local complications and need for amputation was noted. Functional recovery was related to the ability of the casualty to return to military duties.

Forty calcaneal fractures (30 patients) were identified in this study. Mean follow-up was 33.2 months. The median NISS was 17, with the lower extremity the most severely injured body region in 90% of cases. Nine (30%) had an associated spinal injury. The overall amputation rate was 45% (18/40); 11 limbs (28%) were amputated primarily, with a further 3 amputated on return to the UK. Four (10%) casualties required a delayed amputation for chronic pain (mean 19.5 months). Of the 29 calcaneal fractures salvaged at the field hospital, wound infection developed in 11 (38%). At final follow-up, only 2 (6%) were able to return to full military duty with 23 (76%) only fit for sedentary work or unfit any military duty.

Calcaneal injuries following under-vehicle explosions are commonly associated with significant polytrauma, of which the lower limb injury is the most severe. Spinal injuries were frequently associated with this injury pattern and it is recommended that radiological evaluation of the spine be performed on all patients presenting with calcaneal injuries from this injury mechanism. The severity of the hindfoot injury witnessed is reflected by the high infection rate and amputation rate seen in this cohort of patients. Given the high physical demands of a young, active military population, only a small proportion of casualties were able to return to pre-injury duties. We believe that the key to the reduction in the injury burden to the soldier lies in the primary prevention of this injury. Work is currently on going to develop experimental and numerical models of this injury in order to drive future mitigation strategies.

Ballistic fractures are devastating injuries often necessitating reconstructive surgery or amputation. Complications following surgery are common, particularly in the austere environment of war. Workload from the recent conflict was documented in order to guide future medical need. All data on ballistic fractures was collected prospectively. Fractures were scored using the Red Cross Fracture Classification.

During the first two weeks of the conflict, 202 Field Hospital was the sole British hospital in the region. Thereafter, until the end of the conflict, it became the tertiary referral hospital for cases requiring orthopaedic and plastic surgery opinions. Thirty-nine patients, with 50 ballistic fractures were treated by British military surgeons. Patients were predominantly Iraqi (20 enemy prisoners of war and 15 civilians); 4 children sustained five fractures.

Fifty percent were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. A total of 30 per cent of wounds became infected, 12 per cent were deep infection necessitating surgical drainage. Thirteen limbs were amputated; seven were traumatic amputations.

Ballistic fractures remain a challenge for surgeons in times of war. There is a continued need to relearn the principles of war surgery in order to minimise complications and restore function. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts.