We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain.

This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.

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.

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.

The biomechanics of civilian fractures have been extensively studied with a view to defining the forces responsible e.g. bending, torsion, compression and crushing. Little equivalent work has been carried out on military fractures, although fractures from gunshot can be divided into direct and indirect. Given that the effects of blast can be sub-divided into primary, secondary, tertiary and quaternary, the aim of this study was to try to determine which effects of the blast are responsible for the bony injury. This may have implications for management and prognosis as well as prevention.

We reviewed emergency department records, case notes, and all radiographs of patients admitted to the British military hospital in Afghanistan over a 6 month period (Apr 08–Sept 08) to identify any fracture caused by an explosive mechanism. In addition we reviewed all relevant radiographs from the same period at the Royal Hospital Haslar, who report all radiographs taken, and keep a copy of the images. Early in the study it became clear that due to the complexity of some of the injuries it was inappropriate to consider bones separately and we used the term ‘fracture zone’ to identify separate areas of injury, which could involve from 1 – 28 bones. It also became clear that the pattern of injury differed considerably between patients in open ground, and those in houses or vehicles. These 2 groups were considered separately and compared.

We identified 86 patients with fractures. The 86 patients had 153 separate fracture zones (range 1–6). 56 casualties in the open sustained 87 fracture zones (mean 1.55 fracture zones per casualty). 30 casualties in a vehicle or other cover sustained 66 fracture zones (2.2 per casualty). Of the casualties in the open, 17 fracture zones were due the primary effects of blast, 10 a combination of primary and secondary effects, 30 due to secondary effects and 30 from the tertiary effects of blast. Of the casualties in vehicles we could not identify anyone with a fracture due to either the primary or secondary effects of blast, all 66 fracture zones appeared to be due to the tertiary effects.

In both groups there appeared to be a significant number of fractures, often with no break in the skin, caused by severe axial loading of the limb. This was possibly due to the casualty impacting against the ground, building or the inside of a vehicle, and this is a group of injuries we are now studying in greater detail.

It has stated that the application of a pre-hospital tourniquet could prevent 7% of combat deaths, but their widespread use has been questioned due to the potential risk from prolonged ischaemia, or local pressure. The debate centres on their ability to improve survival after major haemorrhage, versus the potential risk of limb loss. A recent US military prospective study on their use demonstrated improved survival when a tourniquet was applied, and reported that no limb was lost solely from tourniquet use. However, this study focused on early limb loss, with a median follow-up of only 7 days, and so could not consider later morbidity. The aim of this study was to investigate if the pre-hospital application of a tourniquet resulted in an increase in morbidity following significant ballistic limb injury.

We reviewed members of the UK armed forces who sustained severe limb-threatening injuries in Iraq and Afghanistan, and based on the presence or absence of a pre-hospital tourniquet a cohort study was then performed. Of the 23 lower limbs that definitely had a pre-hospital tourniquet applied it was possible to match 22 limbs with 22 that did not have a pre-hospital tourniquet. The injuries were matched for anatomical location, severity of the bony injury, initial surgical management, Injury Severity Score and Mangled Extremity Severity Score as much as possible.

Of the 22 limbs with a pre-hospital tourniquet applied, 19 limbs had a least 1 complication. Of the 22 with no tourniquet applied, 15 had at least 1 complication (p=0.13). There were 10 limbs with at least 1 major complication in the pre-hospital tourniquet group but only 4 in the group with no tourniquet (p=0.045). There was no difference in the amputation rate.

The significant difference in the incidence of major complications is a concern, particularly as the difference was mainly due to a deep infection rate of 32% vs. 4.5%. Although there are a number of variables which could have influenced these small groups, such as choice of implant, method and timing of wound closure, the use of a cohort and a p < 0.05, does suggest the use of a pre-hospital tourniquet was a factor.

Although the use of pre-hospital tourniquets cannot be decried as a result of this study, there does remain the need to continually review their use, prospectively, to determine their risk/benefit ratio.

Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today’s global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties.

We retrospectively reviewed hospital charts and autopsy reports of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention and cause of death was recorded.

During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 (7%) actually survived to reach hospital. Four subsequently died from injuries within 72 hours. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation, however this patient died as result of a co-existing head injury.

Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life threatening conditions.

Amputation is one of the most feared injuries in service personnel, particularly a worry that it will mean the end of their military career. The aim of this study was to determine the outcome, in relation to military service in UK military amputees.

UK service personnel who sustain an amputation undergo rehabilitation and prosthetic limb fitting at the Defence Medical Rehabilitation Centre Headley Court. This includes a realistic assessment of their employment capabilities, and they are graded by a Functional Activity Assessment (FAA). FAA ranges from 1 (fully fit) to 5 (unfit all duties). In addition the Short Form-36 Health Survey (SF-36) is completed on initial admission and at follow-up. We reviewed this information to determine the outcome of military amputees.

We identified 53 casualties who had sustained amputations. 8 had sustained an upper limb amputation, 41 a lower limb amputation, and 4 had sustained both an upper and lower limb amputation. 9 patients (including 1 Reservist) have left the forces by medical discharge, with the remaining 44 continuing to serve. 32 of the 44 have returned to work, albeit at a lower level. 49 patients have FAA grades and are at least 6 months post-injury. No patients were graded as FAA 1, 8 as FAA 2 (Fit for Trade and fit for restricted General or Military Duties), 18 as FAA 3 (Unfit for Trade but fit for restricted General or Military Duties), 18 as FAA 4 (Unfit for all but Sedentary Duties) and 5 as FAA 5. All bilateral and triple amputees were FAA 4 or 5. Other injuries such as blindness, severe brain injury or mental health issues also increased the FAA. Of the 32 patients who have returned to work, 8 are FAA 2, 12 are FAA 3, 11 are FAA 4, and 1 has not been graded. SF-36 data was available in 40 patients, available as paired scores for 34. The mean time between SF-36 scoring was 6.7 months (range 0.2 – 17.4). The mean SF-36 scores for Physical Component Summary (PCS) increased from 34.40 (SD 9.3) to 42.06 (SD 11.1), with Mental Component Summary (MCS) 52.01 (SD12.9) remaining similar at 52.92 (SD 12.0). Pre- and post-rehabilitation PCS scores improved with rehabilitation (p=0.0003). MCS scores were similar in these patients to the normal population, 50 (SD 10). No differences could be found within the unilateral lower limb amputation group regarding amputation level (trans-tibial, through-knee disarticulation, trans-femoral) and SF-36 scoring. Furthermore due to the low numbers, no conclusion could be made comparing the unilateral lower limb amputation group with the bilateral lower limb group, the unilateral lower limb plus upper limb, the bilateral lower limb and upper limb (trilateral), and the isolated upper limb groups.

This study is the first to report the outcomes, with regards to return to work, of the UK military amputee population injured in Afghanistan and Iraq. There is an almost even distribution of FAA score between 2, 3, and 4 for those back at work. Level of amputation and SF-36 scores do not seem to correlate, partly due to other injuries sustained that confound the patients’ perception of their health. SF-36 PCS scores increase significantly with rehabilitation, whilst MCS remain similar to the normal population.

Over 75% of combat casualties from Iraq and Afghanistan sustain injuries to the extremities, with 70% resulting from the effects of explosions. Damage to peripheral nerves may influence the surgical decision on limb viability in the short-term, as well as result in significant long-term disability. To date, there have been no reports of the incidence and severity of nerve injury in the current conflicts.

A prospective assessment of United Kingdom (UK) Service Personnel attending a specialist nerve injury clinic was performed. For each patient the mechanism, level and severity of injury to the nerve was assessed and associated injuries were recorded.

Fifty-six patients with 117 nerve injuries (median 2, range 1–5) were eligible for inclusion. This represents 12.9% of casualties sustaining an extremity injury. The most commonly injured nerves were the tibial (19%), common peroneal (16%) and ulnar nerves (16%). 25% (29) of nerve injuries were conduction block, 41% (48) axonotmesis and 34% (40) neurotmesis. The mechanism of injury did not affect the severity of injury sustained (explosion vs gunshot wound (GSW), p=0.53). An associated fracture was found in only 48% of nerve injuries and a vascular injury in 35%. The presence of an associated vascular injury resulted in more severe injuries (conduction vs axonotmesis and neurotmesis, p< 0.05). Nerves injured in association with a fracture, were more likely to develop axonotmesis (p< 0.05).

The incidence of peripheral nerve injury from combat wounds is higher than previously reported. This may be related to increasing numbers of casualties surviving with complex extremity wounds. In a polytrauma situation, it may be difficult to assess a discrete peripheral neurological lesion. As only 35% of nerves injured are likely to have anatomical disruption, the presence of an intact nerve at initial surgery should not preclude the possibility of an injury. Therefore, serial examinations combined with appropriate neurophysiologic examination in the post-injury period are necessary to aid diagnosis and to allow timely surgical intervention. In addition, conduction block nerve injuries can be expected to make a full recovery. As this accounts for 25% of all nerve injuries, we recommend that the presence of an insensate extremity should not be used as an indicator for assessing limb viability.

The role of Evidence Based Medicine in modern surgical practice is to provide a framework for the integration of expertise, evidence and the biology of the individual patient. The research presented at the Combined Services Orthopaedic Society (CSOS) annual meeting is an important source of evidence which is used to support clinical decisions made about patients on military operations and in the NHS. The purpose of this study is to review the levels of evidence presented at this meeting since 2001.

We reviewed all of the abstracts presented at the annual meetings of the CSOS between 2001 and 2008, and a single meeting of both the Society of Military Orthopaedic Surgeons (SOMOS) and the British Trauma Society (BTS). Basic science studies, animal studies, cadaveric studies, surveys and guest lectures were excluded. The research abstracts were coded by the lead author (TJB), according to the Oxford Centre for Evidence-based Medicine Levels of Evidence. A second author (AM) reviewed the coding of all abstracts to provide inter-observer reliability. Statistical analysis included a chi-squared test to compare the percentages of each level of evidence between the meetings and between each year of the CSOS meeting.

We identified 140, 51 and 96 abstracts in the CSOS, SOMOS and BTS group respectively, which met the inclusion criteria. Level 1 evidence accounted for 73.8%, 64.7% and 68.8% in the CSOS, SOMOS and BTS groups respectively. Level 1 evidence was uncommon at all three meetings representing 4.1%, 5.9% and 8.3% in the CSOS, SOMOS and BTS groups respectively. The chi-squared test did not demonstrate any statistical difference in the evidence levels between the three groups (X2=11.63 (8df), p=0.17). There was no significant difference in the levels of evidence between years during the study period at the CSOS meeting.

The average level of evidence presented at the CSOS annual meeting compares favourably with other trauma meetings. The high proportion of level 4 evidence presented at these meetings reflects the challenging task of performing research in trauma surgery. This challenge is further exacerbated in the military environment where operational commitments must be the priority. However, simple methods to strengthen research may involve the inclusion of control groups, prospective patient enrolment, standard treatment protocols, well-defined outcome measures, logistical support for good follow-up and use of patient-focused assessment tools. Co-ordination and focus of military orthopaedic research effort may advance the quality of research produced.

Chronic instability of the acromioclavicular joint is relatively common and normally occurs following a fall onto the point of the shoulder. Reconstruction of the joint (Weaver-Dunn procedure) is often required in service personnel, and numerous methods of fixation have been used, including vicryl tape, PDS loops and the use of a hook plate. Many of these operative methods require a second operation to remove the plates and/or screws, and are associated with a failure rate of up to 30%.

The ‘Surgilig’ was designed as a method of revision for failed Weaver-Dunn procedures. However this study evaluates its use in the primary operation.

We prospectively followed up the Modified Weaver Dunn procedures using surgilig. The post-operative x-rays were reviewed at six weeks, 3 months and then 6 months when the patients were discharged to assess the radiological success of the procedure.

We have performed this procedure in 11 patients. Of the eight patients that have reached the six month postoperative time so far, at which they would be discharged from clinic follow-up, none have had radiological failure of the fixation. One patient even had weight-bearing x-rays taken at 6 weeks, with no detrimental effect. Even though a small study, the initial results for primary fixation of acromioclavicular joint disruption with surgilig are extremely encouraging. The study suggests that surgilig should continue to be used in its current role. As patient numbers increase, a follow-up study should be conducted to evaluate these preliminary findings.

Failure of fracture healing is a significant problem, resulting in considerable morbidity and financial costs to the NHS. It is also a major complication of ballistic injuries.

We reviewed our experience in the management of non-union by revision of fracture fixation and use of Bone Morphogenic Protein at Ministry of Defence Hospital Unit Frimley Park. Bone Morphogenic Proteins have been identified as promoting osteogenesis and have been used to stimulate bone growth in fracture revision surgery and spinal surgery. BMP’s are a subgroup of the TGF-β family and consist of at least 20 different subtypes of which BMP 2 and BMP 7 are commercially available. Current preparations include a solution for application to a gel matrix and as a powder for reconstitution to a paste for implantation to the fracture site. Costs per graft are in the region of £2,000.

BMPs have been used at Frimley Park since 2005 in the management of 12 patients with established non-union. These included fractures of 4 femurs, 5 humerai, 2 clavicles and 1 metatarsal. Early results are encouraging and support continued use of BMP’s in fracture revision surgery for established non-union.

Non-union remains a difficult problem and even with this treatment there was a significant failure rate, often associated with failure of fixation.

Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate following high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The purpose of this study was to assess the validity of Mangled Extremity Severity Score (MESS), the only verified score, in a population of military patients with ballistic mangled extremity injuries.

52 military patients with 58 limbs who had ballistic mangled extremity injuries were identified, 13 of whom required amputation. Using both the trauma audit and the hospital notes, demographics were assessed. Patients were retrospectively evaluated with the MESS system for lower extremity trauma.

The MESS would not help in the decision-making. However, we were able to develop an algorithm for management, in particular the need for early amputation.

The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have developed an algorithm to provide guidelines for management.

Extremity injuries on the battlefield are commonly secondary to high energy mechanisms. These cause significant injury to soft tissue and bone and are contaminated. Evacuation to medical care can be difficult in the operational environment and may delay the time to initial surgery. There is already substantial literature on the complications of such injuries but this is the first report from UK forces. Our aim was to assess the complications, but specifically infections, in relation to delay in surgery and also the method of fracture stabilisation.

Military patients who had ballistic mangled extremity injuries were identified from the database (courtesy of ADMEM). Using both the trauma audit and the hospital notes, demographics were assessed. The injuries sustained (including the fractured bones), time to theatre, associated injuries, method of stabilisation at Role 3, definitive fixation and complications were noted.

81 patients were identified with 95 limbs injured (68 lower limb, 27 upper limb). The most commonly fractured bones were the tibia, radius/ulna, femur and humerus. Primary stabilisation was either ExFix (53%) or plaster (44%). Of those stabilised by ExFix, the definitive stabilisation was mainly by either a nail (44%) or plate (17%). Those stabilised by plaster mainly stayed in plaster. 72% of patients developed at least one complication, the most common of which was superficial infections. Other complications were deep infections, delayed union, haematomas, neuropathic pain and flap failures. The main organisms involved were Acinetobacter, Bacillus and Pseudomonas. There was no association between delay to theatre and decision to amputate. There was an association between the use of plaster for definitive stabilisation and superficial infection and plates for definitive stabilisation and deep infections. There was no association between time delay to theatre and infections.

This provides the first report of complications from extremity injuries secondary to ballistic missile devices in UK forces. It allows for comparison with reports from other sources on similar injuries and helps to guide further management of patients. In particular it agrees with recent civilian data that initial surgery does not have to be carried out as soon as possible, which has implications for military planning.

There are well-established guidelines for musculoskeletal and connective tissue disorders in the assessment of potential recruits. There have been no critical appraisals of the application of these guidelines since their recent revision. The aim of this study was to examine whether common presenting conditions are covered by the guidelines and whether there was adherence by the assessor to the recommended outcome. We reviewed 110 potential recruits presenting to an Orthopaedic Consultant. There were a number of conditions not covered and a few occasions when the decision seemed contrary to the guidelines. In particular we think more consideration is needed of congenital deformities.

Introduction SLAP (superior labrum anterior and posterior) lesions are a recognised cause of shoulder pain and instability. They can occur following a direct blow, (biceps) traction and compression injuries, and are commonly seen in overhead athletes. Military personnel are physically active and often subjected to trauma. We assessed the incidence of SLAP lesions within a military population presenting with shoulder symptoms.

Methods A retrospective review, of all shoulder arthroscopies performed by a single surgeon between June 2003 and December 2004 at a district general hospital serving both a military and civilian population, was undertaken. The presentation and incidence of SLAP lesions were recorded for both military and civilian patients.

Results 178 arthroscopies were performed on 70 (39.3%) military and 108 (60.7%) civilian patients. The average age was 42.3 (range 17–75), 50 females and 128 males were included. Indications for arthroscopy included pain (75.3%), instability (15.7%), pain and instability (7.9%), or “other symptoms” (1.1%). 39 SLAP lesions (22%) were found and grouped according to the Snyder classification – 20.5% type 1, 69.3% type 2, 5.1% type 3, 5.1% type 4. Patients with a history of trauma or symptoms of instability were more likely to have a SLAP lesion (p< 0.05). The incidence of SLAP lesions in the military patients was 38.6% compared to 11.1% in civilian patients (p< 0.05). After allowing for the increased incidence of trauma and instability in the military, SLAP lesions were still more common in the military patients (p< 0.05).

Conclusions There is a higher than average incidence of SLAP lesions in military patients compared to civilian patients. They tend to present with a history of trauma, as well as symptoms of pain and instability. Given the high incidence in military personnel, this diagnosis should be considered in military patients presenting with shoulder symptoms, and there should be a low threshold for shoulder arthroscopy.

Background: Ballistic fractures produce a significant burden on medical facilities in war. Workload from the recent conflict was documented in order to guide future medical needs.

Method: All data on ballistic fractures was collected prospectively. Wounds were scored using the Red Cross Wound Classification and the Red Cross Fracture Classification.

Results: 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, had their initial surgery performed by British military surgeons. Fifty-two percent (26/50) were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. Four children sustained five fractures. Thirty per cent of wounds became infected. Thirteen limbs were amputated; seven were traumatic amputations. The relationship between those fractures with adverse outcomes and their fracture and wound scores will be discussed.

Conclusion: War is changing; modern conflicts appear likely to be fought in urban or remote environments, producing different wounding patterns and placing civilians in the line of fire. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts.

Stability of the elbow joint is provided primarily by the integrity of the ulno humeral articulation. Secondary contributions to stability are provided by the radio-capitelar joint and the medial collateral ligament complex. Lesser contributions are provided by the lateral ligament and the joint capsule.

A dislocation which is complicated by an injury to one of these main stabilising structures will have a greater risk of instability and recurrent dislocation. Poor outcomes have been noted to occur with both coronoid fractures and significant radial head fractures. There is a group of patients with a more severe injury within this spectrum who have a pattern of injury which leads to gross instability. This “unhappy triad” is a dislocation where there is an associated coronoid fracture, a radial head fracture and complete disruption of the medial collateral ligament complex.

These severe injuries tend to present to a specialist after significant delay with recurrent dislocation following failure of initial management. Three cases will be presented to illustrate the anatomical considerations and management strategies for this pattern of injury by immediate reconstruction, hinged external fixation or elbow replacement.

Forward surgical teams have been employed in many recent conflicts. However, as in the Gulf War, they have not usually been sited further forward than the Field Ambulance level. During recent operations in Northwest Pakistan and Afghanistan, two Special Forces Field Surgical Teams were forward deployed to isolated and remote desert areas to provide a completely independent surgical facility, backed up only by a small guard force.

Advanced resuscitation and damage control surgery including major vessel ligation, wound debridement and skeletal stabilization was undertaken. These operations all took place within a two resuscitation bay, two table surgical complex set up within a C-130 Hercules aircraft. This allowed for an extremely mobile response to any perceived threats approaching the complex. A small laboratory with a ruggedised ‘Thermopol’ blood refrigeration unit was also carried. This allowed for the forward provision of 50 units of mixed blood type. This facility was found to be life saving.

Following surgical stabilization, these patients were then casevaced by a separate pre-positioned, aeromed pre-fitted C-130 aircraft to a Deployed Operating Base Hospital in Oman. Here, further stabilization surgery, skeletal fixation and wound care was carried out. Twenty-four hours later, all casualties were in a teaching hospital in the UK where final definitive surgery took place.

The management and care of these patients at all of the above stages is presented and discussed with some appropriate lessons for future operations

Forward surgical teams have been employed in many recent conflicts. However, as in the Gulf War, they have not usually been sited further forward than the Field Ambulance level. During recent operations in Northwest Pakistan and Afghanistan, two Special Forces Field Surgical Teams were forward deployed to isolated and remote desert areas to provide a completely independent surgical facility, backed up only by a small guard force.

Advanced resuscitation and damage control surgery including major vessel ligation, wound debridement and skeletal stabilisation was undertaken. These operations all took place within a two resuscitation bay, two table surgical complex set up within a C-130 Hercules aircraft. This allowed for an extremely mobile response to any perceived threats approaching the complex. A small laboratory with a ruggedised ‘Thermopol’ blood refrigeration unit was also carried. This allowed for the forward provision of 50 units of mixed blood type. This facility was found to be life saving.

Following surgical stabilisation, these patients were then casevaced by a separate pre-positioned, aeromed pre-fitted C-130 aircraft to a Deployed Operating Base Hospital in Oman. Here, further stabilisation surgery, skeletal fixation and wound care was carried out. Twenty-four hours later, all casualties were in a teaching hospital in the UK where final definitive surgery took place.

The management and care of these patients at all of the above stages is presented and discussed with some appropriate lessons for future operations.