“If you believe doctors, nothing is wholesome; if you believe theologians, nothing is innocent; if you believe the military, nothing is safe.”

Robert Gascoyne-Cecil(1830-1903)

British statesman, Conservative politician and Prime Minister

The Bone & Joint Journal had great foresight a decade ago during the middle east conflicts to engage with orthopaedic trauma surgeons from the US and the UK military who were actively treating battlefield casualties. The two articles that resulted comprehensively document the nature of the new trauma that was presenting itself, its challenges, and the solutions that were rapidly evolved. The resulting step-changes and end-to-end trauma management, exploring and optimising all possible variables, lead to significant improvements in the survivability of catastrophic battlefield injuries. To put these outcomes into appropriate context, the trauma scoring systems developed during the Vietnam War, which had proved their value for decades in determining which injuries could be survived, were redefined by the progress made during these recent conflicts.

Though battlefield injuries are often of much greater severity than the injuries encountered in civilian practice both these detailed papers not only give insight into the world of military surgery but also identify the direct benefits that have fed into civilian trauma care.  It is very useful to understand not only where the evidence for the management of compound and severely contaminated fractures originated from but also how it has developed during the 20^th and 21^st century into the commonly accepted practice protocols that benefit all traumatised patients.

It is a real pleasure this month to shine a light on these Bone and Joint Journal “gems” once again.

From the UK, Surg Lt Cdr Penn-Barwell, RN and Lt Col T K Rowlands RAMCs’ paper from 2013 “Infection combat injuries: Historical lessons in evolving concepts” reminds us that limb injuries have remained relatively consistent in terms of their prevalence over the last 100 years of conflict, accounting for 50-60% of military injuries.  They also point out that the change in injury mechanism from World War II gunshots to the middle eastern conflicts is a stark one. Approximately 80% of injuries during the Iraq and Afghanistan conflicts were due to blast injuries from standard heavy munitions as well as improvised explosive devices.

Their very well referenced work also reminds us of the seminal papers that demonstrated the value of early surgical lavage, antibiotics and skeletal stabilisation for compound fractures.

More recent evidence behind the importance of repeating surgical lavage and debridement and irrigation, as well as TNP therapy are all very well covered in this excellent article.

Additional and very detailed perspective from the US forces is provided by Lt Col P J Belmont Jr, Col S Hetz, and Major B K Potter in their paper “Lessons from the front line: Orthopaedic surgery in modern warfare” .  It is a stark reminder of the human cost that almost 50,000 US service personnel were wounded in action during the Iraq and Afghanistan wars and almost 5,000 killed.  Again, the majority of US combat casualties were caused by explosive injuries for the same reasons as seen with the British military.

It is interesting also to learn that with the widespread use of body armour and improved access to medical services the chance of a gunshot wound leading to death has been significantly reduced from 33% in the Second World War to less than 5% in current conflicts.

The effectiveness also of such a basic measure as the widespread use of tourniquets in reducing pre-hospital deaths is also very interesting to read. Since their introduction the 9% death rate from extremity exsanguination seen during the Vietnam conflict has been reduced to only 2%.

Unfortunately, the impact of both these measures has been lessened with the ubiquitous blast injuries in the middle east theatre which brought a new set of surgical and medical challenges. This paper is impressive in its scope and clarity and is another hugely educative work.

From our perspective, we would love to have orthopaedic military surgery techniques on the OrthOracle platform and invite any military surgeons interested in working with us to get in contact.

What we do detail currently is a wide range of fracture surgery with plating and nailing techniques as well as standard and fine-wire external fixators.

Amputation surgery will always have a role in managing the most severely traumatised limbs and I doubt that anywhere in any format can a surgeon Kartik Hariharan come across as detailed or clear a demonstration of how to safely and correctly execute a below knee amputation as Hari Haran’s Below knee amputation technique.

Less common amputation techniques are also covered on the platform, including through knee amputation, Hindquarter amputation , transfemoral amputation and in the  upper limb Forequarter amputation. A new transfemoral amputation technique from Professor Peter Bieberthaler at the MRI Hospital in Munich will follow in our next operative techniques update.

Fasciotomies are also “bread & butter” trauma techniques that every orthopaedic surgeon must be familiar with and Ross Fawdingtons’ exemplary instruction on below knee fasciotomy is something every resident and trainee should read:

Compartment fasciotomy and Hoffmann 3 spanning external fixator for open tibial fracture.