[National challenges for trauma surgery in Germany due to violence and war]. / Nationale Herausforderungen für die Unfallchirurgie in Deutschland bei Gewalt und Krieg.

Due to the war in Ukraine and the treatment of patients with war wounds in the hospitals of the TraumaNetworks of the German Society for Trauma Surgery (TraumaNetzwerke DGU®), injuries from life-threatening mission situations (LebEL), terrorism, violence and war have become a matter of daily professional life. Furthermore, the societal and global feeling of security has fundamentally changed. The much-cited term "turning point in history", the reorientation of the Armed Forces and the investigation of the resilience of the healthcare system with respect to the "fitness for war", approximate to the description of the current challenges for trauma surgery (UCH) in Germany. Based on the developments following the terrorist attacks in Paris in 2015 and in Brussels in 2016, a clarification is given as to which adaptations have already been successful and how quickly an improvement could successfully be achieved. In this context, the concept of tactical care and the course on Terror and Disaster Surgical Care (TDSC), for example, have been game changing. The main challenge currently lies in overcoming the structural alterations in the German healthcare system and professionally in the treatment of war wounded personnel from Ukraine. The knowledge gained from these two national tasks must be analyzed for the future development and adaptation of established treatment structures, e.g., of the TraumaNetzwerke DGU®, under the requirements of the increased resilience against war, terrorism and violence. The aim is to name that which has already been achieved with respect to the national challenges for UCH and at the same time to outline or discuss further necessities for improvements and elimination of possible gaps in capabilities.

War-related traumatic brain injuries during the Syrian armed conflict in Damascus 2014-2017: a cohort study and a literature review.

BACKGROUND: The decade-long Syrian armed conflict killed or injured more than 11% of the Syrian population. Head and neck injuries are the most frequent cause of war-related trauma, about half of which are brain injuries. Reports about Syrian brain trauma victims were published from neighboring countries; However, none are available from Syrian hospitals. This study aims to report war-related traumatic brain injuries from the Syrian capital. METHODS: We conducted a retrospective cohort study between 2014 and 2017 at Damascus Hospital, the largest public hospital in Damascus, Syria. Target patients were the victims of combat-related traumatic brain injuries who arrived alive and were admitted to the neurosurgery department or to another department but followed by the neurosurgery team. The collected data included the mechanism, type, and site of injury based on imaging findings; types of invasive interventions; intensive-care unit (ICU) admissions; as well as neurological status at admission and discharge including several severity scales. RESULTS: Our sample consisted of 195 patients; Ninety-six of them were male young adults, in addition to 40 females and 61 children. Injuries were caused by shrapnel in 127 (65%) cases, and by gunshots in the rest, and most of them (91%) were penetrating. Sixty-eight patients (35%) were admitted to the ICU, and 56 (29%) underwent surgery. Neurological impairment was reported in 49 patients (25%) at discharge, and the mortality rate during hospitalization was 33%. Mortality and neurological impairment associated significantly with higher values on clinical and imaging severity scores. CONCLUSIONS: This study captured the full spectrum of war-related brain injuries of civilians and armed personnel in Syria without the delay required to transport patients to neighboring countries. Although the clinical presentation of injuries at admission was not as severe as that in previous reports, the inadequate resources (i.e., ventilators and operation rooms) and the lack of previous experience with similar injuries might have resulted in the higher mortality rate. Clinical and imaging severity scales can provide a handy tool in identifying cases with low probability of survival especially with the shortage of personal and physical resources.

D-Day to December 1944: The odyssey of the third auxiliary surgical group in World War II.

ABSTRACT: As a Major in the US Army Medical Corps, Darrell A. Campbell, MD, led Team 13 of the Third Auxiliary Surgical Group in Europe in World War II. The team began work on June 7, 1944, in a clearing station tent near the beach at Normandy. Subsequently, over the next 7 months, it was assigned to mobile hospitals in 15 different locations in France, Belgium, Luxembourg, and Germany. Major Campbell kept the log books used to record all of the operations done by his team during this time and brought them home where three were discovered more than 70 years later. These log books contain descriptions of more than 500 consecutive operations done by Team 13. They provide a unique insight into the activities of the surgeons who worked to save lives on the front lines of battle in the European Theater of Operations between June and December 1944 and form the basis for this historical perspective.This is an article on the history of surgery.

Performance of a novel temporary arterial shunt in a military-relevant controlled hemorrhage swine model.

BACKGROUND: In military trauma, temporary vascular shunts restore arterial continuity until delayed vascular reconstruction, often for a period of hours. A novel US Air Force-developed trauma-specific vascular injury shunt (TS-VIS) incorporates an accessible side port for intervention or monitoring, which may improve patency under adverse hemodynamic conditions. Our objective was to evaluate TS-VIS patency in the setting of volume-limited resuscitation from hemorrhagic shock. METHODS: Female swine (70-90 kg) underwent 30% hemorrhage and occlusion of the left external iliac artery for 30 minutes. Animals were allocated to one of three groups (n = 5 per group) by left external iliac artery treatment: Sundt shunt (SUNDT), TS-VIS with arterial pressure monitoring (TS-VIS), or TS-VIS with heparin infusion (10 µ/kg per hour, TS-VISHep). Animals were resuscitated with up to 3 U of whole blood to maintain a mean arterial pressure (MAP) of >60 mm Hg and were monitored for 6 hours. Bilateral femoral arterial flow was continuously monitored with transonic flow probes, and shunt thrombosis was defined as the absence of flow for greater than 5 minutes. RESULTS: No intergroup differences in MAP or flow were observed at baseline or following hemorrhage. Animals were hypotensive at shunt placement (MAP, 35.5 ± 7.3 mm Hg); resuscitation raised MAP to >60 mm Hg by 26.5 ± 15.5 minutes. Shunt placement required 4.5 ± 1.8 minutes with no difference between groups. Four SUNDT thrombosed (three before 60 minutes). One SUNDT thrombosed at 240 minutes, and two TS-VIS and one TS-VISHep thrombosed between 230 and 282 minutes. Median patency was 21 minutes for SUNDT and 360 minutes for both TS-VIS groups (p = 0.04). While patent, all shunts maintained flow between 60% and 90% of contralateral. CONCLUSION: The TS-VIS demonstrated sustained patency superior to the Sundt under adverse hemodynamic conditions. No benefit was observed by the addition of localized heparin therapy over arterial pressure monitoring by the TS-VIS side port.

Treatment of Peripheral Nerve Injuries in Syria's War Victims: Experience from a Northern Israeli Hospital.

BACKGROUND: The collapse of the Syrian healthcare system during the civil war led numerous citizens to cross the Syrian-Israeli border to seek medical care. OBJECTIVES: To describe the epidemiology of peripheral nerve injuries (PNIs) sustained in war, their management, and short-term outcomes. METHODS: A retrospective case series study was conducted on 45 consecutive patients aged 25.7 ± 9.3 years. These patients were referred to the hand surgery unit of the department of orthopedic surgery and traumatology at Galilee Medical Center between December 2014 and June 2018. Median time between injury and presentation was 60 days. Injury pattern, additional injuries, surgical findings and management, complications, and length of hospital stay were extracted from medical records. RESULTS: Most injuries were blast (55.6%) followed by gunshot injuries (37.8%). There were 9 brachial plexus injuries, 9 sciatic nerve injuries, and 38 PNIs distal to the plexus: specifically 20 ulnar, 11 median, and 7 radial nerve injuries. In the latter group, neurotmesis or axonotmesis was found in 29 nerves. Coaptation was possible in 21 nerves necessitating cable grafting in 19. A tendon transfer was performed for 13 peripheral nerves, occasionally supplementing the nerve repair. The patients returned to their country after discharge, average follow-up was 53.6 ± 49.6 days. CONCLUSIONS: For nerve injuries sustained in war, early surgical treatment and providing adequate soft tissue conditions is recommended. Tendon transfers are useful to regain early function.

POSTERIOR SEGMENT INJURIES IN OPERATION IRAQI FREEDOM AND OPERATION ENDURING FREEDOM: 2001 to 2011.

BACKGROUND/PURPOSE: To characterize the nature of posterior segment ocular injuries in combat trauma. METHODS: Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed. RESULTS: Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004). CONCLUSION: Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

Augmented reality visualization tool for the future of tactical combat casualty care.

ABSTRACT: The objective of this project was to identify and develop software for an augmented reality application that runs on the US Army Integrated Visual Augmentation System (IVAS) to support a medical caregiver during tactical combat casualty care scenarios. In this augmented reality tactical combat casualty care application, human anatomy of individual soldiers obtained predeployment is superimposed on the view of an injured war fighter through the IVAS. This offers insight into the anatomy of the injured war fighter to advance treatment in austere environments.In this article, we describe various software components required for an augmented reality tactical combat casualty care tool. These include a body pose tracking system to track the patient's body pose, a virtual rendering of a human anatomy avatar, speech input to control the application and rendering techniques to visualize the virtual anatomy, and treatment information on the augmented reality display. We then implemented speech commands and visualization for four common medical scenarios including injury of a limb, a blast to the pelvis, cricothyrotomy, and a pneumothorax on the Microsoft HoloLens 1 (Microsoft, Redmond, WA).The software is designed for a forward surgical care tool on the US Army IVAS, with the intention to provide the medical caregiver with a unique ability to quickly assess affected internal anatomy. The current software components still had some limitations with respect to speech recognition reliability during noise and body pose tracking. These will likely be improved with the improved hardware of the IVAS, which is based on a modified HoloLens 2.

Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties.

BACKGROUND: Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties. METHODS: Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included. Log-binominal regression was used to identify SSI risk factors. RESULTS: Of 4,304 combat casualties, 341 patients underwent a total of 1,053 laparotomies. Abdominal SSIs were diagnosed in 49 patients (14.4%): 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p < 0.001), small bowel (p = 0.010), duodenum (p = 0.006), pancreas (p = 0.032), and abdominal vascular injuries (p = 0.040), as well as prolonged open abdomen (p = 0.004) and more infections diagnosed before the SSI (or final exploratory laparotomy) versus non-SSI patients (p < 0.001). Sustaining colorectal injuries (risk ratio [RR], 3.20; 95% confidence interval [CI], 1.58-6.45), duodenum injuries (RR, 6.71; 95% CI, 1.73-25.58), and being diagnosed with prior infections (RR, 10.34; 95% CI, 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intra-abdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device was associated with reduced likelihood compared with penetrating nonblast (e.g., gunshot wounds) injuries. Non-intra-abdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood. CONCLUSION: Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14%, with similar risk factors and rates reported following severe civilian trauma. LEVEL OF EVIDENCE: Epidemiological, level III.

Clinical utilization of deployed military surgeons.

BACKGROUND: Combat casualty care has been shaped by the prolonged conflicts in Southwest Asia, namely Afghanistan, Iraq, and Syria. The utilization of surgeons in austere locations outside of Southwest Asia and its implication on skill retention and value have not been examined. This study hypothesizes that surgeon utilization is low in the African theater. This lack of activity is potentially damaging to surgical skill retention and patient care. METHODS: Military case logs of surgeons deployed to Africa under command of Special Operations Command Africa between January 1, 2016, and January 1, 2020, were examined. Cases were organized based on population served, general type of procedure, current procedural terminology codes, and location. RESULTS: Twenty deployment caseloads representing 74% of the deployments during the period were analyzed. In 3,294 days, 101 operations were performed, which included 45 on combat/terrorism related injuries and 19 on US personnel. East and West African deployments, combat, and noncombat zones, respectively, were compared. East Africa averaged 4.1 ± 3.8 operations per deployment, and West Africa, 7.3 ± 8.0 (p = 0.2434). In East Africa, 56.1% of total operations were related to combat/terrorism, compared with 29.6% of total operations in West Africa (p = 0.0077). West Africa had a significantly higher proportion of elective (p = 0.0002) and humanitarian cases (p = <0.0001). CONCLUSION: Surgical cases for military surgeons were uncommon in Africa. The low volumes have implications for skill retention, morale, and sustainability of military surgical end strength. Reduction in deployment lengths, deployment location adjustments, and/or skill retention strategies are required to ensure clinical peak performance and operational readiness. Failure to implement changes to current practices to optimize surgeon experience will likely decrease surgical readiness and could contribute to decreased retention of deployable military surgeons to support global operations. LEVEL OF EVIDENCE: Economic/decision, level III.

Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties.

BACKGROUND: Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties. METHODS: Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals. RESULTS: Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively. CONCLUSIONS: Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.

Early Fasciotomy and Limb Salvage and Complications in Military Lower Extremity Vascular Injury.

BACKGROUND: Military guidelines endorse early fasciotomy after revascularization of lower extremity injuries to prevent compartment syndrome, but the real-world impact is unknown. We assessed the association between fasciotomy and amputation and limb complications among lower extremitys with vascular injury. METHODS: A retrospectively collected lower extremity injury database was queried for limbs undergoing attempted salvage with vascular procedure (2004-2012). Limbs were categorized as having undergone fasciotomy or not. Injury and treatment characteristics were collected, as were intervention timing data when available. The primary outcome measure was amputation. Multivariate models examined the impact of fasciotomy on limb outcomes. RESULTS: Inclusion criteria were met by 515 limbs, 335 (65%) with fasciotomy (median 7.7 h postinjury). Of 212 limbs, 174 (84%) with timing data had fasciotomy within 30 min of initial surgery. Compartment syndrome and suspicion of elevated pressure was documented in 127 limbs (25%; 122 had fasciotomy). Tourniquet and shunt use, fracture, multiple arterial and combined arteriovenous injuries, popliteal involvement, and graft reconstruction were more common in fasciotomy limbs. Isolated venous injury and vascular ligation were more common in nonfasciotomy limbs. Fasciotomy timing was not associated with amputation. Controlling for limb injury severity, fasciotomy was not associated with amputation but was associated with limb infection, motor dysfunction, and contracture. Sixty-three percent of fasciotomies were open for >7 d, and 43% had multiple closure procedures. Fasciotomy revision (17%) was not associated with increased amputation or complications. CONCLUSIONS: Fasciotomy after military lower extremity vascular injury is predominantly performed early, frequently without documented compartment pressure elevation. Early fasciotomy is generally performed in severely injured limbs with a subsequent high rate of limb complications.

Plastic Surgery at War: A Scoping Review of Current Conflicts.

INTRODUCTION: The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations. MATERIALS AND METHODS: Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered. RESULTS: The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain. CONCLUSIONS: Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.

Severe pediatric war trauma: A military-civilian collaboration from retrieval to repatriation.

BACKGROUND: Modern conflicts take a disproportionate and increasing toll on civilians and children. Since 2013, hundreds of Syrian children have fled to the Israeli border. Severely injured children were triaged for military airborne transport and brought to civilian trauma centers in Israel. After recovery, these patients returned to their homes in Syria.We sought to describe a unique model of a coordinated military-civilian response for the stabilization, transport, and in-hospital management of severe pediatric warzone trauma. METHODS: Prehospital and in-hospital data of all severe pediatric trauma casualties transported by military helicopters from the Syrian border were extracted. Data were abstracted from the electronic medical records of military and civilian medical centers' trauma registries. RESULTS: Sixteen critically injured children with a median age of 9.5 years (interquartile range [IQR], 6.5-11.5) were transported from the Syrian border to Level I and Level II trauma centers within Israel. All patients were admitted to intensive care units. Eight patients underwent lifesaving procedures during flight, 7 required airway management, and 5 required thoracostomy. The median injury severity score was 35 (IQR, 13-49). Seven laparotomies, 5 craniotomies, 3 orthopedic surgeries, and 1 skin graft surgery were performed. The median intensive care unit and hospital length of stay were 6 days (IQR, 3-16) and 34 days (IQR, 14-46), respectively. Fifteen patients survived to hospital discharge and returned to their families. CONCLUSION: The findings of this small cohort suggest the benefits of a coordinated military-civilian retrieval of severe pediatric warzone trauma. LEVEL OF EVIDENCE: Therapeutic, Level V.

A three-tier Rescue stent improves outcomes over balloon occlusion in a porcine model of noncompressible hemorrhage.

BACKGROUND: Noncompressible hemorrhage remains a high-mortality injury, and aortic balloon occlusion poses limitations in terms of distal ischemic injury. Our hypothesis was that a retrievable Rescue stent would confer improved outcome over aortic balloon occlusion. METHODS: A three-tier, retrievable stent graft was laser welded from nitinol and polytetrafluoroethylene to provide rapid thoracic and abdominal coverage with an interval bare metal segment to preserve visceral flow. Anesthetized swine had injury of the thoracic or abdominal aorta followed by balloon occlusion or a Rescue stent. A 1-hour long damage-control phase with blood repletion was used to simulate the prolonged interval between injury and repair, especially in the battlefield setting. Following the damage-control phase, the balloon or stent were retrieved followed by vascular repair and recovery to 48 hours. Animals were compared in terms of hemodynamics, blood loss, neurophysiologic spinal cord ischemia, ischemic organ injury, and survival. RESULTS: Despite antegrade hemorrhage control, balloon occlusion averaged 3.5 L of retrograde hemorrhage, loss of visceral perfusion, and permanent spinal cord ischemia by neurophysiology in six of seven animals. After permanent repair, all balloon occlusion animals died with only a single short term (5 hours) survivor. Conversely, Rescue stent animals revealed rapid hemorrhage control (in under 2 minutes) whether the injury was thoracic or abdominal with improved hemodynamics, preserved visceral flow, reduced spinal cord ischemia, negligible histologic organ injury and survival to end of study in all abdominal injured animals (n = 6) and four of six thoracic injured animals, with two deaths related to arrhythmia. CONCLUSION: Compared with aortic balloon occlusion, a Rescue stent offers superior hemorrhage control and survival by virtue of reduced ischemic injury and direct control of the hemorrhagic injury. The Rescue stent may become a useful tool for damage control, especially on the battlefield where definitive repair presents logistical challenges.

Medical and surgical management of lower extremity war-related injuries. Experience of the French Military Health Service (FMHS).

Lower extremity war wounds are characterized by high-energy trauma occasioning loss of complex and pluritissular substances. The support pipeline put into place by the French defense health service (SSA) is designed to rapidly evacuate the injured person from the scene of injury to mainland France, following initial surgery in the framework of a sequential tactic known as "Damage Control Surgery". This strategy is aimed at stabilizing the traumatized individual and enabling his evacuation. Patients are subsequently treated in a restorative surgery unit in a Hôpital d'Instruction des Armées (HIA), a level 1 trauma center (HIA Percy, HIA Saint-Anne) Cooperation between the plastic and orthopedic surgery specialties is essential insofar as it allows for surgical optimization aimed at saving the limb while restoring function to the greatest possible extent. Notwithstanding painstaking application of this common strategy, septic pseudoarthrosis remains the principal and most feared complication, at times rendering impossible any therapeutic solution other than amputation. Whether prosthetic or non-prosthetic, the rehabilitation provided by doctor/physiotherapists is conducive to patients' social and professional reintegration. The nation's duty to assist its wounded veterans is carried out with determination by the French defense ministry. As concerns lower extremity war wounds, the authors detail the reconstruction doctrine based on the 6/7/8/9 rule, in accordance with which strategies for repair of soft tissue and reconstruction of the lost bone substance have been developed.

Military civilian partnerships: International proposals for bridging the Walker Dip.

The Walker Dip refers to the cycle of the improvement of care for the battle injured soldier over the course of a conflict, followed by the decline in the skills needed to provide this care during peacetime, and the requisite need to relearn those skills during the next conflict. As the operational tempo of the conflicts in Afghanistan and Iraq has declined, concerns have arisen regarding whether US military surgeons are prepared to meet the demands of future conflicts. This problem is not unique to the US military, and allied nations have taken creative steps to address the Walker Dip in their own surgical communities. A panel entitled "Military and Civilian Trauma System Integration: Where Have We Come; Where Are We Going and What Can We Learn from Our International Partners" at the 2018 American Association for the Surgery of Trauma meeting brought together a cadre of civilian and military surgeons with experience in this area. The efforts described involved the creation of a new trauma training program in Doha, Qatar, the military civilian partnership in the Netherlands, and the steps taken to address the deficit of penetrating trauma in Sweden. This article focuses on the lessons that can be learned from our allied partners to assure readiness for deployment among military surgeons. LEVEL OF EVIDENCE: Economic and Value Based Evaluations, level V.

New Functional Evaluation Scheme - Modality of the Results of Forearm Tendon Transfers Evaluation in Cases of Irreparable Radial Nerve Injury.

INTRODUCTION: There are several evaluation schemes for the results of tendon transfers in case of radial nerve paralysis, and the most logical and commonly used are evaluation schemes that use the range of active joint movements to evaluate the results. AIM: Present an original evaluation scheme for tendon transfer results based on functional wrist and fingers joint movements. The aim of the article is to present the advantages of our own Functional scheme in comparison with other schemes, its simplicity and applicability in the evaluation of all clinical cases of different postoperative outcome of the variables being evaluated, and to present the ease of comparison of the achieved results with other authors who would possibly use our scheme because it minimizes the subjective error of the examiner. The secondary aim is to compare the results of flexor carpi radialis (FCR) vs. flexor carpi ulnaris (FCU) tendon transfers (TT). METHODS: The study was conducted as clinical and retrospective. The study included 60 patients with isolated radial nerve palsy operated by two tendon transfer surgical methods (FCR and FCU) over a 10-year period. The evaluation of the results was performed by using Zachary, Neimann-Pertecke, Tajima evaluation schemes, our own Functional Evaluation Scheme as well as subjective patient evaluation. RESULTS: The time elapsed from injury to surgery ranged from 105 to 956 days in case of FCR tendon transfer and from 109 to 712 days in cases of FCU tendon transfer. The overall average age of patients is 36.71 years. A statistically significant difference in values with t -test based on the Functional Evaluation Scheme was found in the variables of ulnar deviation (p=0.000731), extension of the MP fingers joints II-V (p=0.04610) and extension of the MP of the thumb joint (p=0.0475). Evaluation of the total results with t-test (p=0.007532) and with U-test (p=0,00433) showed statistically better FCR tendon transfer results. A statistically significant difference in value measured by the t-test was found in the evaluation of the overall results (p=0.022) with Zachary and Neumann-Pertecke schemes and by the Tajima evaluation Scheme (p=0.042) in favor of better FCR tendon transfer results. With a use of Functional Evaluation Scheme, it is possible to evaluate all the results unlike most available schemes. CONCLUSION: The functional evaluation scheme is based on the functional joint movements evaluated and incorporating radial and ulnar deviation of the wrist (RD and UD), extension of the metacarpophalangeal (MCP) joint and flexion of the intephalangeal (IP)joint of the thumb in the final evaluation becomes completely original. A functional evaluation scheme is simply applicable for the evaluation of all clinical cases of different postoperative outcome of the variables being evaluated. FCR tendon transfer achieves better results than FCU TT.

Missile War Injuries of the Craniofacial Region.

Many factors govern the nature, severity, and outcome of missile war injuries and associated soft tissue damages. Managements of primary phase and trauma care have improved significantly. Many of these injured victims survived and require immediate care for primary phase management. Secondary phase was achieved by reconstruction of soft tissue by local, regional flaps, and bony defect by bone grafting.There is no consensus on timing of treatment of bone and soft tissue of missile war injuries.Currently, in Iraq, anti-government's protestors' movement for the last 3 months mainly unemployed young people demanding for human rights has resettled in 22,000 people being injured. This includes more than 600 young men who were assassinated by unknown killers through confrontation with security and police men using tear gas canisters and sound bombs. The demonstrators used mini cars (Tuck Tuck) for attacking policemen and security people and used them for transferring injured demonstrators as ambulance to a special tent in the Tahrir Square for receiving first aid.