Pattern of upper limb amputation associated with lower limb amputation: the UK military experience from Iraq and Afghanistan.

INTRODUCTION: The conflicts in Iraq and Afghanistan resulted in large numbers of personnel sustaining extremity injuries. In the context of polytrauma, partial hand amputation is often unrecorded. The aim of this work was to quantify the burden of upper limb (UL) amputation at any level occurring concurrently with a major (ankle and proximal) lower limb (LL) amputation. Knowledge of this cohort could aid in prosthetic modification to further improve quality of life outcomes in a population with dexterity loss. METHOD: A trauma database search was undertaken for all UK military LL amputees from the conflicts in Iraq and Afghanistan. A manual search method was employed to identify from the major LL amputees those who had a concurrent UL amputation at any level (including isolated finger amputation). Demographics, level of amputation, and injury profile data were recorded. RESULTS: Sixty-eight individuals were identified; the most prevalent population was bilateral LL with a unilateral UL amputation (60%). Most UL amputations were partial hand (75%). The was no statistically significant difference between left or right side (p=0.13). On the left side, correlation was found between amputation of the thumb and third digit (rho=0.34; p=0.005) not seen on the right. CONCLUSION: We have determined the rate of UL amputation at any level, in combination with LL amputation as a result of blast injury. Knowledge of these combinations enables further research to support anecdotal evidence that there is a need for tailored prosthetics in the context of potential dexterity loss making donning and doffing problematic.

The pattern of paediatric blast injury in Afghanistan.

INTRODUCTION: Between 2009 and 2015, 3746 children died, and 7904 were injured as a result of armed conflict within Afghanistan. Improvised explosive devices (IEDs) and explosive remnants of war accounted for 29% of child casualties in 2015. The aim of this study was to review the burden of paediatric blast injuries admitted to Camp Bastion, Afghanistan, and to investigate the hypothesis that children suffer proportionally more head injuries than adults. METHOD: A retrospective analysis was undertaken of prospectively collected data derived from the UK Joint Theatre Trauma Registry of ambulant paediatric (aged 2-15 years) admissions with blast injuries at the Role 3 Field Hospital, Camp Bastion from June 2006 to March 2013. The data set included demographic information, injury profile and severity (New Injury Severity Score) and operative findings. The pattern of injuries were investigated by looking at trends in the number and severity of injuries sustained by each body region. RESULTS: During this period, 295 admissions were identified, 76% of whom were male, with an overall mortality rate of 18.5%. The most common blast mechanism was an IED (68%) causing 80% of fatalities. The lower extremities were the most commonly injured body region, accounting for 31% of total injuries and occurring in 62% of cases. 24.3% of children between 2 and 7 years suffered severe head or neck injuries compared with 19.8% of children aged between 8 and 15 years. 34% of head injuries were rated unsurvivable and accounted for 88% of fatalities. 77% of cases required an operation with a mean operating time of 125 min. The most common first operations were debridement of soft tissues (50%), laparotomy (16%) and lower limb amputation (11%). CONCLUSION: Although paediatric blast casualties represented a small percentage of the overall workload at Camp Bastion Role 3 Medical Facility, the pattern of injuries seen suggests that children are more likely to sustain severe head, face and neck injuries than adults.

Trauma-related amputations in war and at a civilian major trauma centre-comparison of care, outcome and the challenges ahead.

The Afghanistan conflict has resulted in a large number of service personnel sustaining amputations. Whilst obvious differences exist between military and civilian trauma-related amputations both settings result in life changing injuries. Comparisons offer the potential of advancement and protection of the knowledge gained during the last 12 years. This paper compares the military and civilian trauma-related amputee cohorts' demographics, management and rehabilitation outcomes measures. The UK military Joint Theatre Trauma Registry and a civilian major trauma centre database of trauma-related amputees were analysed. 255 military and 24 civilian amputees were identified. A significant difference (p>0.05) was seen in median age (24, range 18-43, vs. 48, range 24-87 years), mean number of amputations per casualty (1.6±SD 0.678 vs. 1±SD 0.0), mean ISS (22±SD 12.8 vs. 14.7±SD 15.7) and gender (99% males vs. 78%). Rehabilitation outcome measures recorded included the Special Interest Group in Amputee Medicine score where the military group demonstrated significantly better scores (91% Grade E+ compared to 19%). Differences in patients underlying physiology and psychology, the military trauma system and a huge sustained investment in rehabilitation are all contributing factors for these differing outcomes. However the authors also believe that the use of a consultant-led MDT and central rehabilitation have benefited the military cohort in the acute rehabilitation stage and is reflected in the good short-term outcomes.

40 years of terrorist bombings - A meta-analysis of the casualty and injury profile.

INTRODUCTION: Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide. METHODS: Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed. RESULTS: 58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%). DISCUSSION/CONCLUSION: Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.

Surgical advances during the First World War: the birth of modern orthopaedics.

The First World War (1914-1918) was the first truly industrial conflict in human history. Never before had rifle fire and artillery barrage been employed on a global scale. It was a conflict that over 4 years would leave over 750,000 British troops dead with a further 1.6 million injured, the majority with orthopaedic injuries. Against this backdrop, the skills of the orthopaedic surgeon were brought to the fore. Many of those techniques and systems form the foundation of modern orthopaedic trauma management. On the centenary of 'the War to end all Wars', we review the significant advances in wound management, fracture treatment, nerve injury and rehabilitation that were developed during that conflict.

Refrigeration and freezing of porcine tissue does not affect the retardation of fragment simulating projectiles.

Explosively propelled fragments are the most common cause of injury to UK service personnel in modern conflicts. Numerical injury models to simulate such injuries utilise algorithms based upon gelatin and animal tissue testing but data is limited on many fragment simulating projectiles and these simulants cannot represent human anatomy. Testing with post mortem specimens may overcome this limitation but no information exists about how post mortem tissue changes and storage conditions in humans or animals may affect projectile penetration. Two chisel nosed cylinders (0.49 g and 1.10 g) and a 0.51 g (5 mm) sphere were fired into three groups of porcine tissue (fresh, refrigerated and frozen then refrigerated) and compared to 20% gelatin. Depth of projectile penetration was ascertained with the assistance of computed tomography and kinetic energy absorption by tissues measured using Doppler radar and high speed photography. No difference in depth of penetration was found between porcine tissue stored in the different manners compared with 20% gelatin by impact velocities less than 100 m/s. Insufficient numbers of projectiles were retained in tissue at higher velocities for statistical analysis to be undertaken. Energy absorbed per millimetre of tissue ranged between 0.42 and 0.98 J/mm for different porcine tissue despite differing storage. This pilot study would suggest that the effect of refrigerating or freezing porcine tissue followed by thawing has no effect on its ability to retard these projectiles. Further research is required to ascertain if these results occur at greater velocities and for other types of projectile.

Heterotopic ossification in victims of the London 7/7 bombings.

Heterotopic ossification (HO) is the formation of bone at extraskeletal sites. Over 60% of amputees injured by improvised explosive devices in the recent conflict in Afghanistan have developed HO, resulting in functional impairment. It is hypothesised that a key aetiological factor is the blast wave; however, other environmental and medical risk factors, which the casualties have been exposed to, have also been postulated. The suicide terrorist bombings in London in 2005 resulted in many blast-related casualties, many of whom were managed by the Royal London Hospital. This cohort of severely injured patients whose injuries also included trauma-related amputations shared some, but not all, of the risk factors identified in the military population. We reviewed these patients, in particular to assess the presence or absence of military-established risk factors for the formation of HO in these casualties.

Clinical and post mortem analysis of combat neck injury used to inform a novel coverage of armour tool.

INTRODUCTION: There is a requirement in the Ministry of Defence for an objective method of comparing the area of coverage of different body armour designs for future applications. Existing comparisons derived from surface wound mapping are limited in that they can only demonstrate the skin entry wound location. The Coverage of Armour Tool (COAT) is a novel three-dimensional model capable of comparing the coverage provided by body armour designs, but limited information exists as to which anatomical structures require inclusion. The aim of this study was to assess the utility of COAT, in the assessment of neck protection, using clinically relevant injury data. METHOD: Hospital notes and post mortem records of all UK soldiers injured by an explosive fragment to the neck between 01 Jan 2006 and 31 December 2012 from Iraq and Afghanistan were analysed to determine which anatomical structures were responsible for death or functional disability at one year post injury. Using COAT a comparison of three ballistic neck collar designs was undertaken with reference to the percentage of these anatomical structures left exposed. RESULTS: 13/81 (16%) survivors demonstrated complications at one year, most commonly upper limb weakness from brachial plexus injury or a weak voice from laryngeal trauma. In 14/94 (15%) soldiers the neck wound was believed to have been the sole cause of death, primarily from carotid artery damage, spinal cord transection or rupture of the larynx. COAT objectively demonstrated that despite the larger OSPREY collar having almost double the surface area than the two-piece prototype collar, the percentage area of vulnerable cervical structures left exposed only reduced from 16.3% to 14.4%. DISCUSSION: COAT demonstrated its ability to objectively quantify the potential effectiveness of different body armour designs in providing coverage of vulnerable anatomical structures from different shot line orientations. To improve its utility, it is recommended that COAT be further developed to enable weapon and tissue specific information to be modelled, and that clinically significant injuries to other body regions are also incorporated.

Heterotopic ossification: a systematic review.

Heterotopic ossification (HO) is the formation of mature lamellar bone in extraskeletal soft tissues. It was first described 1000 years ago in the healing of fractures, and in relation to military wounds, texts from the American Civil War and World War I refer to HO specifically. It continues to cause problems to injured service personnel; the consequences of wound and soft tissue complications in traumatic amputations pose particular problems to rehabilitation and prosthetic use. While HO is seen in rare genetic conditions, it is most prevalent after joint replacement surgery and trauma. In the civilian setting HO has been commonly described in patients after traumatic brain injuries, spinal cord injuries and burns. Militarily, as a consequence of recent operations, and the characteristic injury of blast-related amputations, a renewed interest in HO has emerged due to an increased incidence seen in casualties. The heterogeneous nature of a blast related amputation makes it difficult for a single aetiological event to be identified, although it is now accepted that blast, amputation through the zone of injury, increased injury severity and associated brain injuries are significant risk factors in HO formation. The exact cellular event leading to HO has yet to be identified, and as a consequence its prevention is restricted to the use of anti-inflammatory medication and radiation, which is often contraindicated in the acute complex military casualty. A systematic review in PubMed and the Cochrane Database identified research articles related to HO to illustrate the military problem of HO and its management, current research concepts and experimental theories regarding HO. This also served as a gap analysis providing the researchers detail of any knowledge deficit in this field, in particular to the military aspects of HO; 637 out of 7891 articles initially identified that referenced HO were relevant to this review.

UK combat-related pelvic junctional vascular injuries 2008-2011: implications for future intervention.

In a recent publication, 297 of 6450 (4.6%) military coalition deaths over ten years were reported to be due to junctional bleeding. The authors suggested that some of these deaths could have been avoided with a junctional haemorrhage control device. Prospectively collected data on all injuries sustained in Afghanistan by UK military personnel from 1 August 2008 to 31 July 2011 period were reviewed, using the UK Joint Theatre Trauma Registry. All fatalities with significant pelvic injuries were identified and analysed, and the cause of death established to assess the potential role for a junctional haemorrhage control device. Significant upper thigh, groin or pelvic injuries were recorded in 124 casualties, of which 93 died. Of these the pelvic injury was the cause of death in 37, but only 1 casualty with potentially survivable injuries was identified where death was due to a vascular injury below the inguinal ligament, not controlled by a CAT. This represents <1% of all deaths in this period, a lower figure than previously published. We further identified 32 casualties where the cause of death was due to a vascular injury between the aortic bifurcation and the inguinal ligament. Eight of these survived to a medical facility but subsequently died of their wounds. These represent a subset in which vascular control proximal to the inguinal ligament could have altered the outcome. Some potentially survivable deaths due to exsanguination may be amenable to proximal vascular control. Our study does not substantiate previous conclusions that this can be achieved through use of a groin junctional tourniquet. We believe there may be a role for more proximal vascular control of pelvic bleeding, and this merits further research.

Blast-mediated traumatic amputation: evidence for a revised, multiple injury mechanism theory.

INTRODUCTION: The accepted mechanism of blast-mediated traumatic amputation (TA) is blast wave induced fracture followed by limb avulsion from the blast wind, generating a transosseous amputation. Blast-mediated through-joint TAs were considered extremely rare with published prevalence <2%. Previous studies have also suggested that TA is frequently associated with fatal primary blast lung injury (PBLI). However, recent evidence suggests that the mechanism of TA and the link with fatal primary blast exposure merit review. METHODS: A trauma registry (UK Joint Theatre Trauma Registry) and postmortem CT (PM-CT) database were used to identify casualties (survivors and deaths) sustaining a blast-mediated TA in the 2 years from August 2008. TA metrics and associated significant injuries were recorded. Detailed anatomical data on extremity predebridement osseous and soft tissue injuries were only consistently available for deaths through comprehensive PM-CT imaging. RESULTS: 146 cases (75 survivors and 71 deaths) sustaining 271 TAs (130 in survivors and 141 in deaths) were identified. The lower limb was most commonly affected (117/130 in survivors, 123/141 in deaths). The overall through-joint TA rate was 47/271 (17.3%) and 34/47 through-joint injuries (72.3%) were through knee. More detailed anatomical analysis facilitated by PM-CT imaging revealed only 9/34 through-joint TAs had a contiguous fracture (ie, intra-articular involving the joint through which TA occurred), 18/34 had no fracture and 7/34 had a non-contiguous (ie, remote from the level of TA) fracture. No relationship between PBLI and TA was evident. CONCLUSIONS: The previously reported link between TA and PBLI was not present, calling into question the significance of primary blast injury in causation of blast mediated TAs. Furthermore, the accepted mechanism of injury can't account for the significant number of through-joint TAs. The high rate of through-joint TAs with either no associated fracture or a non-contiguous fracture (74%) is supportive of pure flail as a mechanism for blast-mediated TA.

Ergonomic assessment of enhanced protection under body armour combat shirt neck collars.

INTRODUCTION: Combat neck injury due to explosively propelled fragments is a significant cause of mortality and long-term morbidity in UK soldiers deployed on current operations. Reinforcing the collar of the existing under body armour combat shirt (UBACS) has been suggested as a potential method for reducing the incidence of combat neck injury. METHOD: 20 soldiers serving in Afghanistan objectively compared three designs of enhanced protection UBACS (EP-UBACS) using 10 representative military tasks against a baseline of a standard UBACS. Each EP-UBACS design was trialled using three constituent materials: two layers of para-aramid felt, one layer of ultra high molecule weight polyethylene (UHMWPE) felt or two layers of a silk fabric. Subjective assessment of these nine configurations in terms of comfort, heat dissipation and overall acceptability were compared with the standard UBACS using a χ² test. RESULTS: All military tasks could be performed with all nine configurations of EP-UBACS. Although silk was the most comfortable material, it was not functionally practical in any of the three designs. Crossover collars incorporating UHMWPE or para-aramid were the only two of the nine configurations to demonstrate similar user acceptability to a standard UBACS. CONCLUSIONS: The EP-UBACS has the potential to provide neck protection without reducing performance incorporating materials analogous to either of the felts assessed in this study. The collar should provide stand-off from the skin to improve heat dissipation and comfort, which can be maximised by changing the current UBACS collar shape to one that crosses over at the front. Should a zip be desired, it should be moved to one side of the midline to reduce rubbing on the chin and be covered with ballistic protective material. Additional semi-circles of silk beneath the collar at the front and back would improve protection without affecting comfort.

Case suitability for definitive through knee amputation following lower extremity blast trauma: analysis of 146 combat casualties, 2008-2010.

INTRODUCTION: Analysis of recent UK Armed Forces combat casualty data has highlighted a significant number of through joint traumatic amputations (TAs), most commonly through knee (through knee amputations (TKAs)). Previously, a consensus statement on lower limb amputation from the UK Defence Medical Services reported better outcomes in some patients with TKAs when compared with those with above knee amputations. This study sought to define the proportion of recent combat casualties sustaining severe lower extremity trauma with acute osseous and soft tissue injury anatomy amenable to definitive TKA. METHODS: The UK Joint Theatre Trauma Registry and post mortem CT (PM-CT) databases were used to identify all UK Armed Forces personnel (survivors and fatalities) sustaining a major extremity TA (through/proximal to wrist or ankle joint) between August 2008 and August 2010. Through knee and all below knee TAs were grouped as 'potential TKAs' (pTKAs), that is, possible candidates for definitive TKA. RESULTS: 146 Cases (75 survivors and 71 fatalities) sustaining 271 TAs (130 in survivors, 141 in fatalities) were identified. The through-joint TA rate was 47/271 (17.3%); 34/47 through-joint injuries (72.3%) were TKAs. Overall, 63/130 TAs in survivors and 66/140 TAs in fatalities merited analysis as the pTKA group. Detailed anatomical data on pre-debridement osseous and soft tissue injury levels were only consistently available for fatalities through PM-CT findings. Further analysis of the soft tissue injury profile revealed that a definitive TKA in the pTKA group (all BKAs as well as TKAs) would have been proximal to the zone of injury (ZOI) in only 3/66 cases. CONCLUSIONS: Traumatic TKAs following explosive blast are more common than previously reported. The majority of lower limb TAs are skeletally amenable to a definitive TKA. Maximising residual stump length carries the risks of definitive level amputation within the original ZOI but this study demonstrates that the proximal extent of the soft tissue injury may frequently make this unavoidable. Further work is required to determine the relative merits of definitive below, through and above knee amputations in the short, medium and long term to ensure survivors are subject to minimal complications while maintaining capacity to achieve optimal functional outcomes.

Determining the velocity required for skin perforation by fragment simulating projectiles: a systematic review.

INTRODUCTION: Explosively propelled fragments are the most common cause of injury to soldiers on current operations. Researchers desire models to predict their injurious effects so as to refine methods of potential protection. Well validated physical and numerical models based on the penetration of standardised fragment simulating projectiles (FSPs) through muscle exist but not for skin, thereby reducing the utility of such models. METHOD: A systematic review of the literature was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology to identify all open source information quantifying the effects of postmortem human subject (PMHS) and animal skin on the retardation of metallic projectiles. Projectile sectional density (mass over presented cross-sectional area) was compared with the velocity required for skin perforation or penetration, with regard to skin origin (animal vs PMHS), projectile shape (sphere vs cylinder) and skin backing (isolated skin vs that backed by muscle). RESULTS: 17 original experimental studies were identified, predominantly using skin from the thigh. No statistical difference in the velocity required for skin perforation with regard to skin origin or projectile shape was found. A greater velocity was required to perforate intact skin on a whole limb than isolated skin alone (p<0.05). An empirical relationship describing the velocity required to perforate skin by metallic FSPs of a range of sectional densities was generated. DISCUSSION: Skin has a significant effect on the retardation of FSPs, necessitating its incorporation in future injury models. Perforation algorithms based on animal and PMHS skin can be used interchangeably as well as spheres and cylinders of matching sectional density. Future numerical simulations for skin perforation must match the velocity for penetration and also require experimental determination of mechanical skin properties, such as tensile strength, strain and elasticity at high strain rates.

The changing pattern of amputations.

INTRODUCTION: Conflict in the Middle East over the past 10 years has seen a change in warfare tactics from the use of ballistic missiles to blast weapons, which has resulted in a well-documented change in wounding patterns. Due to the severity of these injuries, there have been large numbers of amputations, both as life and limb saving procedures. The purpose of this paper is to retrospectively review all UK service personnel who have undergone limb amputation in the last 8 years of conflict and compare those from the early years with the more recent. METHODS: All UK service personnel scoring more than 1 on the extremity score of the Abbreviated Injury Score were identified from the UK Joint Theatre Trauma Registry and separated into two temporal cohorts (August 2003-February 2008 and August 2008-July 2010). Intheatre medical facility and Role 4 hospital notes from the Queen Elizabeth Hospital Birmingham were examined for details of mechanisms of injury, number of limbs injured, associated injuries, method of amputation, microbiology of contaminating organisms and outcome. RESULTS: There were significant differences in the nature of the amputations, the number of multiple amputations and soft tissue perineal wounds, as well as a significantly higher Injury Severity Score in the later time period. There were also significant differences in the surgical techniques, with more guillotine amputations in the early group, and mechanism of injury, with more blast injuries in the late group. CONCLUSIONS: This study has confirmed the clinical impression that there has been a significant change in the limb trauma from the Iraq conflict to Afghanistan. These injury patterns have significantly different logistic implications and this must be considered when planning the required medical assets in future conflicts.

Modelling for conflict: the legacy of ballistic research and current extremity in vivo modelling.

Extremity ballistic injury is unique and the literature intended to guide its management is commonly misinterpreted. In order to care for those injured in conflict and conduct appropriate research, clinicians must be able to identify key in vivo studies, understand their weaknesses and desist the propagation of miscited and misunderstood ballistic dogma. This review provides the only inclusive critical overview of key studies of relevance to military extremity injury. In addition, the non-ballistic studies of limb injury, stabilisation and contamination that will form the basis from which future small animal extremity studies are constructed are presented. With an awareness of the legacy of military wound models and an insight into available generic models of extremity injury and contamination, research teams are well placed to optimise future military extremity injury management.

Spinal fractures in current military deployments.

OBJECTIVE: To describe spinal fracture patterns presenting to deployed medical facilities during recent military operations. METHODS: Retrospective analysis of the United Kingdom Centre for Defence Imaging Computed Tomography database, 2005-2009. Fractures are classified, mechanism noted and associated injuries recorded. Statistical analysis is by Fisher's Exact test. RESULTS: 128 fractures in 57 casualties are analysed. Ballistic (79%) and non-ballistic mechanisms contribute to vertebral fracture at all regions of the spinal column in patients treated at deployed medical facilities. There is a high incidence of lumbar spine fractures, which are more likely to be due to explosion than gunshot wounding (p < 0.05). Two thirds of thoracolumbar spine fractures caused by explosive devices are unstable and are mainly burst-fractures in configuration. 60% of spinal fracture patients had concomitant injuries. There is a strong relationship between spinal fractures caused by explosions and lower limb fractures. CONCLUSION: Injuries to the spine caused by explosive devices account for greater numbers, greater associated morbidity and increasing complexity than other means of spinal injury managed in contemporary warfare. With the predominance of explosive injury in current conflict, this work provides the first detail of an evolving injury mechanism with implications for injury mitigation research.

Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring.

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis. Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C). We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01). Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

Limb salvage of severely injured extremities after military wounds.

Severely wounded extremities following battlefield injuries present a surgical dilemma to military surgeons of whether to attempt salvage or amputate the limb. There are many considerations to be made, including local and systemic patient factors, other wounded personnel and logistical constraints. Attempts have been made previously to form objective scoring criteria so as to remove possible subjectivity in this decision-making process. Furthermore, paediatric patients present their own particular dilemmas. This paper examines these various matters and, with contemporaneous evidence, presents recommendations for management.