Management of conflict injuries to the upper limb. Part 1: assessment and early surgical care.

Upper limb injuries are common in conflict zones. The functions of the upper limb are impossible to replicate with prosthetic replacement and wherever possible attempts should be made to preserve the limb with further secondary reconstruction aimed at restoration of function. Casualty assessment, haemorrhage control and resuscitation are simultaneously undertaken at the receiving medical facility.

High velocity gunshot injuries to the extremities: management on and off the battlefield.

The gunshot wounds sustained on the battlefield caused by military ammunition can be different in nature to those usually encountered in the civilian setting. The main difference is that military ammunition has typically higher velocity with therefore greater kinetic energy and consequently potential to destroy tissue. The surgical priorities in the management of gunshot wounds are hemorrhage control, preventing infection, and reconstruction.

Translational research to improve the treatment of severe extremity injuries.

Objectives: Severe extremity injuries are the most significant injury sustained in combat wounds. Despite optimal clinical management, non-union and infection remain common complications. In a concerted effort to dovetail research efforts, there has been a collaboration between the UK and USA, with British military surgeons conducting translational studies under the auspices of the US Institute of Surgical Research.

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.

Dual-purpose bone grafts improve healing and reduce infection.

Objective: To determine if a dual-purpose bone graft can regenerate bone and reduce infection in highly contaminated bone critical size defects in rats.

Methods: Biodegradable polyurethane (PUR) scaffolds were loaded with recombinant human bone morphogenetic protein-2 (BMP-2) and vancomycin (Vanc). The release kinetics of the BMP-2 were tuned to take advantage of its mechanism of action (ie, an initial burst to recruit cells and sustained release to induce differentiation of the migrating cells).

Effect of various concentrations of antibiotics on osteogenic cell viability and activity.

Infection is a common complication of open fractures. Systemic antibiotics often cause adverse events before eradication of infected bone occurs. The local delivery of antibiotics and the use of implants that deliver both growth factors and antimicrobials are ways to circumvent systemic toxicity while decreasing infection and to reach extremely high levels required to treat bacterial biofilms.

Improving bone formation in a rat femur segmental defect by controlling bone morphogenetic protein-2 release.

Nonunion is a common complication in open fractures and other severe bone injuries. Recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on a collagen sponge enhances healing of fractures. However, the burst release of rhBMP-2 necessitates supra-physiological doses of rhBMP-2 to achieve a robust osteogenic effect, which introduces risk of ectopic bone formation and severe inflammation and increases the cost.

Comparison of development of heterotopic ossification in injured US and UK Armed Services personnel with combat-related amputations: preliminary findings and hypotheses regarding causality.

Background: Recent reports have documented the rate of heterotopic ossification (HO) formation in the residual limbs of combat-related amputees from the US Armed Forces injured in Operations Iraqi and Enduring Freedom. Final amputation level within the zone of injury and blast as the mechanism of injury were identified as possible risk factors for the occurrence and grade of HO. There has been no previous description of HO in combat-related amputees from the UK service personnel.

Infectious complications of combat-related mangled extremity injuries in the British military.

Background: During the wars in Iraq and Afghanistan, extremity injuries have predominated; however, no systematic review of field and stabilization care with subsequent infectious complications exists. This study evaluates the infectious complications and possible risk factors of British military casualties with mangled extremities, highlighting initial care and infections.

Methods: This is a retrospective cohort study of British military casualties in Iraq and Afghanistan between August 2003 and May 2008.

Sustained release of vancomycin from polyurethane scaffolds inhibits infection of bone wounds in a rat femoral segmental defect model.

Infection is a common complication in open fractures that compromises the healing of bone and can result in loss of limb or life. Currently, the clinical standard of care for treating contaminated open fractures comprises a staged approach, wherein the wound is first treated with non-biodegradable antibiotic-laden poly(methyl methacrylate) (PMMA) beads to control the infection followed by bone grafting. Considering that tissue regeneration is associated with new blood vessel formation, which takes up to 6 weeks in segmental defects, a biodegradable bone graft with sustained release of an antibiotic is desired to prevent the implant from becoming infected, thus allowing the processes of both vascularization and new bone formation to occur unimpeded.

Earlier debridement and antibiotic administration decrease infection.

Timing of debridement and local antibiotic administration on infection has not been clearly defined. A contaminated critical size rat femur defect model was used to determine if earlier debridement with local antibiotics decreased infection. Defects were inoculated with Staphylococcus aureus.

Predicting the need for early amputation in ballistic mangled extremity injuries.

Background: Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate after high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values.

Complications of extremity vascular injuries in conflict.

Introduction: The extremities remain the most common sites of wounding in conflict, are associated with a significant incidence of vascular trauma, and have a high complication rate (infection, secondary amputation, and graft thrombosis).

Aim: The purpose of this study was to study the complication rate after extremity vascular injury. In particular, the aim was to analyze whether this was influenced by the presence or absence of a bony injury.