J Clasper

The Interaction of Projectiles with Tissues and the Management of Ballistic Fractures

Wounds to the limbs are the commonest injuries seen during armed conflict and injury results from the transfer of energy from the missile to the tissues. There are a number of factors that determine the transfer of energy, and thus the extent of wounding. These include the velocity of the missile, its shape and stability, and the tissue through which the missile passes. Many of the wounds involve bone, and because of the interaction of missiles with bone, significant fractures can occur. In many previous conflicts amputation was considered the treatment of choice for many limb injuries, but with recent advances in the management of severe open fractures, many of these limbs are now salvageable. Whilst the basic principles of the initial débridement remain unchanged, techniques of fracture stabilisation and definitive soft tissue cover have changed, and it is necessary to consider these in relation to military fractures. Definitive soft tissue closure can be safely delayed until evacuation further down the medical chain, but stabilisation of the fracture must be considered at the time of initial surgery. Many of the advances in fracture management may be unsuitable for use in a military environment due to logistical constraints. In addition it is likely that wound infection will be more common with military injuries, and this will influence the treatment. This paper considers the interaction of missiles with soft tissue and bone, and discusses possible methods of fracture stabilisation in the military environment.

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.

Incidence of SLAP lesions in a military population

Objectives 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 One hundred and seventy eight 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<0.0001). The incidence of SLAP lesions in the military patients was 38.6% compared to 11.1% in civilian patients (p<0.0001). After allowing for the increased incidence of trauma and instability in the military, SLAP lesions were still more common in the military patients (p<0.001). 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.

An Unusual Case Of Segmental Clavicle Fracture

Fracture of the clavicle is a common traumatic injury and comprises 4% of all fractures in adults. Amongst these, midshaft injuries account for the majority and medial fractures are uncommon (1). Whilst segmental fractures have been reported in the literature, concurrent lateral and medial injuries are very rare. These injuries are, therefore, susceptible to being missed, due to failure to look for a second injury after the initial diagnosis, and difficult X-ray interpretation around the area of the medial clavicle. The nature of segmental fractures can pose a difficult management problem for numerous reasons, and initial operative fixation is usually indicated. Early diagnosis is therefore imperative, and as such, clinical examination is essential even if an obvious mid or lateral shaft fracture is seen on X-ray. This unusual case of combined lateral and medial fractures was initially missed and the presentation and management is discussed.

Anti-Personnel Mine Injury; Mechanism and Medical Management

Injury from anti-personnel mines remains a serious threat to military and civilian populations, even after conflict has ceased (Groom 1984; Jeffreys 1996). It was estimated that in 1996, there were approximately 100 million anti-personnel mines laid worldwide and many of these were, and still are, situated in unmarked mine fields. This article discusses the mechanism, medical management and outcome from anti-personnel mine injury and also looks at recent advances in protection concepts.

Preliminary Results of the ‘Surgiligtm’ Synthetic Ligament in the Management of Chronic Acromioclavicular Joint Disruption

Background 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] using the coracoacromial ligament is often required in service personnel, and a number of methods to augment this repair have been used. Many of these operative methods require a second operation to remove the metalwork, and in addition can be associated with a failure rate of up to 30%. The ‘Surgilig™’ was originally designed for use in the revision of failed Weaver-Dunn procedures. However this study evaluates its use in the primary operation, reinforcing the autologous graft, in an attempt to reduce the failure rate. Data Collection And Analysis We prospectively followed up the Modified Weaver Dunn procedures using Surgilig™. The post-operative x-rays were reviewed at six weeks, three months and then six months to assess the radiological success of the procedure. Our patients were discharged at six months. Results We have performed this procedure in 11 patients. One of the 11 patients was excluded from the study as the Surgilig™ graft was used in addition to a hook plate. The remaining ten patients have all reached the six-month post-operative time with no incidence of radiological failure of the graft. After six months they were discharged from clinic follow-up as the coracoacromial graft had sufficient strength to no longer rely on the augment for mechanical stability of the joint. All 10 patients had a good clinical and radiological result. One patient even had inadvertent stress/ weight-bearing x-rays taken at six weeks, with no discernable detrimental effect to outcome. Conclusion Although a small study, these initial results for primary fixation of acromioclavicular joint disruption with Surgilig™ are extremely encouraging. The results suggest that Surgilig™ should continue to be used in its current role. As patient numbers increase, a follow-up study to evaluate these preliminary findings should be conducted.

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.

Poland's Syndrome And Military Personnel

We describe three cases of undiagnosed Poland’s syndrome in Army personnel and discuss their fitness according to the PULHHEEMS system. This syndrome has variable clinical features that include unilateral chest wall and upper limb abnormalities. The syndrome is not hereditary and is of unknown origin. If the syndrome was diagnosed prior to enlistment the potential recruit would normally be graded P8, and unfit to enlist. However, these individuals had managed to pass routine medical examination as well as successfully complete basic training. The suitability of continuation in the army of personnel with Poland’s syndrome is discussed.

Management of shoulder instability in a military population.

Objectives Recurrent instability is common after shoulder dislocation in the young, particularly those engaged in physical jobs or sport. The management of recurrent traumatic shoulder instability is predominantly operative. However, the best method of surgery i.e. open or arthroscopic is still a matter of debate. We have developed an algorithm to decide on the choice of surgery and the aim of this study is to report this and compare the two different groups of military patients. Methods A retrospective review of all shoulder stabilisations performed on military personnel, by a single surgeon, between August 2004 and August 2005 at a district general hospital serving both military and civilian population was undertaken. The presentation, clinical and operative findings were noted and compared in the groups treated by arthroscopic or open stabilisation. Results Using our protocol 39 shoulder stabilisations were performed in military personnel. Of the shoulders, 25 (64%) underwent arthroscopic and 14 (36%) underwent open stabilisation. The indication for surgery was more than 2 episodes of shoulder dislocation. Open surgery was found to be more common in those who had their first dislocation at a younger age. Bilateral shoulder laxity was the most common indication to choose the open method. Both open and arthroscopic stabilisation gave good results in the high demand military population. Only one patient had recurrent instability after arthroscopic procedure. However, this was not statistically significant when compared with open stabilisation.

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.