Aims. Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. Methods. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. Results. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. Conclusion. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations. Cite this article: Bone Joint J 2023;105-B(1):21–28

Extremity injury and complications such as wound infection remain a significant problem for the military. This study investigates the anti-microbial efficacy of four dressings used in militarily relevant complex extremity injury. Under general anaesthesia, the flexor carpi ulnaris of 24 New Zealand White rabbits was exposed to a high-energy impact and then inoculated with 10. 6. colony forming units of Staphylococcus aureus. Dressings: gauze soaked in saline, Chlorhexidine, Betadine or Acticoat¯, were randomised and applied 3 hours post injury, to replicate casualty evacuation. Once recovered, animals were checked at least twice daily and body temperature recorded. Analgesia was administered once a day. At 48hrs animals were culled, the muscle harvested and analyzed by a blinded investigator. Group sizes of 6 were required to detect a statistically significant effect of a mean one log reduction in bacterial counts at 48 hours. No dressing gave a significant reduction in bacterial counts at 48 hours. A paired t-test of contamination versus recovered dose gave p values of 0.903, 0.648, 0.396 and 0.336 for saline, Acticoat¯, chlorhexidine and iodine respectively. Contamination dose between groups compared using ANOVA showed no significant difference (p=0.566). Recovered bacterial loads between groups revealed no significant difference (p=0.280). This study indicates that over a 48 hour period, dressings with reported anti-bacterial properties offer no advantage over saline soaked gauze in reducing the bacterial burden in a contaminated soft tissue injury. Future work will extend the study temporally and introduce multiple contaminants

Crown copyright 2009. Published with the (permission of the Defence Science and Technology Laboratory on behalf of the Controller of HMSO. Introduction. The optimum strategy for the care of war wounds is yet to be established. A need exists to model complex extremity injury, allowing investigation of wound management options. Aim. To develop a model of militarily relevant extremity wounding. Study Design. Laboratory study with New Zealand White Rabbits. Methods. Phase 1. Development of injury. Following induction of general anaesthesia, a muscle belly on the flexor aspect of the forelimb of the rabbit was exposed. This was achieved by creating a fascial tunnel under the belly of flexor carpi ulnaris (FCU). Utilising a custom built drop test rig a high energy, short duration impact was delivered. To replicate casualty evacuation timelines, the animal was maintained under anaesthesia for three hours and recovered. The wound was dressed with saline soaked gauze and supportive bandaging. 48 hrs later, the animal was culled and the muscle harvested for histological analysis. Analgesia was administered once a day. Animals were checked by experienced staff at least twice a day and body temperature recorded by a subcutaneous transponder. Phase 2. Contamination of muscle injury. Sequential animals had inoculums of 1×102/100μl, 1×106/100μl and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered from anaesthetic and monitored as per phase 1. Delivery was evaluated by droplet spread and via injection by fine bore needle into the muscle belly. At the 48 hour point, the animals were culled, dressings removed, the muscle harvested and auxiliary lymph nodes sampled. Quantitative microbiological analysis was performed to determine colony forming unit counts (CFU) at 24 hours post-collection. Results. Phase 1. Six animals were exposed to a loading of 0.5kg. Histological analysis demonstrated a consistent injury pattern with 20% of the muscle belly becoming necrotic. Following discussion with subject matter experts this was found to be representative of the nature of injury from ballistic limb trauma and was adopted as standard. Phase 2. Twenty-two animals were exposed to the standardised injury and then inoculated at the prescribed challenge doses and delivery methods. A challenge dose of 1×106/100μl S. aureus delivered by droplet provided the greatest consistency. A group of six animals with an average challenge dose of 3.3×106/100μl yielded growth at 48hrs on average of 9.2×106 CFU. There were no adverse effects on animal welfare throughout, with body temperatures within normal limits at all times. Discussion. The use of rabbits in the investigation of musculoskeletal injury and infection is well established. No study to date however has addressed high energy complex soft tissue wounding, contamination and its optimum management. Considering the current burden of such wounds the need for this question to be answered in a research setting is transparent. This model enables a significant, reproducible, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management options including wound coverage and fracture fixation

Purpose: Musculoskeletal injuries affect up to 13% of adults annually. Despite this high incidence, quality of primary care, including analgesia, may be sub-optimal. The goal of this study is to describe the quality of primary care for ambulatory patients with isolated limb injury and to identify related factors. Method: A cross sectional study was undertaken on 166 consecutive ambulatory adult patients with isolated limb injury who presented to orthopedics service in a Level one Trauma Centre. Quality of care was assessed by evaluating analgesia, walking aids, immobilization, and quality of referral diagnosis according to actual expert recommendations. Patient satisfaction was assessed by Visit Satisfaction Questionnaire. Results: This study revealed low quality of primary care for more than 50% of injured patients. More than half the patients had pain level over 5/10 and more than a quarter had insufficient/absent analgesia prescriptions. A third had unacceptable immobilization and 36% of patients with a lower limb injury did not receive a walking aid prescription. A total of 37% had an absent or inadequate referral diagnosis. Factors associated with lower quality depended on the specific quality indicator and included: living further away from the hospital, younger age, initially consulting at another health care center, having a fracture, and being a smoker. Conclusion: The high frequency of low quality of care underlines the necessity for orthopedic surgeons to be involved in primary care education. Identifying factors associated with lower quality of care will orient efforts to improve medical care of patients with isolated traumatic injury

Two discrete legal factors enable the surgeon to treat an injured patient the fully informed, autonomous consent of the adult patient with capacity via civil law; and the medical exception to the criminal law. This article discusses current concepts in consent in trauma; and also considers the perhaps less well known medical exception to the Offences against the Person Act 1861, which exempts surgeons from criminal liability as long as they provide ‘proper medical treatment’.

Cite this article: Bone Jt Open 2024;5(7):565–569.

Purpose of the study: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy.

Materials and methods: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting.

Results: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation.

Discussion: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation.

Aim To develop a militarily relevant complex extremity wounding model. Study Design Controlled laboratory study with New Zealand White Rabbits. Method Phase One: Injury Development. Under general anaesthesia, the flexor carpi ulnaris of the right forelimb was exposed and high energy, short duration impact delivered via drop test rig. Anaesthesia was maintained for three hours, the animal was recovered and saline soaked gauze and supportive bandaging applied. 48 hrs later, the animal was culled and muscle harvested for histological analysis. Analgesia was administered daily, animals checked by experienced staff at least twice daily and temperatures recorded by subcutaneous transponder. Phase Two: Contamination. Sequential groups of animals had inoculums of 1×102, 1×106 and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered as phase one. At 48 hours, animals were culled, muscle harvested and axillary lymph nodes sampled. Quantitative microbiological analysis was performed on the muscle. Results: Six animals given a loading of 0.5kg yielded consistent injury with 20% of the muscle becoming necrotic. Representative of injury from ballistic trauma, this was adopted as standard. Twenty-two subsequent animals were exposed to the injury and inoculated with the challenge doses. 1×106/100μl S.aureus provided the greatest consistency in recovered yield. There were no adverse effects on animal welfare and body temperatures were always within normal limits. Discussion. This model enables a consistent, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management including wound coverage and fracture fixation.

Complex regional pain syndrome type 1 (CRPS-I) is a devastating complication that can occur after limb extremity injuries. The effectiveness of vitamin C in preventing CRPS-I incidence is debatable. Therefore, we conducted a systematic review and meta-analysis to assess the role of vitamin C in CRPS-I prevention and its effect on pain score, functional outcomes and complications rate after wrist, ankle, and foot fractures. We searched Medline, Embase, the Cochrane Library, . Clinicaltrial.gov. , and Google Scholar from infinity to May 2021 for relevant studies comparing the incidence of CRPS-I with administration of perioperative vitamin C versus placebo after wrist, ankle, and foot fractures. Continuous data such as functional outcomes and pain scores were pooled as mean differences (MD), whist dichotomous variables such as the incidence of CRPS-I and complications were pooled as odds ratios (OR), with 95% confidence interval (CI). Data analyses was done using R software (meta package, version 4.9-0) for Windows. Eight studies, including two quasi-experimental studies, were included. The timeframe for vitamin C administration ranged from 42 to 50 days post-injury and/or surgical fixation and the dosage was either 500 mg or 1000 mg. The results showed that vitamin C was associated with a lower rate of CRPS-I relative to a placebo (OR 0.33, 95% CI [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (OR 1.90, 95% CI [0.99, 3.65]), functional outcomes (MD 6.37, 95% CI [-1.40, 14.15]), and pain scores (MD -0.14, 95% CI [-1.07, 0.79]). The findings demonstrate that when compared to placebo, at least 42 days of vitamin C prophylaxis is associated with prevention of CRPS-I following wrist, ankle, and foot fractures, irrespective of vitamin C dosage or fracture type. No significant differences were found with secondary outcomes

Introduction. Tibial Pilon fractures are potentially limb threatening, yet standards of care are lacking from BOFAS and the BOA. The mantra of “span, scan, plan” describes staged management with external fixation to allow soft tissue resuscitation, followed by a planning CT-scan. Our aim was to evaluate how Tibial Pilon fractures are acutely managed. Methods. ENFORCE was a multi-centre retrospective observational study of the acute management of partial and complete articular Tibial Pilon fractures over a three-year period. Mechanism, imaging, fracture classification, time to fracture reduction and cast, and soft tissue damage control details were determined. Results. 656 patients (670 fractures) across 27 centres were reported. AO fracture classifications were: partial articular (n=294) and complete articular (n=376). Initial diagnostic imaging mobilities were: plain radiographs (n=602) and CT-scan (n=54), with all but 38 cases having a planning CT-scan. 526 fractures had a cast applied in the Emergency Department (91 before radiological diagnosis), with the times taken to obtain post cast imaging being: mean 2.7 hours, median 2.3 hours, range 28 mins – 14 hours). 35% (102/294) of partial articular and 57% (216/376) of complete articular (length unstable) fractures had an external fixator applied, all of which underwent a planning CT-scan. Definitive management consisted of: open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intramedullary nail (n=25), other (n=18). Conclusion. The management of Tibial Pilon fractures is variable, with prolonged delays in obtaining post cast reduction radiographs, and just over half of length unstable complete articular fractures being managed with the gold standard “span, scan, plan” staged soft tissue resuscitation. A BOFAS endorsed BOAST (British Orthopaedic Association Standard for Trauma) for Tibial Pilon fractures is suggested for standardisation of the acute management of these potentially limb threatening injuries, together with setting them apart from more straightforward ankle fractures

Aims. We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial. Methods. HeFT recruited 151 patients aged over 16 years with closed displaced, intra-articular fractures of the calcaneus. Patients with significant deformity causing fibular impingement, peripheral vascular disease, or other significant limb injuries were excluded. Participants were randomly allocated to open reduction and internal fixation (ORIF) or nonoperative treatment. We report Kerr-Atkins scores, self-reported difficulty walking and fitting shoes, and additional surgical procedures at 36, 48, and 60 months. Results. Overall, 60-month outcome data were available for 118 patients (78%; 52 ORIF, 66 nonoperative). After 60 months, mean Kerr-Atkins scores were 79.2 (SD 21.5) for ORIF and 76.4 (SD 22.5) for nonoperative. Mixed effects regression analysis gave an estimated effect size of -0.14 points (95% confidence interval -8.87 to 8.59; p = 0.975) in favour of ORIF. There were no between group differences in difficulty walking (p = 0.175), or on the type of shoes worn (p = 0.432) at 60 months. Additional surgical procedures were conducted on ten participants allocated ORIF, compared to four in the nonoperative group (p = 0.043). Conclusion. ORIF of displaced intra-articular calcaneal fractures, not causing fibular impingement, showed no difference in outcomes at 60 months compared to nonoperative treatment, but with an increased risk of additional surgery. Cite this article: Bone Joint J 2021;103-B(6):1040–1046

Aims. To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury. Methods. Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care. Results. The median age of the participants was 51 years (interquartile range 35 to 64). At three and six months post-injury respectively, 32% (222/702) and 30% (234/787) had neuropathic pain, 56% (396/702) and 53% (413/787) had chronic pain without neuropathic characteristics, and the remainder were pain-free. Pain severity was higher among those with neuropathic pain. Linear regression analyses found that those with neuropathic pain at six months post-injury had more physical disability (DRI adjusted mean difference 11.49 (95% confidence interval (CI) 7.84 to 15.14; p < 0.001) and poorer quality of life (EQ-5D utility -0.15 (95% CI -0.19 to -0.11); p < 0.001) compared to those without neuropathic characteristics. Logistic regression identified that prognostic factors of younger age, current smoker, below knee fracture, concurrent injuries, and regular analgaesia pre-injury were associated with higher odds of post-injury neuropathic pain. Conclusion. Pain with neuropathic characteristics is common after lower limb fracture surgery and persists to six months post-injury. Persistent neuropathic pain is associated with substantially poorer recovery. Further attention to identify neuropathic pain post-lower limb injury, predicting patients at risk, and targeting interventions, is indicated. Cite this article: Bone Joint J 2021;103-B(6):1047–1054

Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate following high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The purpose of this study was to assess the validity of Mangled Extremity Severity Score (MESS), the only verified score, in a population of military patients with ballistic mangled extremity injuries. 52 military patients with 58 limbs who had ballistic mangled extremity injuries were identified, 13 of whom required amputation. Using both the trauma audit and the hospital notes, demographics were assessed. Patients were retrospectively evaluated with the MESS system for lower extremity trauma. The MESS would not help in the decision-making. However, we were able to develop an algorithm for management, in particular the need for early amputation. The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have developed an algorithm to provide guidelines for management

Background. The decision to attempt limb salvage vs to amputate in a significant traumatic limb injury is based on patient´s best predicted outcome. When amputation cannot be avoided the aim is to provide a pain free limb whilst preserving the soft tissue and limb length. Methods. Retrospective study covering 5 years (2011–2016), all the trauma patients requiring lower limb amputation (LLA) included. Demographics, mechanism, type of injury, amputation type, cause and level, theatre trips for stump management were analysed. Results. 19 patients aged 27–93 included. RTC was the leading cause (47%) of LLA. Amputation type: traumatic, caused by the injury itself (31.5%) acute surgical, amputation performed in a limb threatening injury (37%); 72% of them had vascular compromise delayed amputations after failure of limb salvage surgery (31.5%); failed soft tissue coverage and poorly functioning limb were the lead cause (33% each) Type of injury: open fractures (89%), isolated to a limb segment (53%). One level/extended level=9/10 patients. More than 50% of initial amputations were extended with multiple subsequent theatre trips (33/10 patients) for stump management. Conclusions. It was difficult to predict the patients needing an extended amputation. Early MDT and prosthetic rehab service involvement is crucial in LLA decision. When consenting patients for LLA consider a 50% change to extend the initial level of amputation with subsequent theatre trips

Introduction: Complex extremity injury remains a challenge to those involved in both its emergent and definitive care. Anecdotal concerns exist regarding exposure of orthopaedic trainees to such cases in the light of recent changes in surgical training. We aim to establish the perceived confidence, exposure to caseload and adequacy of training of United Kingdom (UK) Orthopaedic Specialist Trainees in the management of significant extremity trauma. Method: A web-based survey was sent to a sample of orthopaedic trainees. 222 responses from 888 trainees were required to achieve a 5% error rate with 90% confidence. 232 responses were received. Results: Perceived confidence and adequacy of training in wound debridement and fasciotomy is high despite infrequent exposure and training is perceived as adequate. With regards to assessment of limb viability and amputation for extremity injury, exposure is minimal, perceived confidence is lower, particularly in the case of amputation and for this scenario over a third of trainees report their training as inadequate. Perceived confidence in dealing with hand trauma is low and is associated with sparse exposure to cases resulting in a quarter of trainees reporting their training as inadequate. For all scenarios, confidence is seen to increase with time spent in training with the notable exception of post-CCT trainees whom report a lower confidence to their colleagues in the latter years of training. Discussion: Despite infrequent exposure, it has been demonstrated that perceived confidence and adequacy of training in many aspects of extremity injury is high. Concerns are apparent with the management of hand trauma and amputation surgery. This study is the first of its kind to offer a valuable insight into the current training perceptions and requirements of junior orthopaedic surgeons at a national level

Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative management. However, there is significant variability between practitioners with no consensus among clinicians on the most effective nonoperative protocol, despite how common the form of treatment. This systematic review identified published conservative treatment modalities for acute metatarsal fractures and compares their non-union rate, chronic pain, and length of recovery, with the objective of identifying a best-practices algorithm. Searches of CINAHL, EMBASE, MEDLINE, and CENTRAL identified clinical studies, level IV or greater in LOE, addressing non-operative management strategies for metatarsal fractures. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. Studies were excluded if a rehabilitation program outlining length of immobilization, weight-bearing and/or strengthening approaches was not reported. A total of 12 studies (8 RCTs and 4 PCs), from the 2411 studies that were eligible for title screening, satisfied inclusion criteria. They comprised a total of 610 patients with acute metatarsal fractures, with a mean age of 40.2 years (range, 15 – 82). There were 6 studies that investigated avulsion fractures, 2 studies on true Jones fractures, and 4 studies with mixed fracture types. Studies assessed a variety of treatment modalities including: WB and NWB casts, elasticated support bandages, hard-sole shoes, plaster slippers, metatarsal shoe casts, and air cast boots. Most studies investigated the outcomes of NWB casts and elasticated support bandages. The NWB short leg cast had no reported non-unions, delayed-unions, or refractures for avulsion fractures. In true Jones fractures, there was an average non-union rate of 23.6% (range, 5.6 – 27.8%), delayed-union rate of 11.8% (range, 5.6 – 18.8%), and refracture rate of 3% (range, 0 – 5.6%). Overall, the average AOFAS score was 87.2 (range, 84 – 91.7) and the average VAS score was 83.7 (range, 75 – 93). The elasticated support bandage had an average non-union rate of 3.4% (range, 0 – 12%), and delayed-union rate of 3.8% for acute avulsion fractures, with no reported refractures. No included study arm investigated outcomes of elasticated support bandages for the true Jones fracture. The average AOFAS score for elasticated support bandages was 93.5 (range, 90 – 100). The average VAS score was 88.9 (range, 90 – 100). Most acute metatarsal fractures heal well, with good-to-excellent functional outcomes and moderate-to-high patient satisfaction. Conservative strategies for avulsion fractures are highly successful and based on this data the authors recommend patients undergo a schedule that involves 3 – 4 weeks in an elasticated support bandage, short leg cast, or equivalent, and WB thereafter as tolerated, with return-to-activity after clinical union. Despite poorer conservative outcomes for true Jones fractures, patients should undergo 8 weeks in a NWB short leg cast, followed by a walking cast or hard-sole shoe for an additional 4 – 6 weeks, or until clinical union. However, surgical consultation is recommended

Extremity injuries on the battlefield are commonly secondary to high energy mechanisms. These cause significant injury to soft tissue and bone and are contaminated. Evacuation to medical care can be difficult in the operational environment and may delay the time to initial surgery. There is already substantial literature on the complications of such injuries but this is the first report from UK forces. Our aim was to assess the complications, but specifically infections, in relation to delay in surgery and also the method of fracture stabilisation. Military patients who had ballistic mangled extremity injuries were identified from the database (courtesy of ADMEM). Using both the trauma audit and the hospital notes, demographics were assessed. The injuries sustained (including the fractured bones), time to theatre, associated injuries, method of stabilisation at Role 3, definitive fixation and complications were noted. 81 patients were identified with 95 limbs injured (68 lower limb, 27 upper limb). The most commonly fractured bones were the tibia, radius/ulna, femur and humerus. Primary stabilisation was either ExFix (53%) or plaster (44%). Of those stabilised by ExFix, the definitive stabilisation was mainly by either a nail (44%) or plate (17%). Those stabilised by plaster mainly stayed in plaster. 72% of patients developed at least one complication, the most common of which was superficial infections. Other complications were deep infections, delayed union, haematomas, neuropathic pain and flap failures. The main organisms involved were Acinetobacter, Bacillus and Pseudomonas. There was no association between delay to theatre and decision to amputate. There was an association between the use of plaster for definitive stabilisation and superficial infection and plates for definitive stabilisation and deep infections. There was no association between time delay to theatre and infections. This provides the first report of complications from extremity injuries secondary to ballistic missile devices in UK forces. It allows for comparison with reports from other sources on similar injuries and helps to guide further management of patients. In particular it agrees with recent civilian data that initial surgery does not have to be carried out as soon as possible, which has implications for military planning

Introduction: Arterial bleeding following pelvic fractures is widely recognized as an indication for angiography and embolization although controversy persists as to the timing of this procedure in the treatment algorithm. Less well appreciated is its application in similar circumstances following blunt injury to the pelvic arteries and limb injuries. We describe our experience in a variety of haemorrhagic orthopaedic pathologies. Patients and Methods: Angiography was performed in 29 patients- 16 with pelvic fractures, 9 with extremity injuries, and 4 with tumors. Seldinger technique was used for angiographic access, usually from the groin although on occasion extensive local injury required use of the brachial approach. Following the initial diagnostic study the a selective catheter was placed at the target, appropriate embolic material was selected and the source of haemorrhage was closed off. Results: In our experience of pelvic traumatic bleeding (14 associated with fracture, 2 without) embolization was successful in promptly arresting hemorrhage in all but one case of advanced DIC. Mortality was confined to this last case and two others, all of whom were referred for embolization following prolonged hypotension and commenced angiographic intervention with blood pressure unmeasureable or of the order of 30mm systolic. With 9 cases of extremity injury, 1 iatrogenic, 5 penetrating, 2 blunt and one following fracture of the femur, embolization successfully treated the hemorrhage. Finally we present our experience in preventing hemorrhage in 4 cases, 3 of which were vertebral body tumours and 1 pathological fracture of the humerus due to RCC. At surgery following embolization none bled significantly. Conclusions: The present study describes our experience in various orthopedic conditions. Less well recognized is its role in preventing hemorrhage; as a prelude to bloody operations on vertebral body metastases, aneurysmal bone cysts and hemangiomata as well as open reduction and internal fixation of pathological extremity fractures. We conclude that this technique is a valuable addition to the tools available to the orthopedic surgeon and whose application is not necessarily limited to the examples quoted, but should be applied in any case where the direct surgical approach is considered hazardous or ineffective

This review explores recent advances in fixator design and used in contemporary orthopaedic practice including the management of bone loss, complex deformity and severe isolated limb injury

The October 2013 Trauma Roundup. 360 . looks at: Radiological, electromagnetic or just leave it out altogether?: distal locking in intramedullary nailing; Internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure; Obesity and trauma; Short and sweet?: antibiotics in open fractures; Extremity injuries more important than previously thought?; Cement nails tiptop for osteomyelitis; Oxygen measurements for compartment syndrome?