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The acute medical care in Germany after gunshot and stab wounds in the pre-hospital and in-hospital setting is a rarity in an international comparison. The resulting lack of routine in the acute care of critically injured people after penetrating trauma should therefore be countered with regular theoretical and practical training. In addition to standardized care algorithms for the care of severely injured people, knowledge of kinetics and wound ballistics is required for focused treatment. The article focuses mainly on the early treatment phase., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Due to recent rampage and terror attacks in Europe, gunshot wounds have become a focus of attention even though they are still rare in Europe. Approximately 50% of gunshot wounds affect the extremities and to understand the sequelae, a basic knowledge of wound ballistics is indispensable. The energy transmitted from the bullet to the tissue is responsible for the severity of the injury and is dependent on the type of weapon and ammunition. A differentiation is made between low-energy injuries caused, e.g. by pistols and high-energy injuries mostly caused by rifles. The higher energy transfer to the tissue in high-energy injuries, results in a temporary wound cavity in addition to the permanent wound channel with extensive soft tissue damage. High-energy gunshot fractures are also more extensive compared to those of low energy injuries. Debridement seems to be necessary for almost all gunshot wounds. Fractures should be temporarily stabilized with an external fixator due to contamination.

Disasters and armed conflicts are often the unfortunate basis for aid projects run by Doctors Without Borders/Médecins Sans Frontières (MSF). The nature of war and disasters means that surgery is an integral part of this medical emergency aid. In these situations, resources are usually limited. As a result, surgical work in these contexts differs significantly from the daily routine of a surgeon working in a highly resourced hospital. The principles of surgery do not change but surgeons must adapt their tactical approach to the changed context otherwise there is a high risk of failing to improve the health of patients and potentially jeopardizing their prospects for recovery. Every experienced war surgeon has learned new skills the hard way. The Field Guide to Manage Limb Injury in Disaster and Conflict has been written to help new surgeons who may face the challenges of disaster and war surgery and to avoid unnecessary suffering for patients ( https://icrc.aoeducation.org ). Under the guidance of the International Committee of the Red Cross (ICRC), with participation of the World Health Organization (WHO), financed by the AO Foundation, and featuring the experiences of experts from different organizations (amongst them MSF), the book details techniques and guidelines for surgery in low resource settings. The following article provides a short summary of some of the surgical challenges when working with limited resources and reflects on a few specific recommendations for so-called war surgery.

Much like other countries, Germany has recently seen terrorist attacks being planned, executed or prevented at the last minute. This highlights the need for expertise in the treatment of penetrating torso traumas by bullets or explosions. Data on the treatment of firearm injuries and, even more so, blast injuries often stems from crises or war regions. However, it is difficult to compare injuries from such regions with injuries from civilian terrorist attacks due to the ballistic body protection (protective vests, body armour) worn by soldiers. Methods An analysis was performed based on data from patients who were treated in the German Military Hospital Mazar-e Sharif for gunshots or injuries from explosions in the years 2009 to 2013. The data selection was based on patients with penetrating injuries to the thorax and/or abdomen. For better comparability with civilian attack scenarios, this study only included civilian patients without ballistic body protection (body armour, protective vests). Results Out of 117 analysed patients, 58 were affected by firearms and 59 by explosive injuries of the thorax or abdomen. 60% of patients had a thoracic injury, 69% had an abdominal injury, and 25.6% had combined thoracic-abdominal injuries. Blast injury patients were significantly more affected by thoracic trauma. As regards abdominal injuries, liver, intestinal, and colonic lesions were leading in number. Patients with blast injuries had significantly more injured organs and a significantly higher ISS averaging 29. 26% of the shot patients and 41% of the blast wounded patients received Damage Control Surgery (DCS). Despite a lower ISS, gunshot victims did not have a lower total number of operations per patient. Overall mortality was 13.7% (10.3% gunshot wounds, 16.7% blast injury). The highest mortality rate (25.7%) was recorded for patients with combined thoracoabdominal injuries (vs. 8.3% for thoracic and 8.7% for abdominal injuries). The ISS of deceased patients was significantly higher at 32.9%. Conclusion Patients without ballistic protection of the torso have high mortality rates, especially when suffering thoracoabdominal blast injuries. Blast injuries frequently lead to the DCS indication. The care of firearm and blast injury patients requires knowledge and competence in the damage control procedures for thorax and abdomen., Competing Interests: Interessenkonflikt: C. Güsgen, A. Willms, I. Richardsen, D. Bieler, E. Kollig, R. Schwab geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

We report the case of a 24-year-old female after sustaining a shotgun wound in the left upper extremity and chest. Initial emergency diagnostics revealed numerous shotgun pellets scattered throughout the left-side soft tissue, chest and upper lung lobe with one pellet having migrated into the left ventricle of the heart.Due to the devastating injury pattern, gunshot wounds are interdisciplinarily challenging and should include extended initial diagnostics, such as contrast agent CT. The potential toxicity of elevated lead blood levels have to be taken into further account.

The authors present a case report of a 38-year-old man who suffered combined gunshot injuries of the heart and lungs from a small caliber gun. The gunshot resulted in combined injuries of a penetrating wound of the left lung, the right heart chambers and the right lung which were successfully managed despite a delay in surgery of several hours by pledget sutures of the heart wounds, wedge resection of the lingula and right lower lung lobectomy performed via a clamshell thoracotomy.

Background: Orbital gunshot wounds are rarely found after suicide. A gunshot fired at point blank range into the temple has devastating effects on all intraorbital and neighboring structures., Case Reports: This article reports on two cases of gunshot wounds to the lateral orbit in attempted suicides with different weapons from 2012 and 2013 and treated at the Ruhr University Eye Hospital in Bochum. In both cases treatment was carried out in cooperation with the department of oral and maxillofacial surgery, Ruhr University Hospital, Bochum. In the first case a 7.65 mm gun was used. The patient presented with a double penetration of both orbits with total destruction of both globes and a reconstruction was not possible. The second patient presented with multiple shots to the head from a small caliber gun (5.6 mm) where one bullet entered the right orbit behind the globe. The bullet could be localized using computed tomography (CT) and surgically removed with preservation of the globe and with a postoperative visual acuity of 20/60., Conclusion: The preservation of visual function after orbital gunshot wounds depends on both the projectile channel and the characteristics of the gun and bullet. Close collaboration in surgical management between ophthalmologists, maxillofacial surgeons and neurosurgeons in specialized centers is necessary because patients often present with multiple trauma and prompt interdisciplinary treatment is needed.

Background: Projectiles or metal fragments can remain lodged in the body of victims of gunshot injuries. This also applies to projectiles which do not tend to deform or fragment on impact. When a projectile fragments on penetration, jacket or lead core particles are likely to remain lodged in the affected region even if the projectile has exited the body., Aim of the Study: A frequently asked question in the surgical management of such injuries is whether there are medical indications for the surgical removal of projectiles or fragments., Material and Methods: This article presents some typical cases of patients who have received treatment at our institution and reviews the pertinent literature to show general recommendations in special cases concerning the removal of projectiles or fragments and when additional surgical trauma is justified. Parameters for decision making are presented in an algorithm., Results: From our own patients, 5 with remaining fragments in the soft tissue were invited for a clinical follow up. Serum probes and 24 h urine output was analysed for serum lead levels and urinary aminolevulinic acid levels. 74 months (max. 128 - min. 42 months) after injury we documented not elevated serum lead levels of 8.25 μg/ml and urinary aminolevulinic acid levels of 4.8 mg/24 h., Discussion: When lead-containing projectiles or fragments remain lodged in the body, monitoring is required and includes the measurement of serum lead levels and urinary aminolevulinic acid levels. The most important clinical symptoms of lead poisoning are gastrointestinal and neurological in nature. The treatment of choice for lead poisoning is the administration of chelating agents and removal of the lead source by surgical intervention.

Violence is a growing problem worldwide. In Switzerland, interpersonal violence seems to be an increasing problem as well. The aim of the current study was to describe a comprehensive picture of violence in a swiss city with regard to medical and social aspects. A total of 1740 patients injured by violent crimes between April 2004 and January 2011 were enrolled into this study. Most of them were male. There were no relevant changes regarding the number of within the observation period. However, the proportion of affected females increased. Especially at the weekend, there is a need for preventive measures to reduce the high number of affected patients and the associated costs.

We report about a reconstruction of a broad infected defect zone by tractionosteogenesis and following implantation of a graft from the iliac crest and a plate fixation at the distal part of the radius after a gunshot injury by a high-velocity bullet., (© Georg Thieme Verlag KG Stuttgart · New York.)

Patient-controlled analgesia (PCA) is an established standard therapy for providing postoperative analgesia. To avoid possible abuse by patients each PCA pump is secured by a pin code that should be neither known nor accessible to patients. The two case reports described illustrate how manipulation of a PCA pump led to massive opioid abuse by the patients who decoded the pin code for unlimited additional doses. One patient developed withdrawal symptoms after switching the therapy and, as a consequence even had to be admitted to the intensive care unit (ICU). Easy access to the PCA pump codes on the internet for the patients and the impossibility of changing the pin codes by the medical staff played an important role in these two cases.

Gunshot injuries to the hand are rare in Central Europe. As a result of their special trauma morphology they are a serious threat to the functional integrity of the hand and often lead to a loss of function which can be associated with a permanent unfitness to work or disability. Blast injuries to the hand are more common in this part of the world and are usually caused by the inappropriate use of fireworks. This trauma entity is associated with a number of special kinetic features and effects which have therapeutic consequences and should therefore be discussed separately. As a result of the low incidence of these specific types of injuries in times of peace, experience-based expertise is unlikely to be available. The management of gunshot injuries to the hand is a particular challenge to hand surgeons who must have specialist knowledge and skills in order to achieve an optimum outcome. This applies even more so to the treatment of blast injuries to the hand which are associated with far more complex injury patterns. As a rule blast injuries are associated with a high risk of complications and require a rapid assessment and rigorous management of all damaged structures similar to approaches used for infections of the hand. Illustrated by several cases which have been treated at our institution the basic aspects of the development and morphology of these injuries are discussed as well as different treatment options, algorithms and possible treatment outcomes.

A 20-year-old woman sustained massive elbow trauma from a gunshot wound. After initial surgery soft tissue coverage, reconstruction of the proximal third of the ulna, of the ulnar collateral ligament and of the triceps tendon was performed by one multicomponent microvascular free flap. There were no complications, the elbow is stable and reached full weight bearing 11 months after trauma. Active range of motion for extension and flexion is 0-20°-80°.

In this case report we describe a 24-year-old German KFOR soldier who was injured in the night of New Year's Eve 2009/2010 during the Kosovo Mission by a falling bullet in the right shoulder. The falling bullet was a full metal jacket probably shot during a "happy shooting" by a civilian.

The role of ENT surgery in the management of anterior skull base defects has become increasingly important in recent years. Transnasal endoscopic surgical techniques and intraoperative navigation enable a minimally invasive approach in a large proportion of patients, thus helping to avoid morbidity typically associated with neurosurgical subfrontal approaches. Whereas traffic accidents and sport injuries are the main causes of anterior skull base trauma in the civilian setting, penetrating injuries caused by gunshots and improvised explosive devices (IEDs) play an increasing role in the military arena and terroristic attacks. Minor injuries to the anterior skull base are usually managed by ENT surgeons. Major injuries, involving the midface or neurocranium, require an interdisciplinary approach including maxillofacial surgeons and neurosurgeons. A centre for head and neck medicine and surgery is an ideal setting for such interdisciplinary teams to provide appropriate care for patients with complex skull base trauma in cooperation with ophthalmologists and interventional neuoradiologists. The present article describes concepts for the treatment of anterior skull base trauma established at the head, neck and skull base center at the Ulm military hospital in Germany.

The face plays a central role in interpersonal communication and aesthetic perception. Moreover, due to the heavy dependence of ocular function on lid anatomy, the treatment of periocular injuries, particularly those involving soft tissue loss, requires profound knowledge of both anatomy and reconstructive plastic surgery. Numerous surgical procedures are described in the literature. The aim of these procedures is to achieve an optimal functional and aesthetic result according to injury localization and extent. Against this background, treating eyelid injuries presents certain challenges. Close collaboration between all areas of head surgery is required particularly in the case of large defects.

In cases of damaged recipient vessels or short vascular pedicles of the flaps, arteriovenous loops or long vein interposition are necessary for microsurgical defect coverage. These procedures require additional anastomoses with extended access and prolonged surgery and increase the risk of complications.The following article presents an alternative transosseous route of vascular pedicles for improved access to the recipient vessel based on three case studies.

From the military perspective detailed knowledge about the spectrum of operations undertaken abroad is of particular interest to provide indications of the skills that will be required by the surgeons. Therefore, all surgical reports produced in 2008 in the operation theatres of Mazar-e-Sharif, Feyzabad and Kunduz were reviewed. The overview shows that a total of 799 operations were performed equivalent to 0.4-1.6 operations/day. Most of the patients who underwent surgery were local civilians and most of these operations involved osteosynthesis, débridement and soft tissue procedures. Of the surgical procedures 11% involved patients who were German service personnel of which 85% were urgent or emergency procedures and 25% of these involved treatment of combat injuries. When civilian patients with life-threatening injuries or diseases are referred to the medical facilities there is little opportunity to make decisions with regard to acceptance. Often it may be necessary for surgeons to perform procedures which are outside their field of specialization. In order to ensure a favorable outcome in acute situations surgeons mainly required skills in emergency surgery of the body cavities (visceral and thoracic surgery).

Casualties in military conflict produce patterns of injuries that are not seen in routine surgical practice at home. In an era of increasing surgical sub-specialization the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. Improvised explosive devices (IEDs) have become the modus operandi for terrorists and in the current global security situation these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries are relevant to both military and civilian surgeons. To create this kind of military surgeon the so-called "DUO-plus" model for the training of surgical officers (specialization general surgery plus a second specialization either in visceral surgery or orthopedics/trauma surgery) has been developed in the Joint Medical Service of the German Bundeswehr. Other relevant skills, such as emergency neurotraumatology, battlefield surgery with integrated oral and craniomaxillofacial surgery and emergency gynecology, are integrated into this concept and will be taught in courses. Log books will be kept in accordance with the training curricula. On successful completion of the program medical officers will be officially appointed as Medical Officer "Einsatzchirurg" by their commanding officers for a maximum of 5 years and it will be necessary to renew it after this period. These refresher programs will require participation in visiting physicians programs in the complementary surgical disciplines in order to retain the essential specific skills.

Penetrating gunshot neck injuries present a serious challenge for the primary attending surgeon. By means of a case treated in the German Field Hospital in Mazar-e-Sharif (northern Afghanistan) and a review of the literature, the principles of diagnosis and treatment of penetrating zone II neck injuries due to gunshots or shrapnel are presented.

Laryngeal shot injuries are rare. The case of a 65-year-old man who suffered from an injury with lead pellets is reported. After exploration with removal of the pellet from the lateral cricoarytenoid muscle, an immobility of the vocal fold developed, accompanied by impaired vocal function. Despite persisting immobility of the vocal fold, after 12 weeks voice compensation was achieved by voice therapy.

It is well known that so-called bullet-proof vests offer protection against a wide range of penetrating trauma, but their protection against blunt trauma is less well understood. Fast projectiles may result in hematomas and contusions behind the armour. We report a traffic accident involving a young soldier wearing a ballistic protection vest resulting in a right thoracoabdominal blunt trauma leading to a confined liver compression rupture. As nearly no skin marks were detectable, we point out that every emergency department surgeon should be very suspicious if a patient wore a ballistic vest at the time of the accident--there may be no skin marks despite severe intra-abdominal trauma. Our patient recovered following hypotensive ICU treatment, thrombocyte mobilization, and factor VIIa substitution.

Background: In developing countries, war-like injury involving civilians, including children, is still a relevant and massive health problem and the human and economic costs of the injuries are tremendous., Objective: The aim of this study is to report on the spectrum of war-like injuries and their management in children and teenagers in an Iraqi surgical centre during a post-war wave of violence., Patients and Methods: All consecutive war-like injuries in children and teenagers younger than 16 years were documented in a clinical observational study (study design: Case series), who were treated during the time period of employment of the reporting author at the Casualty Unit of the University Hospital in Al Kadhimiyia (UHK), Baghdad (Iraq), over a 2-year period. The cases were studied with regard to descriptive criteria such as demographic patient characteristics, cause, site(s), and combination of injuries as well as their surgical management; among other factors, the specialty-depending distribution and outcome characterised by mortality were evaluated. Representative photographs have been selected from the photographic documentation in most cases., Results: From March 2003 to March 2005, 272 injured children and teenagers aged 16 years or less were enrolled in the study. The injuries in the majority of the casualties were caused by explosions in civilian areas, mortar bombardment of civilian buildings and housing, and family assassinations. The injuries were more common in males with a male to female ratio of 3.1 : 1; 206 (75.7 %) of the casualities were males and 66 (24.3 %) were females. Of the 272 casualties studied, 52 (19.1 %) were 5 years old or less, 95 (34.9 %) were between 6 to 11 years, and 125 (45.9 %) were between 12 to 16 years old. There were 126 (46.3 %) minor casualties, who were managed in the outpatient emergency unit, while 146 (53.6 %) casualties had serious and major injuries, 120 (44.1 %) of whom were admitted to UHK and 6 were transferred to other hospitals. Twenty (7 %) casualties died (12 on arrival and 8 during resuscitation) and two casualties were discharged at their parents demand shortly after admission without receiving adequate medical care. Fragmentation weapons (blast injuries) caused 216 (79.4 %) casualties, 54 (19.8 %) casualties experienced gunshot wounds and 2 (0.7 %) substantial burns. Injuries to the lower limbs and trunk were the most common injuries in this series accounting for 126 (46.3 %) of all injuries., Conclusion: There is a considerable risk not only for adolescents but even for children under conditions similar to those of civil war. However, the challenge is to provide an appropriate treatment in spite of the potential severity of injuries. This requires an adequate logistic management, surgical expertise as well as equipment and even the collaboration with surgical centres from supporting countries.

Small defects of extensor tendons can mostly be covered by local flaps. For larger defects the groin flaps, pedicled flaps from the forearm and free flaps are indicated. Between January 2001 and December 2005, we performed the following pedicled and free flaps to reconstruct the soft tissue defects of the hand or distal forearm: 23 pedicled flaps: 15 posterior interosseus artery or perforator flaps, 8 radial forearm flaps; 26 free flaps: 4 radial forearm flaps, 12 lateral upper arm flaps, 10 latissimus, serratus fascia or scapula flaps. With this study we want to illustrate the different procedures, compare their surgical techniques and outcomes and finally to rate the results. In the context of security, morbidity of the donor site and functional outcomes, our favourite flap is the lateral upper arm flap.

Gunshot wounds to the kidney occur with different regional incidence. They are commonly combined with thoracic and abdominal injuries. Gunshot wounds may be caused by low-velocity or high-velocity bullets. The latter are usually used with military weapons and cause a higher degree of tissue damage. The therapeutic management of renal gunshot wounds has changed in recent decades resulting in more organ-preserving strategies. An imperative indication for surgical exploration of the kidney is critical renal bleeding with symptoms of hypovolaemic shock. We report the case of a 23-year-old male admitted to the hospital with combined gunshot wounds from a small-bore weapon with damage of the liver, stomach and the left kidney. There were no signs of thoracic injuries. The patient underwent transabdominal exploration with treatment of the liver and stomach lesions, removal of the bullet and preservation of the left kidney. A percutaneous nephrostomy and drainage of the retroperitoneal region were inserted; antibiotic prophylaxis was given. A 4-week postoperative intravenous pyelogram showed complete integrity of the upper left tract and good renal function.

Background: Epidemiological analysis of injury patterns and mechanisms help in identifying the expertise that military surgeons need in a combat setting and also in adjusting training requirements accordingly. This paper attempts to assess the surgical specialties and skills of particular importance in the management of casualties in crisis areas., Methods: MEDLINE (1949-2007) and Google search were used. Causes of death among casualties in Afghanistan and the Iraq war were analyzed., Results: The leading causes of injury were explosive devices, gunshot wounds, aircraft crashes, and terrorist attacks. Of the casualties, 55% died in hostile action and 45% in nonhostile incidents. Chest or abdominal injuries (40%) and brain injuries (35%) were the main causes of death for soldiers killed in action. The case fatality rate in Iraq was approximately half as high as in the Vietnam War. In contrast, the amputation rate was twice as high. Approximately 8-15% of the deaths appeared to be preventable., Conclusions: Military surgeons must have excellent skills in the fields of thoracic, visceral, and vascular surgery as well as practical skills in neurosurgery and oral and maxillofacial surgery. It also is of vital importance to ensure the availability of sufficient medical evacuation capabilities. Furthermore, there is a need for a standardized registration system for all injuries similar to the German Trauma Registry.

Background: Gunshot injuries are very rare in the European Union. To show the requirements for the trauma surgeon to deal with gunshot injuries this analysis was performed., Methods: Gunshot injuries seen at Lorenz Boehler Trauma Center from 1997 to 2004 were reviewed. The case histories of 67 patients were analysed for the cause of the gunshot injury, type of weapon, surgical intervention, days of treatment and outcome., Results: The most commonly cause of gunshot injuries were criminal offenses (n = 35). Handguns were used most often (n = 32). The locations of injuries were evenly distributed over head (n = 18 ), trunk (n = 16), upper (n = 15) and lower limb (n = 18). Surgical treatment was performed in 57 patients. The median stay on ICU was 10 days. 6 patients died., Conclusion: Gunshot injuries are frequently not confined to the extremities. The challenge for the trauma surgeon is to deal with injuries of the head, chest and abdomen.

An improvement of prognosis after tumour therapy as well as a rather high number of multiple traumas in the craniofacial area imply a high treatment need for craniofacial tissue defects. For a successful rehabilitation of these individuals, reconstructive oral and maxillofacial surgery and prosthodontics must collaborate closely and synergistically. Besides medical and psychological findings, functional and esthetical aspects need to be taken into account. In this case report the prosthetic reconstruction of a patient with a tooth-supported telescopic defect prosthesis in the maxilla and with a multiple-unit implant-supported fixed prosthesis plus two full ceramic crowns in the mandible is shown. The prosthetic solution was indicated after maxillofacial reconstruction due to the consequence of a suicide attempt.

Background: Nontherapeutic laparotomy and thoracotomy rates in penetrating torso trauma remain high. The aim of this study was to define the value of helical computed tomography (CT) in this emergency situation., Material and Methods: Retrospectively, we studied 11 hemodynamically stable patients with penetrating injury to the torso admitted to our trauma center over a 3-year period who underwent intravenous contrasted helical CT immediately after admission. A positive CT scan was defined as showing any evidence of intrathoracal or intra-abdominal injury necessitating immediate operation. Patients with positive CT underwent laparotomy and/or thoracotomy. Patients with negative CT were observed., Results: Eleven consecutive patients were studied: nine male, two female; mean age 39 years (range 19-62). Nine stab wounds and two shotgun wounds were seen. Seven patients had positive helical CT findings, and four patients were negative. All patients with positive CT findings were operated on; those with negative scans recovered uneventfully. This imaging method accurately predicted whether thoracotomy or laparotomy was needed in 10/11 cases., Conclusion: In penetrating torso trauma, helical CT can clarify the need for thoracotomy or laparotomy vs nonoperative treatment.

Perianal impalement injuries with or without involvement of the anorectum are rare. Apart from a high variety of injury patterns, there is a multiplicity of diagnostic and therapeutic options. Causes of perianal impalement injury are gunshot, accidents, and medical treatment. The diagnostic work-up includes digital rectal examination followed by rectoscopy and flexible endoscopy under anaesthesia. We propose a new classification for primary extraperitoneal perianal impalement injuries in four stages in which the extension of sphincter and/or rectum injury is of crucial importance. Therapeutic aspects such as wound treatment, enterostomy, drains, and antibiotic treatment are discussed. The proposed classification encompasses recommendations for stage-adapted management and prognosis of these rare injuries.

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

Purpose: Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury., Methods: Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine., Results: Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this., Discussion: Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

Penetrating injuries such as gunshot wounds have traditionally been rare in Europe, with the result that European surgeons have only limited experience in their management. Socio-economic changes in the last decade have led to an increase in the frequency of injuries of this type, partly due to the expansion of organized crime and partly because of involvement of the European military in peace-keeping missions in Europe and elsewhere in the world. The purpose of this article is to offer some guidelines in the management of extremely serious or rarely encountered injuries to the neck, chest and peripheral arteries and discuss controversies and possible future changes in their management as a result of the extensive experience of treating penetrating trauma in our hospital.

On military missions abroad, surgical care for penetrating abdominal injuries differentiates from that given at home. The different conditions in the field usually include a single general surgeon with no further specialists or hospitals to rely upon. Thus a mismatch between treatment capacity and needs can be experienced in mass casualty situations. Therefore the focus is on damage control surgery, getting patients fit for evacuation, and transport home under intensive care if needed. Knowledge of ballistics and explosive devices are adjunct fields of interest, as they improve the understanding and treatment of military injuries. Although these aspects add up to additional training requirements to be met by our surgeons, we are convinced that the new German education standards will allow successful training of future military surgeons.

Gunshot injuries to the testicles are rare and usually result in testicular atrophy. In the case of severe bilateral testicular injuries, this could cause not only infertility but also the need for lifetime testosterone-substitution. We report an 18-year-old patient with bilateral testicular gunshot injury. During the surgical exploration an orchiectomy of the complete ruptured left testicle was necessary. Debridement of the damaged tissue and a partial orchiectomy was performed on the right side. After the operation, the patient developed an incretory hypogonadism and oligozoospermia. During follow-up, an improvement in the sperm count and of the hormonal status occurred. These finally reached normal levels. After genital traumata, immediate surgical exploration should be performed. Based on the above results, the patient benefits from conservative debridement and primary repair of the injured testicle, if possible. An improvement in hormonal status and sperm parameters after testicular injury and consecutive testicular malfunction can occur. Regeneration of the testicular tissue seems possible.

Background: Injuries of the head and neck with suicidal intention might create serious situations that require rapid and interdisciplinary treatment., Methods and Patients: Twenty-seven patients with suicidal head and neck injuries were treated at the Department of oto-rhino-laryngology, head and neck surgery, University of Wurzburg/Germany, between 1991 and 2002. The medical histories were analyzed retrospectively., Results: Twenty-three of them were male, 4 female. Mean age at time of attempted suicidal was 48 years (18 - 90). One patient was already treated for a psychiatric disorder. None of the patients had a suicidal attempt in the history. Nine patients suffered from a pharynx or larynx trauma after strangulation. Four out of seven patients with cutting or stabbing injuries showed a perforation of the upper airways. Nine patients had gunshot traumas, one of them with perforation of the pharynx. Thirteen patients underwent immediate endoscopy under general anaesthesia followed by a neck exploration in 3 patients. Six patients received a temporary tracheotomy. All patients were considered suicidal for the duration of stay in the ENT-department resulting in a permanent supervision. All patients were transferred to a psychiatric unit as soon as possible for further treatment. A statistically significant accumulation was observed during the last third of a year. Over the period of 11 years, suicidal injuries of the head and neck tend to occur more frequently., Conclusions: The presented study emphasizes the need of immediate surgical and intensive care treatment of patients with head and neck injuries due to suicide attempts as well as an adequate psychiatric supervision during as well as after the surgical treatment.

Since its introduction by Taylor in 1975, microvascular free fibula transfer has become the gold standard in osseous reconstructions requiring vascularized bone transfer. Various modifications of the free fibula have been described in the literature. We reviewed a series of 76 free vascularized fibula transfers during a 7-year period. Data was retrospectively analyzed with respect to type of procedure and outcome, general surgical complications, and flap-related (specific) complications. Of all 76 free fibula flaps, 47 cases healed uneventfully (62%). Interestingly, 53% of all extremity reconstruction cases had at least one of the above complications, whereas in maxillofacial cases the complication rate was only 25%. Complete osseous consolidation at the time of evaluation was confirmed in 58 patients (76%). Complete flap failure occurred in four patients (5%). The complication rates reflect the complexity of the procedures and appear strongly related to the underlying disease and predisposing medical risk factors. Time will tell if advances, e.g., in the field of tissue engineering, will eventually replace autologous vascularized bone transfer.

Background: It is difficult to verify the treatment of stab and gunshot wounds with prospective randomized studies. That is why the results of observational studies are so important., Material: From 1 January 1989 to 31 December 1998, we saw 74 patients because of stab (64) and gunshot (ten) wounds., Results: Most of the patients, whose injuries were caused mainly for criminal reasons (criminal 54, autoaggressive 14, accidental 4, unknown 2), came to hospital on weekends. We saw 38 abdominal, 23 thoracic, and 13 mixed injuries. On average, 3.8 h passed between the time of injury and getting first aid. Concerning abdominal injuries, we counted 21 negative intraoperative results. Two of 12 thoracic injuries showed no further damage. The patients stayed in hospital for 13.1 days on average. The morbidity was 28.38%, and mortality was 5.41%., Conclusions: Abdominal gunshot wounds need immediate surgical treatment. Concerning stab wounds, obligatory as well as selective surgical methods are both acceptable. Because of valid diagnostic options, thoracic stab wounds allow several ways of treatment.

Slaughterer's guns ("humane killers") are powder-activated cattle skull impacting tools. Today mechanical stunning is typical for country like regions, because in the municipal slaughter-houses electrical stunning of pigs and ruminants is preferred. In rare cases these weapons are used for suicide. They then cause penetrating brain lesions and if the victim survives the brain-damage, an encephalitis caused by the impacted material results. The neurosurgical treatment is to revise the gunshot canal and to remove impacted fragments of bone and contaminated skin (imprimat) under antibiotic cover. A psychiatric treatment of the mostly underlying depression and a rehabilitative treatment should complete therapy. So treatment of slaughterer's gun injury should have a multidisciplinary approach.

Traumatic injuries are common in horses and may be caused by self-infliction, accident or in an increasing number by an act of violence. Over a four year period, 193 horses with injuries caused by self-infliction or accident were referred to the clinic. In addition, ten horses with injuries associated with an act of violence had to be treated. Those injuries were caused by gunshots, or were stab wounds caused by spear like instruments or knives. Furthermore, cases of zoophilism and zoosadism were observed. Penetrating injuries were potentially life-threatening and in particular injuries with soft tissue damage extending over the limits of visible injury required a special approach. Of the ten horses, seven survived by surgical or medical treatment. Beside of medical aspects, forensic aspects should be considered in such cases.

In the view of efficiency and cost effectiveness the increasing incidence of gunshot wounds in Europe demands a modification of treatment protocols. The general basis are debridement of soft tissue injuries, antibiotics and fracture stabilization. The pathology of gunshot wounds and established treatment algorhithms, however have to be adjusted to the ongoing development of gun technology and the thereby caused specific lesions. The treatment of injuries caused by high velocity projectiles necessitates a proactive surgical strategy. Small caliber gunshot wounds can be treated more conservatively. The following review presents an overview on the ballistic and surgical basis for the treatment of gunshot wounds of the musculoskeletal system.

Bony injuries caused by starter's pistols were repeatedly observed in the form of fractures of the temporal squama and other thin osseous lamellae; in experiments rib fractures could also be produced. In the presented case a contact shot from a blank cartridge pistol caused a fracture of the lower jaw (transverse fracture with a bone fragment split off in reg. 46). The friend of the 17-year-old victim had fired a shot to the right mandibular region during an argument. In the depth of the gunshot entrance wound, which communicated with the oral cavity, intense soot deposits were found as signs of the contact shot.