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Reconstructive surgery of detached extremities, especially fingers, has a long historical tradition. The first clinically correctly documented cases go back to the 19th century. During the first and second world wars numerous reports appeared about the surgical care of war victims. Pioneering innovative surgical methods were developed by especially motivated surgeons for the reconstruction of these disfiguring war injuries in Europe. Because of these particular circumstances and the prevailing revolutionary spirit, many innovations in surgery were developed. The report of Otto Hilgenfeldt (1950) described his unusual approach in reconstructing a finger by using the great toe.

Purpose To document the types and causes of ocular and ocular adnexal injuries treated by United States Army ophthalmologists serving in Iraq during the Iraqi Insurgency. Design Prospective hospital-based observational analysis of injuries. Participants All coalition troops, enemy prisoners of war, and civilians with severe ocular and ocular adnexal injuries. Methods We prospectively examined severe ocular and ocular adnexal injuries that were treated at the 31st Combat Support Hospital during the portion of the Iraqi Insurgency that took place from January 20 through September 12, 2004. Main Outcome Measures Incidences and characteristics of ocular and ocular adnexal injuries. Results During the time observed, 207 patients suffered severe ocular or ocular adnexal injuries, including 132 open globes. Blast fragmentation from munitions caused 82% of all injuries. The most common single cause of injury was the improvised explosive device (IED), which caused 51% of all injuries. Of 41 eye excisions, 24 were caused by IEDs. Conclusions During the portion of the Iraqi Insurgency covered in our report, munitions fragments were the most common cause of ocular and ocular adnexal injuries. The single most common cause of injury was the IED, which produced devastating ocular and ocular adnexal injuries. The authors' findings indicate that polycarbonate ballistic eyewear could have prevented many, but not all, of the ocular injuries we report.

Summary: Some volunteer surgeons may be interested in providing care for civilian victims of war in developing countries. More commonly, volunteers will be increasingly confronted with nonintentional acute and chronic trauma cases, mostly from road traffic accidents. On rare occasions, they might even participate in the relief and reconstruction efforts after natural disasters. There are significant differences between the type and management of cases seen overseas versus those seen at home. Key Words: Injuries—Trauma—War—Volunteer.

Background. Vascularized osteoseptocutaneous radial flap is commonly used in the reconstruction of composite bony and soft tissue defects of the lower third of the face due to the outstanding quality of its cutaneous component. The aim was to evaluate the primary and overall success in the reconstruction of mandibular defects, following war injuries, with vascularized osteoseptocutaneous radial flap. Methods. At the Department of Maxillofacial Surgery of the Military Medical Academy Belgrade, there were eight patients with this kind of defect following war injury, and the mandible was reconstructed with a vascularized osteoseptocutaneous radial flap. Bony compartment of the graft was harvested as up to 11 cm long segment of radial circumference. Results. The localization and structure of the defect, features of a harvested compound graft, the procedure of the reestablishment of the mandibular continuity was presented as well as immediate and late complications during the consolidation period, and the primary successful reconstruction in 87.5% of the patients. Conclusion. The primary and overall success in the mandibular defects reconstruction with a vascularized osteoseptocutaneous radial flap was equal or even better than those presented in the literature on the reconstruction of the similar defects after tumor resections.

As of November 9, 2004, a total of 10,153 service members had suffered war injuries. Dr. Atul Gawande writes about a military medical system that has made fundamental and effective changes in the strategies and systems of battle care.

Vascular Surgery began in the period between the first and second world wars, as the need to treat arterial war injuries arose. Vascular operations were performed by general surgeons and often ended in major amputations. Between the second world war and the Vietnam war, Norman Rich published his volume entitled “Vascular Trauma” and Drs. DeBakey and Simeone defined guidelines in vascular surgery. A new vision of this specialty commenced, but it was always considered as a branch of general surgery and was performed by surgeons with varying backgrounds. Few vascular operations were performed by surgeons who restricted their practice exclusively to the vascular field. The necessity of certification came with the modern concept of vascular surgery in Europe in the 1960s, with a new specialist in surgery with vascular competence. The Board of Vascular Surgery came into existence, recognizing the independent figure of the vascular surgeon.

Injuries cause about 10% of all deaths worldwide, with road traffic accidents, self-inflicted injuries, violence and war injuries being the most common causes of traumatic deaths. There is an anticipated increase in all of these categories by the year 2020. In addition to the increasing global incidence of trauma, other major trends in trauma and its management identified in this review include the growing emphasis on prevention and public health aspects of trauma, the globalization of trauma practices due to the rapid access to new information, a critical emphasis on organizational aspects of trauma care and education, the prominent role of efficacious and cost effective management practises, a shift to gentler treatment methods with less interference in the physiological recovery mechanisms, and at the same time, extreme care and the management of its consequences. In order to fight the global epidemic of trauma, it is the duty and the privilege of health care professionals to take the leadership in this task by ‘thinking globally and acting locally’ but most importantly by working together and sharing their expe riences (the successes and the failures) and by knowing that they can make a difference.

The use of fasciocutaneous flaps for the reconstruction of lower leg soft-tissue defects inflicted during the bombing of our country is presented in this case report. The experience with 9 patients with soft-tissue defects of the lower leg is presented with the aim of examining the possibilities of war-wound reconstruction. The results of the earlier use of fasciocutaneous flaps in the lower leg reconstruction as well as the those obtained during the reconstruction of the lower leg soft-tissue defects in war wounds was proven to be safe and reliable method of the reconstructions of severe lower leg injuries, particularly of its distal segment and the malleolus region.

Polytrauma with significant lesion of peripheral nerves is a specific war injury. It is also one of the most delicate problems in rehabilitation treatment because it requires a close cooperation with surgeon and timely surgical interventions. Based on our experience, the best results in the treatment of injured persons with lesion of peripheralnerves have been accomplished after the surgical treatment. Results in the neurolysis were better than those accomplished in neurorrhaphy. Total of 436 patients with lesion of peripheral nerves were recorded and 56 patients with plexus lesion. Out of this number, 78 patients (about 15%) had surgical treatment (41 neurorrhaphy and 37 neurolysis). Due to lack of adequate ENMG diagnostics, the objective valorisation of treatment outcome was not possible.

The following study focuses on three hundred maxillofacial war casualties that were admitted to the Basra Republic Hospital during the Iraq-Iran War. These three hundred cases were chosen on the basis of them being only oral and maxillofacial injuries. Of these cases, there was no mortality recorded. This was in part due to the rapid evacuation, immediate resuscitation and proper management of the casualties. An appropriately staffed hospital, efficient surgical techniques and the presence of highly skilled specialists working as a team also made this result possible. This analysis categorizes, evaluates and discusses the treatment of the casualties based on the severity of the injury and outlines several techniques used to treat such patients.

During the general reaction to trauma, acute phase proteins are synthesized. The aim of the prospective study was to determine CRP concentrations in sera of war casualties during the first 14 posttraumatic days, and to establish the correlation between these changes and severity of trauma. Subjects were 79 war casualties. Controls: 33 blood donors. Methods: Injury severity was determined according to ISS and CRP concentrations with immunonephelometric analysis. Blood samples were collected 12 hours after trauma, then on the 1st, 2nd, 5th and 14th posttraumatic day. In war casualties CRP values were significantly increased (56.257.53 mg/dl after 12 hrs, 107.0976.08 on 1st, 144.3570.23 on 2nd, 71.42558.66 on 5th and 37.656.14 on 14th posttraumatic day; p). Significant differences were observed between groups with TSS and ISS 12 (p) in first two days and later between group with ISS24 (144.1766.94 mg/dl on 5th and 111.588.5 on 14th posttraumatic day) and others (p). Conclusions: During the acute-phase response to trauma, significant changes in concentration of CRP occur in sera of war casualties. These changes are the most promrninent during the first 48 hours, with tendency for normalization after the 5th day. Intensity of these changes depend of the severity of trauma. CRP is valid marker of war wound severity.

Spinal cord injury is a common neurological problem secondary to car accidents, war injuries and other causes, it may lead to varying degrees of neurological disablement, and apart from physiotherapy there is no available treatment to regain neurological function loss. Our aim is to find a new method using autologous hematopoietic stem cells to gain some of the neurologic functions lost after spinal cord injury.277 patients suffering from spinal cord injury were submitted to an intrathecally treatment with peripheral stem cells. The cells were harvested from the peripheral blood after a treatment with G-CSF and then concentrated to 4∼ 6 ml. 43% of the patients improved; ASIA score shifted from A to B in 88 and from A to C in 32. The best results were achieved in patients treated within one year from the injury.Since mesenchymal cells increase in the peripheral blood after G-CSF stimulation, a peripheral blood harvest seems easier and cheaper than mesenchymal cell cultivation prior to injection. It seems reasonable treatment for spinal cord injury.

Intra- orbital foreign bodies are more commonly seen in war injuries. Here the foreign body is normally a metallic object but when such injury occurs due to road traffic accident, the foreign body is usually organic in nature like wood. Much damage occurs to the soft tissue of the eye including globe and optic nerve but foreign body does not usually causes damage to the hard structure of eye. Here we are presenting a case in which a patient of road traffic accident was admitted with intra orbital foreign body of organic nature. The foreign body had not caused damage to the globe of the eye, which is more common, but has fractured the supra orbital rim of the orbit.

Gustatory sweating results from a disruption of the auriculotemporal nerve pathways. Damage to the nerve may cause a misdirected re-growth that results in parasympathetic innervation of sympathetic receptors and, therefore, facial sweating and flushing with gustatory stimulation. Over the past 300 years, the history of gustatory sweating has included observations of typhus-induced parotiditis, war injuries, and occupational accidents. Despite religious and personal persecution, Lucja Frey (1889–1943) systematically investigated gustatory sweating. Following the discovery of a German World War II document regarding Lucja Frey, an international committee was organized to research the history of gustatory sweating and of Dr. Frey's contributions to the understanding of the syndrome. Twenty original scientific publications from 1700 to 1950 on gustatory sweating were reviewed. Frey was the first to describe gustatory sweating as a disorder of both sympathetic and parasympathetic innervation. She proposed novel pathologic and pharmacologic mechanisms to explain the syndrome. Subsequent discoveries, including the work of Andre-Thomas in 1927, have provided a more complete understanding of gustatory sweating and the pathologic mechanism of aberrant neuronal regeneration.

Distraction osteogenesis was originally described in the early 1900s and was clinically applied and advanced in the 1950s by Ilizarov and Ledyaev and their colleagues in Siberia [1,2]. They applied the principle of osteotomies and gradual long-bone distraction for patients with leg-length discrepancies secondary to war injuries. Since their landmark report, many investigators have described use of this technique for lengthening lower and upper legs, arms, fingers, and, recently, the craniofacial skeleton. The first report of clinical distraction of the human mandible was in 1992 by McCarthy, Schreiber, Karp, et al [3]. Today, distraction osteogenesis is a well-accepted technique for reconstruction of the deficient mandible, midface, orbits, and cranium. There are several studies on distraction in the recent literature, but the bulk of them lack objective, long-term data. Most centers have their own protocols based on clinical experience. As distraction osteogenesis is increasingly used in all age groups, the long-term data should be forthcoming.

Approximately 10% of war injuries with major trauma have eye injuries. Primary ocular blast injuries are from the transfer of kinetic energy from the explosive blast wave alone. Secondary ocular blast injuries are the most common type of blast injury (42%) from the impact of shrapnel from the explosive device itself or from exogenous debris propelled by the explosion. Tertiary ocular blast injuries (1%) are caused by indirect damage to the eye when an individual is thrown by the blast wind. Quaternary blast injures (3%) are from any other mechanism related to the blast, usually thermal burns. Quinary blast injuries are a new entity that describes a hyperinflammatory state occurring after an explosion that is thought to cause retinal vascular occlusion. IOFB injuries are given prophylactic systemic antibiotics to protect against endophthalmitis, before surgical removal. Combat eye protection (CEP) significantly reduces secondary and tertiary blast injuries, but increased the proportion with commotio retinae. We rehabilitate blind patients with the BrainPort (Wicab, USA) vision device that substitutes the sense of sight with electrotactile stimulation of the tongue and improves navigation and object recognition

Tetanus occurs in all ages, it can be associated with puncture wounds, war injuries, burns, ear infections, umbilical stump and post partum infections, and heroin abuse.5 Recently, we treated a patient who developed tetanus following frostbite of both feet. The patient had been previously immunized against tetanus, and was receiving antibiotics when the disease became manifest.

Immobilization with external fixation bridging the knee joint in extension is frequently used after sustaining a war injury to the region of the knee joint with femoral and tibial bone fractures. Immobilization of the knee with plaster splints is performed in the same position. This usually prolonged treatment results in extension contractures of the knee joint. From June 1991 until March 1994, 54 patients with extension contractures of the knee caused by war wounds were treated at the Department of Orthopedics, Zagreb University Hospital Center, in Zagreb, Croatia. Results of surgical treatment of 44 patients are presented. The operative procedure consisted of extensive intra- and extra-articular adhesiolysis of the knee. The control group included 30 patients with knee contractures caused by injuries sustained in car crashes or secondary to previous operative procedures. The mean duration of immobilization was 5 months and 6 days. The mean preoperative knee motion amplitude ranged from 5 degrees in extension to 38 degrees in flexion. The mean postoperative knee motion was 98 degrees (range, 2 to 110 degrees). Treatment results did not depend on either duration of preoperative immobilization of the knee or previous infection in the region of injury. Previous knee joint bridging with an external fixator had no impact on the results of extension contracture treatment. Adequate intra- and extra-articular adhesiolysis with appropriate long-term postoperative rehabilitation is essential for the success of the operative treatment for knee joint contracture.

Presented are the results of primary surgical treatment of war injuries of the foot in 250 patients wounded in the territory of former Yugoslavia in the period June 1991-October 1995. Total number of feet treated was 275. Aetiologically, the most frequent injuries were those inflicted by the effect of mine blasts (65.2%) and by bullets from firearms (30.8%). Injuries to a single foot were present in 140 (56.0%), combined injuries in 107 (42.8%) and associated with burn injuries in three (1.2%) patients. Soft tissue injuries were present in 25 (9.1%) and injuries to bone structures and joints in 250 (90.9%) feet. Injuries resulting from solid blasts were found in nine (3.2%) feet. Postoperative bone fragment stabilization was required in 115 (41.8%) feet. Stabilization was by plaster of Paris in 87 (75.6%) and by external fixation in 23 (20. 0%) feet. Amputations were performed in 73 (26.5%) feet. Covering of soft tissue and bone defects was required in 84 (33.6%) patients.

One hundred years ago, apart from the treatment of war injuries, the prevention and treatment of diarrhoea was the dominant preoccupation of the deployed military doctor. Since, then our understanding of the pathogenesis and pathophysiology of enteric disease has developed exponentially and our armamentarium for the treatment of enteric diseases has expanded considerably. However, diarrhoea continues to be the dominant military medical concern in deployed units. Here, we examine the evidence for this, discuss the reasons why and critically evaluate current modes of prevention and treatment that are now available to the military medical officer.

From 1992 to 1995, replacement of the joint with an endoprosthesis after serious wounding and major destruction of joint elements was performed in 10 soldiers. Arthroplasty was performed on five knees, three hips, and two shoulders. The age range of the wounded soldiers was 22 to 55 years (mean, 37.7 years). Six soldiers suffered explosive injuries, and 4 were injured by gunfire. Time elapsed from the moment of wounding to the time of total joint replacement was 9 to 42 months. We decided on arthroplasty as the preferred treatment because of the presence of strong contractures and very painful movement. In 8 patients, the results of the treatment, based on a follow-up time of 36 to 48 months, were good. In 2 patients, early septic arthritis developed after arthroplasty of the knee with concomitant loosening of the endoprosthesis. Staphylococcus aureus was detected in both patients. In those 2 patients, therefore, arthrodesis of the knee with external fixation was performed.

The management of 131 civilians with war injuries, treated at the Department of Surgery, Pozega County Hospital, during the 1991-1995 period is presented. The majority of 55 (42%) of patients were injured at the front line. There were 75 (57.3%) of patients with explosive injuries 67 (51.2%) involved the extremities, while 29 (22.1%) involved the head. Seven (5.3%) patients died. Amputation of part of an extremity was required in five (3.8%) patients. Language: en

War injuries can range from the most minor to the devastating and life-threatening. Multidisciplinary care is required for successful management of survivors. In the acute phase, care may involve emergency surgeons, anaesthetists, neurosurgeons, ophthalmic surgeons, vascular surgeons and ENT specialists in addition to the oral and maxillofacial surgeon. Afterwards, definitive treatment of facial hard and soft tissue gunshot injuries depends ultimately on the abilities and skills of the oral and maxillofacial surgeon and his appreciation of such injuries. The timing and sequence of the surgical procedures used for reconstruction and rehabilitation of maxillofacial gunshot injuries are crucial to a successful outcome and aesthetic result. If incorrect, they may lead indefinitely to infection, graft rejection, wound dehiscence with consequent multiple revisional operations and complications which will prolong hospital stay, and increase treatment costs and morbidity in these patients. In this article, we describe the treatment protocol for reconstruction and rehabilitation of a typical case of devastating gunshot injury to the lower face and propose a staged sequence of surgical treatment based on an 8-year experience gained in treating war casualties during the Iraq-Iran war (1980-1988).

Dr. Cyril Kaplan died July 11, 2012 at the age 95 from pneumonia. Born in Durban, South Africa in 1917, while a medical student at the University of Cape Town, Cyril Kaplan joined the Cape Garrison Artillery as a volunteer gunner on the outbreak of World War II in 1939. Following graduation, he enlisted in the South African Medical Corps in 1942, where he was exposed to war injuries and became interested in orthopaedics (Fig. 1). Fig. 1 In 1942, Dr. Kaplan enlisted in the South African Medical Corps, where he was exposed to war injuries and became interested in orthopaedics. Following his discharge from the Army in 1946, Dr. Kaplan worked in Liverpool and Guy’s Hospital in London. With the newly proclaimed State of Israel at war in 1948, Dr. Kaplan joined the military in Israel, leading an orthopaedic department in Haifa. There, he met Sylvia, his future wife. He returned to Durban, South Africa following 14 months of service. In Durban, Dr. Kaplan started an orthopaedic practice and worked in leprosy and tuberculosis hospitals. In 1976, Dr. Kaplan (Fig. 2) accepted an invitation to work in the department of orthopaedic surgery at Montefiore Medical Center, a teaching hospital affiliated with Albert Einstein College of Medicine in the Bronx, New York. One of his close colleagues at Montefiore Medical Center was Dr. Edward T. Habermann, an Association of Bone and Joint Surgeons member, who died in 2009. Kaplan previously worked with Dr. Haberman at the Hadassah Medical Center in Jerusalem during the Yom Kippur War in 1973. Fig. 2 Colleagues often consulted with Dr. Kaplan on bone tuberculosis management, a significant pathology among the immigrant population in the Bronx. Dr. Kaplan’s interests included hip and extremity surgery, and colleagues would often consult with him regarding bone tuberculosis management, a significant pathology among the immigrant population in the Bronx. Kaplan remained in New York until 1980, when he returned to South Africa. He practiced there until 1989, then moved back to New York to work at Montefiore Medical Center once again before retiring in 2002. In 2008, Dr. Kaplan published his memoir, In Three Wars: a Personal and Orthopaedic Prospective [1] at the age of 91. His nonmedical interests included European and African history. Dr. Kaplan also collected old maps and Persian miniature paintings, and after retirement, sculpted in bronze. Cyril Kaplan is survived by his wife, three sons, a daughter, and two grandchildren.

Genitourinary injuries as a result of current warfare may be severe and result in significant long term morbidity. There is no high quality evidence to guide management and the logistics involved require the development of bespoke management strategies. The multidisciplinary Genitourinary Working Group (Trauma) has the remit of leading this service, primarily addressing the management of casualties in the medical evacuation chain of the Defence Medical Services of the UK. The recommendations made are based mainly upon expert opinion and are intended to provide guidance to the deploying surgeon and the teams that manage these casualties thereafter.

This study was undertaken to document whether a basic set of a new unilateral external fixation device could provide sufficient stability in complex musculoskeletal injuries involving upper and lower extremities and in patients with unstable pelvic ring disruptions. The initial clinical evaluation was performed in Sweden (stage 1) followed by field evaluation at the Swedish Field Hospital during the Mogadishu conflict in Somalia (stage 2). In stage 1, there were 90 patients with 116 acute limb injuries and six patients with an unstable pelvic ring disruption. Ninety limb injuries and all six pelvic fractures were primarily stabilized by the external fixation device. The other 26 fractures were managed at the index operation with intramedullary nailing, open reduction, and internal fixation or cast immobilization. Twelve patients had a local pedicle or free vascularized flap for soft tissue coverage. One multiply injured with an open Gustilo IIIB tibial shaft fracture had an early amputation. The basic set provided adequate stabilization for soft tissue recovery in 89 limb injuries (89 of 90), thereby providing optimal conditions for continued management to skeletal consolidation in 88 patients. Hemodynamic stabilization was achieved in all six patients with unstable pelvic fractures. In stage 2, there were 63 patients with war injuries and 33 patients injured in traffic accidents. All were managed under field conditions. The basic set was sufficient for soft tissue recovery in all 96 cases. It is concluded that the rigidity of this device is adequate for stabilization of severe musculoskeletal injuries requiring major surgical procedures. In addition, the simplicity of this device, which allows for only a limited number of possible configurations makes it suitable for inexperienced surgeons working under war or mass-casualty conditions to manage these complex musculoskeletal injuries.

In this study the authors present the results of 44 patients with 49 interfascicular nerve grafting procedures necessitated by gunshot wounds. The aim was to establish the effectiveness of microsurgical interfascicular nerve grafting for war injuries. The 49 interfascicular nerve grafting procedures were performed between July 1991 and January 1993. All but one were performed within 6 months of injury. Nerve recovery was assessed independently by a neurologist. The M/S scale was used for median, ulnar and radial nerves, and the grading scale recommended by Millesi was used for the sciatic, tibial and peroneal nerves. Follow-up was for between 2.5 and 3.5 years. Patients scoring at least M3/S3+, or Grade 2 on the Millesi scale, were considered to have useful functional recovery which occurred in high median (0 out of 1), low median (4 out of 9), high ulnar (0 out of 2), low ulnar (5 out of 11), high radial (4 out of 6), low radial (2 out of 2), sciatic (5 out of 9), peroneal (4 out of 7), and tibial (2 out of 2). The extent of recovery correlated inversely with the patient’s age and the length of the graft, but was independent of the time between injury and surgery and of presumed projectile energy. Our results suggest that microsurgical interfascicular nerve grafting is of value in the management of wartime nerve injuries.

The results of retrospective analysis in the treatment of 189 wounded with colorectal lesions treated at the Military Medical Academy from July 1991 to December 1993 were presented. Primary surgical management was performed in 33 (17.5%) wounded. The others were transported into this hospital for further treatment after primary surgical management in war hospitals in the combat zone. Colorectal lesions (46.0%) were primarily inflicted by bullets of various calibers and high kinetic energy. The time interval between wounding and surgery was less than 6 hours for 39.6% of the wounded, whereas 80.1% were operated on within 12 hours. Multiple or combined colonic and rectal injuries were found in 91.5% of the wounded. Different surgical procedures were performed in accordance with the surgical war doctrine. Postoperative complications (colorectal cause) were found in 40 (21.2%) wounded. Reoperation was performed in 35 (18.5%) wounded. Total mortality rate was 10.1% (19 wounded).

WAR INJURIES The historical incidence of combat urologic injuries is 0.5 to 8.0%. Current conflicts in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) have resulted in greater than 50,000 American trauma casualties with over 16,000 trauma admission entries in the Joint Theater Trauma Registry (JTTR). In the study by Serkin et al, 819 patients (5%) had one or more genitourinary (GU) injuries for a total of 887 GU injuries in OIF/OEF from October 2001 to January 2008. Lower urinary tract (bladder and urethra) trauma accounts for approximately 30% of these GU injuries. It is crucial that these injuries are promptly recognized and appropriately managed in theater.

Ocular injury from blast loading is associated with severe ocular morbidity and visual impairment [1]. Improvised explosive devices are a common cause of ocular injury and were responsible for 51% of ocular war injuries in a study by Mader et al [2].

Extremity War Injuries (EWI) with large open segmental and periarticular defects constitute a high volume and high morbidity challenge for the military trauma management system. Open segmental tibia and elbow fractures caused by Improvised Explosive Device (IED) wounds, are two examples of such injuries. Several problems occur when trying to repair such a wound. The large, gaping wounds make skin closure difficult. Infection is also a prevalent complication typically caused by debris contaminating the wound. Lastly, large amounts of damaged tissue including segmental bone defects make repair difficult.Copyright © 2012 by ASME

BACKGROUND: War injuries, especially blast injuries, have a high risk of infection. However, no animal models of infected war injuries have been built in large animals, which retards both the understanding and the treatment optimization of infected war injuries. METHODS: Soft tissue blast injuries were created by explosion of electric detonators in white domestic pigs. The ultra structure of the tissue around the wound was determined by transmission electron microscope. To develop infection of blast injury wounds, the pigs were housed in a standard animal house which was disinfected periodically, and the wounds were left untreated for 3 days. Wound specimens were collected daily to determine the bacterial load and bacterial components. To determine whether infection induces tissue necrosis in infected soft tissue blast injury wounds, uninfected blast injury wounds were created as controls of infected wounds by surgical debridement daily, and the wound area and wound depth of both wounds were measured. RESULTS: The wound area and the wound depth of the soft tissue blast injury created in this study fell in the range of human moderate soft tissue war injuries, and the ultra structure of the wounds was comparable with that of human blast injury wounds. The bacterial load of uninfected wounds was under 10 colony forming unit/g during the first 3 days of injury, while that of infected wounds was over 10 colony forming unit/g after 2 days of injury. The infected soft tissue blast injury wounds contained most of the bacteria frequently isolated in battlefield wounds. In addition, infection induced evident tissue necrosis in infected blast injury wounds. CONCLUSION: The infected soft tissue blast injury wounds mimic those in human, and they can be used to address key points of treatment optimization.

Purpose: To evaluate the technique of tissue traction for the management of severe facial injuries. Patients and Methods: Twenty patients, 15 adults and five children, with severe soft tissue facial disfigurement resulting from war injuries were treated by the tissue traction technique. Results: This procedure provides a cosmetically acceptable appearance when used as an immediate measure. A few complications were encountered in delayed case such as areas of skin breakdown and some stiffness. Conclusion: The described technique proved to have several advantages over other more commonly used methods for closure of large wounds.

A system of orderly triage of the injured in World War I and a protocol for early wound management of war injuries were introduced by Antoine De Page in 1914 at the beginning of World War I. The five steps of the De Page protocol (coined by the author as Ordre de Triage) were to be followed in detail by the French and Belgian armies. A younger Belgian colleague, Robert Danis, was recruited to aid in the management of the ambulance corps to transport the injured from dressing ("clearing") stations to centers of more advanced care, away from the Franco-Belgian front. Danis, also from Brussels, introduced the principles of osteosynthesis of bone a little over a decade later. De Page and Danis, both surgeons, tendered immense carry-forwards for future generations.

Trauma is a significant cause of mortality (10%) worldwide and is responsible for 15% of all disability-adjusted life years (DALYs) (Murray & Lopez, 1997). Seven of the top 30 contributors to the global burden of disease are due to injury, including motor vehicle accidents, falls, war injuries, self-inflicted injuries, violence, drowning and burns. All of these injuries are seen in the trauma setting and places trauma workers at risk of exposure to blood and other body fluids. The relevance of HIV and trauma is increasing as the global prevalence of HIV continues to rise. Sixty million have been infected with HIV since the beginning of the epidemic and 25 million have died of HIV-related causes (UNAIDS, 2009). Of those newly infected, 40% were young people the group most likely to be involved in trauma.

The wars in Iraq and Afghanistan have resulted in the most severe survivable war injuries ever seen in prolonged conflict. The Armed Forces Institute of Regenerative Medicine (AFIRM) was conceived as a way to deliver solutions to the existing gaps in military trauma care. The AFIRM is a collaborative effort between the Department of Defense, academia and private industry to accelerate the development of critically needed technology for the treatment of severely wounded warriors, and to restore to meaningful form and function those who have followed orders into harm’s way.

Traumatic brain injury (TBI) remains a major cause of death and disability worldwide, and missile-induced TBI remains the most deadly of all traumas since first reported and has always been associated with high mortality and morbidity. The prevalence of TBI secondary to gunshots is strikingly variable and reflects the global scenery of violence. Injuries from gunshot wounds (GSW) to the head place an extreme economic burden on the public while disabling the victims in the zenith of their life and imposing enormous medical, legal, and emotional costs. Since every gun/projectile combination is associated with a typical pattern of injury, war injuries differ significantly from others. We will focus here on predominantly penetrating civilian gunshot wounds with low muzzle velocity (

Soft-tissue coverage after war injuries poses a challenge because, unlike other conditions, often there is involvement of bones, nerves, and blood vessels combined with massive soft-tissue damage. Before deciding on a surgical procedure, a thorough evaluation of the injured area should be made. The main goal of limb reconstruction is to restore function. Limb trauma is often associated with other injuries, which can be life-threatening. Once the life-threatening conditions are solved, the work on the injured limb can begin. If prostheses are a reasonable solution for severe lower limb injuries, maximum efforts should be made for the upper limb where prostheses have less functional results. A good functional limb should have a strong skeleton, a good blood supply, and sensation in the areas that are prone to work injuries, such as the plantar and palmar areas. A good and sensate soft-tissue coverage may fulfil this need.

Objectives: The aim of this study was to analyze the epidemiology, treatment and incidence of complications among the patients with upper extremity war injury. Methods: In retrospective study, 123 patients with war injuries of the upper extremity have been analyzed. The results of treatment were assessed according to the rate of: complications, amputations, fracture healing and mortality. Results: Complications appeared in 17.9% of cases. Traumatic amputations were present in 19.4% of cases and in 2.4% of cases amputation was performed due to III C open fracture. Satisfactory bone healing was achieved in 49 of 55 patients available to follow up. Mortality rate was 2.4%. Conclusion: Self-inflicted injuries resulted in 41.6% amputation rate. High-energy war injuries of the upper extremity could be treated between 6 and 12 hours after injury without an increase in complication rate, compared to treatment up to 6 hours from injury. In selected cases primary reconstruction of war injury could be performed., {"references":["U.S. Department of Defense. Emergency war surgery – First U.S. revision of the emergency war surgery – NATO Handbook. U.S. Government Printing Office Washington, D.C., 1975.","Lerner A, Fodor L, Soudry M. Is Staged External Fixation a Valuable Strategy for War Injuries to the Limbs? Clin Orth 2006;448: 217-224.","Manojlovic RD, Vuckovic C, Tabakovic D, Nikola G, Bumbasirevic M. Free Fibula and Corticocancellous Bone grafting for Salvage of War-injured Forearm. J Orthop Trauma 2006;20: 495-498.","Aldea PA, Shaw WW. The evolution of the surgical management of severe lower extremity trauma. Clin Plast Surg 1986;13: 549–569.","Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A Profile of Combat Injury. J Trauma 2003;54: S13-S19.","Lovric Z, Wertheimer B, Candrlic K, et al. War injuries of major extremity vessels. J Trauma 1994;36: 248-251.","Covey DC. Blast and Fragment Injuries of the Musculoskeletal System. J Bone Joint Surg Am 2002;84-A(7): 1221-1234.","Jabaley ME, Peterson HD. Early Treatment of War Wounds of the Hand and Forearm in Vietnam. Ann Surg 1973; 167-173.","Bowyer GW. Management of small fragment wounds: experience from the Afgan border. J Trauma 1966;40: 170–172.","Granberry WM. Gunshot wounds of the hand. Hand 1973;5: 220-228.","Elton RC, Bouzard WC. Gunshot and fragment wounds of metacarpus. South Med J 1975;68: 833-843.","Swanson TV, Szabo RM, Anderson DD. Open hand fractures: Prognosis and classification. J Hand Surg 1991;16A: 101–107.","Hardin WD, O´Conell RC, Adinolti MF, Kerstain MD. Traumatic arterial injuries of the upper extremity: Determinants of disability. Am J Surg 1985;150: 266-270.","Gustilo RB, Merkow RL, Tempelman D. The management of open fractures. J Bone Joint Surg Am 1990;72A: 299-304.","Huljev D, Rašić Ž, Trajbar T, Košuta D, Nadinić V. External fixation in war trauma management of the extremities - experience from the war in Croatia. J Trauma 1994;37: 831-834.","Korzinek K. War injuries of the extremities. Unfallchirurg 1993;96: 242-247.","Duncan RW, Freeland AE, Jabaley ME, Meydrech EF. Open hand fractures: An analysis of the recovery of active motion and of complications. J Hand Surg 1993;18A: 387–394.","Omer GE Jr. Injuries of nerves to upper extremity. J Bone Joint Surg Am 1974;56A: 1615-1624.","Gonzalez MH, Hall M, Hall RF Jr. Low-velocity gunshot wounds of the proximal phalanx: treatment by early stable fixation. J Hand Surg Am 1998;23: 150-155.","Ordog GJ, Balasubramanium S, Wasserberger J, Kram H, Bishop M, Shoemaker W. Extremity gunshot wounds: Part I. Identification and treatment of patients at high risk of vascular injury. J Trauma 1994;36: 358-368.","Rautio J, Paavolainen P. Delayed treatment of complicated fractures in war wounded. Injury 1987;18: 238-240.","Tikka S, Bostman O, Marttinen E, Makitie I. A retrospective analysis of 36 civilian gunshot fractures. J Trauma 1996;40: S212-S216.","Coupland RM. Technical aspects of war wound excision. Br J Surg 1989;76: 663-7.","Covey DC, Lurate RB, Hatton CT. Field Hospital Treatment of Blast Wounds of the Muskuloskeletal System during the Yugoslav Civil War. J Orthop Trauma 2000;14(4): 278-286.","Luce EA, Griffen WO. Shotgun injuries of the upper extremity. J Trauma 1978;18: 487-492.","Pukljak D: External fixation-minimal osteosynthesis: indications, role and place in war surgery. J Trauma 1997;43: 275-282.","Davila S, Mikulić D, Davila NJ, Popović L, Zupančić B. Treatment of war injuries of the shoulder with external fixators. Mil Med 2005;170(5): 414-7.","Lerner A, Stahl S, Stein H. Hybrid External Fixation in High-Energy Elbow Fractures: A Modular System with A Promising Future. J Trauma 2000;49: 1017-1022.","Clouse WD. Rasmunssen TE, Peristein J, et al. Upper extremity vascular injury: a current in-theatre wartime report from Operation Iraqi Freedom. Ann Vasc Surg 2006;20(4): 429-34."]}

Esmarch was born on 9 January 1823 in northern Germany, into a family of physicians, judges and lawyers with a long academic tradition. His father was a highly respected surgeon, who encouraged his gifted son to follow in his footsteps. von Esmarch began his medical studies at the University of Kiel in 1843, to graduate only 3 years later from the University of Gottingen. His career advanced at a rapid pace and he received an appointment as professor and chairman of the department of surgery at the University of Kiel. In 1867 von Esmarch married, an aunt of Emperor Wilhelm II, who raised him to the rank of a peer in 1887 in recognition of his outstanding achievements in the field of medicine. von Esmarch founded the German Society of Surgeons and was named president in 1894. On 23 October 1908 he died from the effects of an influenza infection. In the early 19th century the focus of surgical interventions was primarily on the body surface and the extremities. From the beginning of his medical career von Esmarch showed a passionate interest in trauma care, placing the emphasis on reconstructive surgery instead of the conventional practice of limb amputation in battle victims. The political climate of the time favoured decisions made on the battlefield over diplomatic solutions and his work as a surgeon in the campaigns against Denmark, led by Bismarck in 1848 and 1864, provided him with ample experience in the treatment of war injuries. In contrast to the rapid progress in war technologies with all their horrible consequences, improvements in the military medical service sadly lagged behind and the soldiers received inadequate treatment under unacceptable conditions which had remained unchanged over the preceding centuries. Common consequences of surgical interventions were wound infections, frequently leading to the death of a patient due to massive septic shock. In the 1850s the causes of wound infections were still largely unknown by the practising physicians. von Esmarch’s observation that the cooling of wounds resulted in a reduction in local inflammation and pus-formation and thus to an improvement in the patient’s outcome led him to introduce cryotherapy into clinical practice. In 1862 he published his findings, introducing his new therapeutic

The use of splints and casts in the treatment of war injuries varied according to the particular echelon of command in which they were required. In general, emergency splinting was effected with the regulation army halfring splint. For transportation following primary surgery plaster was almost universally employed. Definitive splinting in the Zone of Communication was accomplished by use of the halfring splint or plaster, frequently by a combination of the two. Internal splinting was, for the most part, reserved for the Zone of the Interior. Two points deserve especial attention; the use of splints in the protection of extensive soft tissue injuries during transportation and the abuse of splints in the treatment of fractures of the hand.