Principles of war surgery

doi:10.1136/bmj.330.7506.1498

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Steve J Mannion, consultant orthopaedic surgeon and honorary lecturer,
Eddie Chaloner, consultant vascular surgeon

Leonard Cheshire Centre of Conflict Recovery, University College London, London.
University Hospital Lewisham, London

Introduction

Managing war injury is no longer the exclusive preserve of military surgeons. Increasing numbers of non-combatants are injured in modern conflicts, and peacetime surgical facilities and expertise may not be available. This article addresses the management of war wounds by non-specialist surgeons with limited resources and expertise. One of the hallmarks of war injury is the early lethality of wounds to the head, chest, and abdomen; therefore, limb injuries form a high proportion of the wounds that present at hospitals during conflicts.

Healing amputation stump

Wounding patterns

Gunshot wounds

The incidence of gunshot wounds in conflict depends on the type and intensity of the fighting. In full scale war the proportion of casualties injured by gunshot is generally less than in low intensity or asymmetric warfare.

Cavitation secondary to high energy transfer bullet wound

Bullets cause injury by:

Direct laceration of vital structures
Stretching of tissue (cavitation), causing fracturing of blood vessels and devitalisation of tissue
Secondary contamination.

The nature and extent of ballistic wounding is related to the energy transfer between bullet and tissue and the characteristics of the organs affected. Bullets cause injury by transferring their energy into the body tissues; the design of the bullet influences this process, with hollow nosed or dumdum bullets being designed to maximise energy transfer.

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Types of injury in modern warfare

A high velocity bullet from a military rifle has more energy, and therefore greater wounding potential, than a handgun round. However, if it passes cleanly through a limb without striking bone, it may impart little of its energy to the victim and therefore cause a relatively minor wound.

Lower limb disruption due to blast injury

Blast injury

Wounding may also be inflicted by explosive munitions such as rockets, aerial bombardment, mortars, and grenades. A small volume of explosive is converted to a large volume of gas in …