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Comments on “Management of civilian ballistic fractures” written by V.S. Seng, A.C. Masquelet published in Orthop Traumatol Surg Res 2013;99:953–958
Orthopaedics & Traumatology: Surgery & Research 100 (2014) 575
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Comments on “Management of civilian ballistic fractures” written by V.S. Seng, A.C. Masquelet published in Orthop Traumatol Surg Res 2013;99:953–958 We would like to make a few comments about the article by VS Seng and AC Masquelet entitled “Management of civilian ballistic fractures” and recently published in Orthopaedics & Traumatology: Surgery & Research. The authors report a case-series study of patients managed in a civilian hospital for ballistic fractures. Among them, 5 received orthopaedic treatment and 10 internal fixation, including 7 with femoral fractures. Healing was achieved promptly, with a low morbidity rate and no infections. However, these patients were very different from those seen in the military [1,2]. The injuries were caused by low-velocity projectiles, the time to treatment was short, the conditions of surgical management were optimal, and the fracture was the only lesion in most of the patients (only 3 patients had concomitant injuries to internal organs). These characteristics probably allow internal fixation in selected cases, provided rules for wound debridement and trimming are followed, as pointed out by the authors. Thus, when making treatment decisions, careful attention must be given to clinical severity, type of projectile, extent of soft tissue lesions, lesions at other sites, and setting [3]. In combat settings, limitations in internal fixation resources and ability to ensure aseptic conditions require a sequential approach to the management of ballistic fractures, known as damage control orthopaedics (DCO). External fixation is used initially and the patient is then sent to a well-equipped centre to undergo secondary internal fixation when possible. Immediate internal fixation has a limited role in combat settings [1,4]. In civilian settings, DCO is appropriate in three situations: multiple injuries with a severe impact on general health requiring prompt surgical treatment, isolated limb bone fracture with a doubtful potential for soft tissue involvement, and complex
DOI of original article: http://dx.doi.org/10.1016/j.otsr.2013.08.005. http://dx.doi.org/10.1016/j.otsr.2014.07.001 1877-0568/© 2014 Elsevier Masson SAS. All rights reserved.
fracture at a location where limitations in available technical and/or human resources require subsequent transfer to a higher level of care. In every case, when possible, immediate or delayed internal fixation can be considered, particularly for articular fractures, to promote healing and early rehabilitation therapy. Finally, the increasing use of military weapons by civilians should be borne in mind, as it may require a shift in therapeutic indications. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Mathieu L, Bazile F, Barthelemy R, Duhamel P, Rigal S. Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers. Orthop Traumatol Surg Res 2011;97:852–9. [2] Lin DL, Kirk KL, Murphy KP, McHale KA, Doukas WC. Evaluation of orthopaedic injuries in operation enduring freedom. J Orthop Trauma 2004;18:300–5. [3] Barbier O, Rigal S, Mathieu L. La fixation externe : du damage control orthopédique au traitement définitif. Montpellier: Sauramps Médical; 2012. [4] Beech Z, Parker P. Internal fixation on deployment: never, ever, clever? J R Army Med Corps 2012;158:4–5.
O. Barbier ∗ D. Ollat G. Versier Hôpital d’Instruction des Armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France ∗ Corresponding
author. E-mail address: [email protected] (O. Barbier) Accepted 4 July 2014
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Comments on “Management of civilian ballistic fractures” written by V.S. Seng, A.C. Masquelet published in Orthop Traumatol Surg Res 2013;99:953–958 We would like to make a few comments about the article by VS Seng and AC Masquelet entitled “Management of civilian ballistic fractures” and recently published in Orthopaedics & Traumatology: Surgery & Research. The authors report a case-series study of patients managed in a civilian hospital for ballistic fractures. Among them, 5 received orthopaedic treatment and 10 internal fixation, including 7 with femoral fractures. Healing was achieved promptly, with a low morbidity rate and no infections. However, these patients were very different from those seen in the military [1,2]. The injuries were caused by low-velocity projectiles, the time to treatment was short, the conditions of surgical management were optimal, and the fracture was the only lesion in most of the patients (only 3 patients had concomitant injuries to internal organs). These characteristics probably allow internal fixation in selected cases, provided rules for wound debridement and trimming are followed, as pointed out by the authors. Thus, when making treatment decisions, careful attention must be given to clinical severity, type of projectile, extent of soft tissue lesions, lesions at other sites, and setting [3]. In combat settings, limitations in internal fixation resources and ability to ensure aseptic conditions require a sequential approach to the management of ballistic fractures, known as damage control orthopaedics (DCO). External fixation is used initially and the patient is then sent to a well-equipped centre to undergo secondary internal fixation when possible. Immediate internal fixation has a limited role in combat settings [1,4]. In civilian settings, DCO is appropriate in three situations: multiple injuries with a severe impact on general health requiring prompt surgical treatment, isolated limb bone fracture with a doubtful potential for soft tissue involvement, and complex
DOI of original article: http://dx.doi.org/10.1016/j.otsr.2013.08.005. http://dx.doi.org/10.1016/j.otsr.2014.07.001 1877-0568/© 2014 Elsevier Masson SAS. All rights reserved.
fracture at a location where limitations in available technical and/or human resources require subsequent transfer to a higher level of care. In every case, when possible, immediate or delayed internal fixation can be considered, particularly for articular fractures, to promote healing and early rehabilitation therapy. Finally, the increasing use of military weapons by civilians should be borne in mind, as it may require a shift in therapeutic indications. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Mathieu L, Bazile F, Barthelemy R, Duhamel P, Rigal S. Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers. Orthop Traumatol Surg Res 2011;97:852–9. [2] Lin DL, Kirk KL, Murphy KP, McHale KA, Doukas WC. Evaluation of orthopaedic injuries in operation enduring freedom. J Orthop Trauma 2004;18:300–5. [3] Barbier O, Rigal S, Mathieu L. La fixation externe : du damage control orthopédique au traitement définitif. Montpellier: Sauramps Médical; 2012. [4] Beech Z, Parker P. Internal fixation on deployment: never, ever, clever? J R Army Med Corps 2012;158:4–5.
O. Barbier ∗ D. Ollat G. Versier Hôpital d’Instruction des Armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France ∗ Corresponding
author. E-mail address: [email protected] (O. Barbier) Accepted 4 July 2014