Surgical Stabilization of Fractures in Combat Trauma: External Fixation During the Global War on Terror

Role 2 (R2) U.S. military treatment facilities (MTFs) provide forward damage control resuscitation and surgery. There are many configurations of R2 surgical teams, but each service defines external fixation (EF) as a requisite skill. To inform planning of potential future conflicts, this study describes EF utilization in recent past conflicts.

The Department of Defense Trauma Registry (DoDTR) was retrospectively reviewed from 2003 to 2023. All combat casualties who underwent EF at U.S. MTFs were included. The primary outcome was the MTF level at which EF was performed. Secondary outcomes included the anatomic site of EF and population receiving EFs. Trends in these outcomes were evaluated across time and military operation.

Six thousand one hundred eleven patients received 9,310 EFs; 2,600 were U.S. casualties, 1,630 foreign civilian, 275 North Atlantic Treaty Organization (NATO) military, and 1,605 non-NATO military. 19.5% of EFs were placed at R2, 67.6% at Role 3 (R3), 4.9% at Role 4 (R4), and 8.0% at R4-Continental US (R4C) MTFs. 78.0% of patients undergoing their first EF at R3 bypassed the R2. 67.5% of EFs were on the lower extremity and 19.4% were on the upper extremity. At both R2 and R3, the lower extremity was the predominant EF site (69.6% and 67.3% respectively). External pelvic fixation was rarely performed (0.3% and 0.1%).

These results offer valuable insight into modern logistical concerns in the delivery of forward surgical care. First and foremost, it underscores the importance of maintaining EF capability in expeditionary surgical teams, especially at lower echelons of care. Given the increasing prevalence of EF at R2s and the logistical challenges of evacuation in future conflicts, consideration should be given to both sustaining orthopedic-trained surgeons in theater and ensuring all general surgeons have robust orthopedic capabilities.