War wounds of bones and external fixation

Missile and explosive limb wounds associated with fractures are common in warfare. The retrieval of function is determined more by the nature of the wound and the wound management than by the method of fracture immobilization. The wound must be managed according to well-proven basic principles and then the advantages and disadvantages of the different methods of fracture immobilization considered for each individual patient. Before embracing external fixation as an indispensable tool for managing war wounds, one must recognize that its popularity in civilian practice is founded on its use for severe open tibial fractures from road trauma. Its principle advantage is to permit access to the soft tissue wound whilst the severity of possible disadvantages is not recognized; its effect on bone healing remains unclear. This review examines the role of external fixation in the management of war wounds and advises caution when considering its widespread or universal use. An approach to war wounds with fractures is described whereby external fixation can be combined with plaster splints or traction; this draws on the advantages of both operative and non-operative methods of fracture immobilization and eliminates many of the disadvantages.