Management of small fragment wounds: experience from the Afghan border

Fragmenting munitions have caused the majority of casualties in recent conflicts. These wounds are often multiple, many affecting only the soft tissues of the extremities. The management of these wounds is controversial; some surgeons advocate aggressive surgical treatment; others believe that a nonoperative policy is appropriate in selected cases. The International Committee of the Red Cross has a great deal of experience in treating the wounds of war. It maintains a war surgery hospital in Pakistan, close to the Afghan border, receiving wounded from the ongoing conflict in Afghanistan. This paper describes the number, distribution, and severity of more than 1200 fragment wounds. These injuries were sustained by 83 casualties who presented to the hospital during a recent flare-up in the fighting. The majority of these fragment wounds affected the limbs. Small-fragment wounds affecting only the skin and muscle were managed nonoperatively, with antibiotics and dressings. More than 850 wounds were managed in this way. There were complications in only two of the 63 casualties who had wounds that were treated nonoperatively. The complications were localized abscesses, one of which required surgical drainage. The policy of carefully assessing the wounds and treating selected wounds conservatively appears to have been both successful, in terms of saved surgical resources, and safe, with no life- or limb-threatening complications. This paper makes recommendations as to which wounds might be suitable for nonoperative management, but acknowledges that further work is needed to define the optimal treatment of these common wounds.