FRACTURES IN WARTIME CONDITIONS

---

Oleksandr ZHOLUDEV

Major of the Medical Service

Head of the Traumatology Department of the Zaporizhzhia Military Hospital

Iurii MIKHEIEV

Major of the Medical Service, DrSci(Med),

Leading Surgeon of the Medical Forces and Sustainment Group “East”

Roman KUZIV

Lieutenant Colonel of the Medical Service

Commander of the Military Medical Clinical Center of the Eastern Region

---

Extremity trauma constitutes a substantial percentage of all musculoskeletal injuries sustained in combat environments, ranging from 44% to 70%

Approximately 45% of ballistic injuries to the extremities are associated with concomitant fractures.

Combat-related fractures are frequently characterized by high-energy comminution and significant osseous defects, often resulting in multiple bone fragments and extensive tissue destruction.

In contemporary high-intensity warfare, the overwhelming majority of fractures (approximately 98%) result from fragmentation and blast-related injuries, whereas gunshot-induced fractures account for only 2%. Such trauma typically presents as complex polytrauma, involving extensive damage to bones, soft tissues, neurovascular structures, and joints, thereby complicating clinical management.

For example, nearly 17.1% of all gunshot wounds involve joint damage. In the case of limb fractures caused by shrapnel, the vast majority of vascular injuries and compartment syndromes are observed in the injuries of the popliteal region, the tibia, and the forearm (large number of anatomical compartments).

Gunshot fractures during combat are often involve a major defective loss of bone tissue, which requires complex surgery, such as external fixation, staged treatment, and defect reconstruction.

There is a high risk of infection, purulent complications, and osteomyelitis - especially in fractures of the upper extremities.

In the case of gunshot fractures, external fixation by pin or wire devices has a great importance as the first stage of treatment, particularly for fractures of long tubular bones and soft tissues injuries, blood vessels, and nerves.

The treatment of comminuted and fragmented fractures is prolonged and resource-intensive. It often requires repeated surgical interventions, reconstructive procedures, and rehabilitation. In some cases, a long-term treatment of osteomyelitis of long tubular bones can lead to septic conditions, the need of limb amputation or to the patient's death due to multiple organ failure.

Closed (non-gunshot) limb and pelvic fractures

Closed fractures (without an open wound) were common in the pre-war period, for example as a result of road traffic accidents, blunt trauma, or by falling objects.

Closed fractures of the long bones of the lower extremities (femur, tibia) and of the humerus are among the most common isolated fractures.

In wartime conditions, the vast majority of closed fractures are caused by falls from military vehicles during movement, drone strikes on vehicles carrying personnel, injuries from moving mechanisms of combat equipment, and during protective actions under shelling - such as jumping into dugouts, shelters, or trenches, etc.

Prognosis is important for closed fractures - risk factors for complications include: comminuted fractures, displacement of fragments, delayed or improper fixation, delays in X-ray control, early weight-bearing, and insufficient rehabilitation.

Although closed fractures without gunshot wound have fewer complications, in wartime conditions they can also become complicated due to evacuation delays, insufficient medical care, overloaded healthcare facilities, and the lack of necessary modern metal fixation devices.

Prevalence and statistics:

Approximate statistics for gunshot fractures: pelvis - 2%, femur - 15%, tibia - 30%, foot - 10%, humerus - 15%, forearm - 5%, hand - 5%. Multiple fractures: more than 2 segments - 18%. These are approximate data.

For closed fractures, lower limb injuries significantly outweigh upper limb injuries: femoral fractures - 10%, tibia and ankle fractures - 40%, foot fractures - 10%, humerus and shoulder girdle fractures - 15%, forearm and hand bones fractures - 10%, pelvic and the spine fractures - 2% each, respectively. Multiple fractures account for approximately 10%.

Main challenges in the treatment of limb fractures in the conditions of modern warfare:

• The lack of centralized and comprehensive supply of fixation devices for stabilization, such as ex-fix devices, rods, plates with screws, etc.

• An extended recovery period following both surgical and conservative interventions, encompassing postoperative management, prolonged immobilization, and comprehensive rehabilitation.

• A critical shortage of inpatient resources dedicated to the treatment of chronic osteomyelitis and suppurative bone infections.

  huh