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Pelvic fractures, although infrequent, are a significant cause of morbidity and mortality in the trauma population. Currently, the mainstay of emergent management of a suspected pelvic fracture is placement of a pelvic binder, and their use in the prehospital setting is recommended for any individual involved in high-energy trauma. Obesity in the trauma patient has been shown to be an independent risk factor of morbidity and mortality, and the incidence of pelvic and lower extremity fractures has consistently demonstrated to be higher in the obese patient compared with an individual with a normal body habitus. This article aims to highlight the challenges associated with pelvic fracture in the obese population.

IntroductionDeath as a consequence of underbody blast (UBB) can most commonly be attributed to central nervous system injury. UBB may be considered a form of tertiary blast injury but is at a higher rate and somewhat more predictable than injury caused by more classical forms of tertiary injury. Recent studies have focused on the transmission of axial load through the cervical spine with clinically relevant injury caused by resultant compression and flexion. This paper seeks to clarify the pattern of head and neck injuries in fatal UBB incidents using a pragmatic anatomical classification.MethodsThis retrospective study investigated fatal UBB incidents in UK triservice members during recent operations in Afghanistan and Iraq. Head and neck injuries were classified by anatomical site into: skull vault fractures, parenchymal brain injuries, base of skull fractures, brain stem injuries and cervical spine fractures. Incidence of all injuries and of each injury type in isolation was compared.Results129 fatalities as a consequence of UBB were identified of whom 94 sustained head or neck injuries. 87 casualties had injuries amenable to analysis. Parenchymal brain injuries (75%) occurred most commonly followed by skull vault (55%) and base of skull fractures (32%). Cervical spine fractures occurred in only 18% of casualties. 62% of casualties had multiple sites of injury with only one casualty sustaining an isolated cervical spine fracture.ConclusionImprovement of UBB survivability requires the understanding of fatal injury mechanisms. Although previous biomechanical studies have concentrated on the effect of axial load transmission and resultant injury to the cervical spine, our work demonstrates that cervical spine injuries are of limited clinical relevance for UBB survivability and that research should focus on severe brain injury secondary to direct head impact.

IntroductionFractures have been a common denominator of the injury patterns observed over the past century of warfare. The fractures typified by the blast and ballistic injuries of war lead to high rates of bone loss, soft tissue injury and infection, greatly increasing the likelihood of non-union. Despite this, no reliable treatment strategy for non-union exists. This literature review aims to explore the rates of non-union across a century of conflict, in order to determine whether our ability to heal the fractures of war has improved.MethodsA systematic review of the literature was conducted, evaluating the rates of union in fractures sustained in a combat environment over a 100-year period. Only those fractures sustained through a ballistic or blast mechanism were included. The review was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Quality and bias assessment was also undertaken.ResultsThirty studies met the inclusion criteria, with a total of 3232 fractures described across 15 different conflicts from the period 1919–2019. Male subjects made up 96% of cases, and tibial fractures predominated (39%). The lowest fracture union rate observed in a series was 50%. Linear regression analysis demonstrated that increasing years had no statistically significant impact on union rate.ConclusionsFailure to improve fracture union rates is likely a result of numerous factors, including greater use of blast weaponry and better survivability of casualties. Finding novel strategies to promote fracture healing is a key defence research priority in order to improve the rates of fractures sustained in a combat environment.

A case of post-operative negative pressure pulmonary oedema in a young, athletic male is reported. We discuss this rare but life-threatening condition and its aetiology, and review the published literature. Military health care providers need to be aware of this condition as young fit personnel may be at increased risk of developing negative pressure pulmonary oedema in the post-operative period.

Condensation of a 3-substituted 5-amino-1,2,4-triazole with an N-cyanocarbonimidate (RX)2CNCN, yields the title compounds, in most cases as a mixture of isomers; separation and elaboration then gives [1,2,4]triazolo[1,5-a][1,3,5]triazines bearing a range of substituents in the 5 and 7 positions. Under milder reaction conditions, less stable isomeric products (e.g., the [1,2,4]triazolo[4,3-a][1,3,5]triazine ring system or an uncyclised N-cyano intermediate) can be isolated and shown to rearrange to the [1,5-a] isomer. A second synthesis is described in which a suitably substituted 2-hydrazido-1,3,5-triazine is cyclodehydrated to give a single isomer with identical substituents in the 5 and 7 positions; the large difference in reactivity between these allows selective replacement at the 7-position with nucleophile. Additionally, the second synthesis is more readily adaptable to the introduction of substitutents at the 2 position of the bicyclic nucleus. 7 Amino-2-(2-furyl)-5-phenoxy[1,2,4]triazolo[1,5-a][1,3,5]triazine 12a is prepared independently by both synthetic sequences and its structure verified by X-ray crystallographic analysis; 1H NMR, 13C NMR and MS data are also presented in support of the proposed structures.

E- and Z-1-alkenyl iodides react with vinylboronate pinacol ester 1 under palladium(0) catalysed, Heck conditions to provide polyenylboronates in moderate yields after purification. The addition of either silver(I) or thallium(I) salts to the reaction mixture is essential. Alkenyl bromides are unreactive under identical reaction conditions.