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Musculoskeletal injury is the most common type of injury among survivors of combat trauma, and combat-related trauma is challenging for an orthopaedic surgeon to treat. Methods of treatment are evolving, but significant gaps remain as knowledge of civilian trauma is extrapolated to combat trauma.

Approximately 70% of war wounds involve the musculoskeletal system, and military orthopaedic surgeons have assumed a pivotal role in the frontline treatment of these injuries in Iraq. Providing battlefield orthopaedic care poses special challenges; not only are many wounds unlike those encountered in civilian practice, but patients also must be triaged and treated in an austere and dangerous environment, undergo staged resuscitation and definitive surgery, and endure prolonged medical evacuation, often involving ground, helicopter, and fixed-wing transport across continents. Most orthopaedic wounds in Iraq are caused by exploding ordnance--frequently, improvised explosive devices, or IEDs. Because of advances in care, rapid medical evacuation, and modern body armor, many casualties have survived in Iraq who would not have done so in previous wars. Treatment of war wounds, many of which are devastating in the scope of soft-tissue and bony injury, requires a team approach using hypotensive resuscitation, damage-control orthopaedics, new or rediscovered techniques of hemostatic and intravenous hemorrhage control, vacuum-assisted wound closure, and advanced reconstruction. Current challenges include prevention of infection, a better understanding of heterotopic ossification as a sequela of blast injury, and the need for a comprehensive, joint service database that encompasses the multilevel spectrum of orthopaedic care.

Trauma care for military personnel injured in Iraq has become increasingly sophisticated. There are five levels, or echelons, of care, each progressively more advanced. Level I care provides immediate first aid at the front line. Level II care consists of surgical resuscitation provided by highly mobile forward surgical teams that directly support combatant units in the field. Level III care is provided through combat support hospitals--large facilities that take time to become fully operational but offer much more advanced medical, surgical, and trauma care, similar to a civilian trauma center. Level IV care is the first echelon at which definitive surgical management is provided outside the combat zone. Level V care is the final stage of evacuation to one of the major military centers in the United States, where definitive stabilization, reconstruction, or amputation of the injured extremity is performed.

A series of 51 active duty patients who elected to undergo ambulatory surgery in a Navy Fleet Hospital Training Set (a modified field hospital) over a 2-year period were followed prospectively for perioperative complications. All patients were active duty personnel, ranging in grade from E1 to O5, who voluntarily gave specific informed consent to have their surgery performed in the training set. Patients were offered surgery in the training set only if attending surgeons were confident that the surgery could be done safely and with the same expected outcome as if performed in the hospital. Their entire surgical experience was contained within this tent-based field facility from admission to discharge. There were 12 orthopedic surgery, 4 general surgery, 3 otolaryngology, 2 urology, 1 ophthalmology, and 29 oral and maxillofacial surgery cases. General, regional, or local anesthesia or intravenous conscious sedation were used as indicated. No patients developed wound infections, and there were no anesthetic, bleeding, or other significant perioperative complications. Selected ambulatory surgical procedures can be safely performed on appropriate patients in this field hospital assemblage.