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Fracture union rates across a century of war: a systematic review of the literature
  1. Sarah K Stewart,
  2. O Tenenbaum,
  3. C Higgins,
  4. S Masouros and
  5. A Ramasamy
  1. The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
  1. Correspondence to Sarah K Stewart, The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London SW7 2AZ, UK; s.stewart18{at}


Introduction Fractures 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.

Methods A 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.

Results Thirty 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.

Conclusions Failure 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.

  • adult orthopaedics
  • limb reconstruction
  • trauma management
  • orthopaedic & trauma surgery

Statistics from


  • Contributors AR conceived the idea for the manuscript. SKS and OT undertook the literature review. SKS wrote the manuscript and performed the data analysis. SM, CH and AR reviewed the final draft of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval As this was a review of the literature and did not involve animal or human subjects, no study approval was required. Authorisation to submit for publication has been granted by the Defence Professor of Trauma and Orthopaedics (Surgeon Captain SA Stapley RN).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. All papers included in the systematic review are accessible on the world wide web.

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