Table 2

Summary of similarities/differences in trauma management

UKUSA and/or Canada
Wound debridementAfter initial debridement at R3, wounds are further inspected and debrided as necessaryWounds are inspected and debrided every 48 h for 3–4 times, then every 72 h till closure
Pulsed lavage is not usedPulsed lavage is used but only when wound is clean
Initial fracture managementMost appropriate stabilisation, that is, plaster cast, traction, external fixatorAll fractures have monolateral external fixators applied in E3
Antibiotic cement beads used as temporary spacers in initial open fracture managementAntibiotic cement beads used
Open tibial fracturesMost appropriate fixation, that is, AO locking plate, unreamed IM nail, monolateral external fixator, Ilizarov or TSFAll monolateral external fixators are converted to TSFs
Bone graft and BMP-2No early use of BMP-2Liberal early use of BMP-2
Delayed bone grafting using synthetic, autologous or allograftDelayed bone grafting using synthetic, autologous or allograft
Large amounts of autologous graft obtained from intramedullary femur canal by Reamer/Irrigator/Aspirator (Synthes, Inc., USA)
Soft tissue reconstructionAppropriate reconstruction technique used, for example, SSG, pedicled flap, free flap by plastic surgeonsHigh failure rate of free flaps. Move to use more pedicled flaps. Techniques performed by orthopaedic surgeons
Wound closureNo standardised closure method, surgeon-dependentModified Allgöwer-Donati suture pattern used
Topical negative pressure dressingsPreviously not available at R3 till 2011, now used extensively. Used extensively at R4Applied universally at E3 for transfer to E4 and E5. Use continued at E5
‘Incisional’ VAC dressing used to protect postoperative wound suture line
Modified Ertl ProcedureNot usedReintroduced at WRAMC but in spite of theoretical benefits, higher complication rate
  • BMP-2, bone morphogenetic protein-2; E3, 4, 5, Echelon 3, 4, 5; IM, intramedullary; R3, 4, Role 3, 4; SSG, split skin graft; TSF, Taylor spatial frame; VAC, vacuum assisted closure; WRAMC, Walter Reed Army Medical Center.