SURGERY FOR MAJOR INCIDENTS
Blast injuries: a guide for
the civilian surgeon
Alastair Beaven
Paul Parker
Abstract
Military clinicians became familiar with blast injuries during recent con-
flicts. Management of these complex injuries has advanced signifi-
cantly. Survival amongst UK service personnel increased year on
year. Civilian casualties from terrorist activities have included multiple
casualties with similar blast injuries. Civilian clinicians should also have
an understanding of blast-injured casualties so as to be prepared for a
major terrorist attack involving explosive devices. This article outlines
the mechanisms by which blast inflicts injury. It describes the manage-
ment steps required to treat these complex, potentially lethal wounds.
Keywords Amputation; blast lung; blast mechanism; blast triad;
damage control surgery; major incident response
Background
Military conflict in the last few decades has generated an
awareness of blast injury among UK military surgeons while
domestic terror events have highlighted this mechanism of
wounding among UK civilian surgeons and the public. The fa-
miliarity of blast injury treatment for UK surgeons has, however,
decreased in recent years as the UK health system has not lately
faced a large number of blast-injured patients. Despite this, the
worldwide threat from terrorist events is higher now than it has
been for much of the late 20th century,1 and knowledge of this
complicated traumatic disease remains important given the
often-emergent nature of the required medical response. This
article summarizes the basic mechanisms of blast injury, the
concept of ‘hidden injury’ and outlines modern proactive treat-
ment strategies.
Overview of blast injuries
In order to successfully treat blast injured persons, it is helpful to
consider blast injuries as a series of distinct sequentially
occurring mechanisms.1
Primary blast injury
Sometimes described as the blast wave, primary blast injury re-
fers to the overpressure generated by the forcibly expanding
Alastair Beaven MRCS is a Registrar in Orthopaedic Surgery at the
Royal Centre for Defence Medicine, Queen Elizabeth Hospital,
Birmingham, UK. Conflicts of interest: none declared.
Paul Parker FRCS(Ed) FIMC FRCS(Orth) is a Consultant in Orthopaedic
Surgery at the Royal Centre for Defence Medicine, Queen Elizabeth
Hospital, Birmingham, UK; and Senior Lecturer in SOF Medicine at
University College Cork, Ireland. Conflicts of interest: none declared.
SURGERY 39:7
gases within explosives. This increased pressure has an effect on
all body regions where an interface exists between tissues of
varying densities as they compress at different rates. This is
particularly evident in gas-filled viscera, and result in damage to
tympanic membranes, lung and bowel most commonly. Tym-
panic membranes rupture at a relatively low pressures of 2 psi,
whereas lung damage typically occurs at 70 psi. The presence of
tympanic membrane rupture is therefore not a reliable marker of
associated severe injury. Primary blast effect is modified by the
environment. Relative protection is seen at greater distances,
with amplification in enclosed spaces. The blast quickly dissi-
pates to the third power of the blast radius (r3), but is reflected
and sustained by solid structures such as walls.
The scene environment is important when considering the
injury burden among survivors. A new taxonomy in explosion
setting describes five locations; closed space (CS), inside a bus
(IB), adjacent to a bus (AB), semi-open spaces (SO), and open
spaces (OS). IB can also clearly apply to underground or metro
systems. This classification has better sensitivity with regard to
injury severity compared to traditional open space versus closed
space descriptions.2 Injury severity, number of operations and
ITU admissions are highest in closed space survivors.
Blast lung occurs as a direct effect of the primary shockwave
compressing and disrupting tissues,3 particularly characterized
by rupture of alveolar capillaries. Haemorrhage and oedema
within the lungs contribute to initial respiratory embarrassment,
and also serve to act as a focus for a further pro-inflammatory
response.4 Blast triad is the accepted term for the physiological
response of bradycardia, apnoea and hypotension and occurs in
around 10% of patients suffering traumatic amputation. Lung
overstretch mediated via the vagus nerve produces bradycardia
and apnoea. The hypotension is mediated by the concurrent fall
in cardiac output and myocardial impairment and also by a
release of nitric oxide, a potent vasodilator, from the pulmonary
circulation.4 The effects of the blast triad may last for some time
and have profound effects on resuscitation. A radiograph
showing blast lung can be seen in Figure 1.
Lung protective ventilation is therefore vital. This must be
proactively considered and started as early as possible. Low tidal
volumes (6 ml/kg predicted body weight) are used to reduce
ventilator-associated lung injury, decrease volutrauma (hyper-
inflation and shearing injury), barotrauma (alveolar rupture and
pneumothorax) and biotrauma (release of inflammatory
mediators).
Primary blast traumatic brain injury (bTBI) is a controversial
topic and we have an uncomplete understanding of this partic-
ular entity. Although different models have been hypothesized, it
is now widely accepted that the neurological injury is a result of
physiological and anatomical disruption of the bloodebrain
barrier.5 Symptoms may include physical, emotional, cognitive
and behavioural manifestations, and may occur alongside af-
fective disorders.
Secondary blast injury
Secondary blast injury includes projectiles propelled by energy
from the exploding device. It is important to note that the lethal
range of secondary blast injury in open spaces exceeds that of
primary blast injury. The projectiles may originate from the de-
vice itself or from the environment. In military ordnance these
393 Ó 2021 Published by Elsevier Ltd.
 SURGERY FOR MAJOR INCIDENTS
Figure 1 Chest radiograph showing wide bilateral opacities reflective
of blast-lung injury.
fragments are often pre-formed (e.g. ball bearings or notched
wire) resulting in a more predictable blast pattern. This is
desirable in weapon design, to better anticipate the effect of the
weapon. In improvised explosive devices (IEDs), fragments are
makeshift and can include the use of nails, screws, scrap metal,
or any other implements to hand. As the fragments are hetero-
geneous, they are variably subjected to air drag, and therefore
produce a less predictable blast pattern.
Environmental projectiles can include damaged components
from the structures affected in the blast, e.g. car parts, concrete
from a building, and debris from the blast origin. Special mention
should be given to suicide bombers: bone, teeth, clothing, and
worn equipment can all be classed as components of secondary
blast injury. Candida, Hepatitis B, C and Human Immunodefi-
ciency Virus (HIV) may theoretically be transmitted from suicide
bomber to casualties via biological fragmentation; there have
been no proven cases of blood borne virus (BBV) transmission
from suicide bomber to victim in this mode of attack.6,7
Guidelines for post exposure management of this situation are
available in the UK.
Tertiary blast injury
Tertiary blast injury occurs when casualties are displaced by the
explosive energy of the blast, sometimes called the blast wind.
The displacement of bodies by the blast wind may cause injury in
the acceleration phase, but are far more likely to occur during
deceleration from collision or impalement with the environment.
Limb loss can also occur (in-bone or through joint), where limb
flail or axial shear waves can cause primary amputation. Hidden
spinal injuries should always be suspected in these cases.
Quaternary blast injury
Quaternary blast injury is the term given to ‘other’ mechanisms
that have the ability to cause harm, such as thermal, radiological
or psychological injury. Thermal injury can result from the
products of combustion of the device itself. Most common are
superficial flash burns to areas of exposed skin, but deeper burns
may be inflicted. In certain types of explosion (i.e. nuclear)
radiological injury is also a risk. There can also be further injury
from weakened structural elements like a collapsing roof.
SURGERY 39:7
Quinternary blast injury
Quinternary blast injury is not universally recognized in all clas-
sification systems but is included here for completeness. It in-
cludes late effects such as chronic pain, malnutrition and
immunosuppression. There is evidence to suggest that the
immunosuppression from blast injury can reactivate latent dis-
eases such as malaria, osteomyelitis and fungal infection. Injury
Severity Score (ISS), massive transfusion, marketplace bombs and
surgical operation time have also been identified as risk factors.
Patterns of injury
Blast injuries produce a unimodal pattern of mortality, with the
vast majority of deaths (>90%) occurring within the first 10
minutes of injury. It has been recognized in both military and
civilian spheres that the individuals closest to the injured person
can have a pivotal part to play in survival whether they are
medically trained or not, named bystander utilization. Bleeding is
the main reversible cause of death, and both the American
Hartford Consensus8 and the UK CitizenAID app9 have identified
strategies to improve survivability from terror attacks.
The nature of blast injuries means they are also always
heavily contaminated. Organic matter, dirt and debris is driven
through tissue planes reaching areas some distance away from
the injury. Blast wounds may harbour between four to six species
of bacteria, and wounds over 6 hours old should be treated as
infected rather than just contaminated. Early antibiotic admin-
istration is vital.
Treatment of injuries
The ten-step blast checklist:

preparation

resuscitation

penicillin

anti-tetanus

damage control

debridement

wash

fasciotomy

pack/TNP

stabilize
Preparation
Incident response:
Blast injuries in civilian practice are often part of multiple ca-
sualty situations and should generate a major incident response.
Sometimes, the first a hospital will know of a major incident will
be the spontaneous presentation of self-evacuating patients with
minor injuries. The most senior surgeon present at the receiving
facility should immediately begin to coordinate the surgical re-
action. While the hospital major incident plan is clearly a guide,
the following didactic advice may benefit most medium-to-large
size UK hospitals.
At Major Incident Standby: Do not wait for the first casualty
to arrive. Stop all elective operating. Clear six bays in the
emergency department (ED), clear six ITU beds, and clear six
theatres. Station a dedicated senior clinical coordinator at the ED
entrance and direct the most severely injured patients
394 Ó 2021 Published by Elsevier Ltd.
 SURGERY FOR MAJOR INCIDENTS
appropriately to these 18 spaces. Plan for four units of red cells
and four units of plasma for each of these 18 patients. Send
walking wounded elsewhere (remote from the ED, to a pre-
determined appropriately staffed area). Do not wait for Major
Incident Declared to start this process.
The response to a terrorist incident mandates a hospital-wide
approach. This involves emergency theatres, staff cascades,
blood bank and intensive care. However, do not forget imaging,
mortuary and portering services. It will also likely be necessary
to discharge inpatients in order to make space for incoming ca-
sualties. Many trusts will have action cards for distribution in the
event of a major incident as role-specific aide-memoirs. The UK
National EPRR initiative has developed action cards for trauma
conditions in much the same way; an example for blast injury is
shown in Figure 2.
Many blast-injured patients who survive to hospital will
require expedient operative management, which should be part
of a continuous resuscitation strategy. It is recommended that a
dedicated senior clinical coordinator remains separate to the
clinical response. This is increasingly important as more casu-
alties are involved. Surgical preparations should anticipate the
need for thoracotomy, laparotomy, craniotomy, limb stabiliza-
tion, and topical negative pressure dressings.
Treatment should occur in accordance with damage control
principles, with resuscitation maintained from reception, through
the perioperative period, and into the critical care environment.
The Royal College of Surgeons of England Damage Control Or-
thopaedic Trauma Surgery (DCOTS) and MISTT (Major Incident
Surgical Training and Teams) courses are recommended for those
who wish to gain further practical experience in this type of care.
Consideration should be given to the number of patients requiring
surgery in the days after the initial event. Ortho-plastic teams are
particularly likely to be burdened for at least two to four weeks
following any major incident.
Equipment
Windlass tourniquets should be applied as close to bleeding
wounds as is practical and tightened until arterial flow is restricted
to the distal limb. If one tourniquet is insufficient to control
bleeding, a second tourniquet should be applied just above the first.
Tourniquets may be left safely for up to 2 hours; between 2e4
hours tourniquets should be converted to pressure dressings, or
if bleeding is not controlled, reapplied acknowledging that the limb
will likely require amputation. Operating theatre pneumatic tour-
niquet machines and cuffs should be brought down to ED in
anticipation of casualty arrival and swap all necessary emergency
tourniquets for pneumatic ones.
Pelvic binders should be used if there is suspicion of pelvic
injury, given that a third of patients injured by blast with bilateral
lower limb amputations have an associated pelvic fracture.10
Novel haemostatics such as CeloxÒ gauze can be used for cavi-
tating wounds or junctional trauma in combination with con-
ventional dressings. Major incident casualties generally require
multiple orthopaedic interventions, and reserve stocks of equip-
ment, including external fixators are held nationally in the UK.
Resuscitative priorities
Most deaths occur in the 10 minutes following the blast, and the
most common injury pattern is to multiple anatomical sites by
SURGERY 39:7
numerous fragments.11 Resuscitation should therefore follow the
traditional teaching of [C>]ABC; [C>] arrest of catastrophic
haemorrhage, [A] securing an airway, [B] treating breathing
problems, and [C] supporting the circulation.
Imaging
Explosions cause multiple injuries with significant anatomical
disruption. If possible, imaging with computed tomography (CT)
is recommended in all cases to assess the extent of injury. All but
the truly unstable trauma patients should be scanned. Patients
responding, even transiently, to appropriate red cell or plasma
fluid resuscitation should undergo whole body CT scan. Trans-
fusion and ongoing resuscitation in the CT scanner is now
standard. The exception to CT scanning is during a major inci-
dent, where some patients in extremis may need emergency
operative intervention, and in more stable patients where im-
mediate imaging may be sacrificed dependent on resource allo-
cation. Timely CT reporting may represent a significant staffing
burden. Radiology responses should accommodate this
consideration.
The concept of damage control surgery
‘Damage control’ as an entity focuses on restoring patient
physiology rather than anatomy, and involves the rapid time-
limited control of haemorrhage and contamination. All modern
resuscitative strategies now embrace damage control surgery.
The earlier damage control surgery is applied, the better the
outcome.
The longer time you take to think, the shorter time you have
to act.
Obvious vessel bleeding can be controlled by ligation,
shunting (Figure 3), or repair of injured vessels as they are
encountered. There are few sequalae to ligating the internal iliac,
axillary, subclavian, external carotid or common carotid ar-
teries.12 For the patient in extremis, simple clamping or shunting
of major vessels only is performed. During damage control lap-
arotomy only essential resections are performed foregoing pri-
mary anastomosis. Injured solid organs are packed based on the
principle that pressure stops bleeding, and pressure vectors
should re-create the tissue planes created by the capsule of the
organ, and not randomly placed. Major extremity and pelvic
fractures should have rapid external fixation applied with control
of vascular injuries and fasciotomies. The Royal College of Sur-
geons offers Damage Control Orthopaedic Trauma Surgery
(DCOTS) and Damage Control to Definitive Care (DCDC) courses
in these techniques.
Initial surgical care
Wound classification
All blast wounds are contaminated and should not be closed
primarily. The best surgical treatment is effective and early
wound excision,13 reducing the mortality and morbidity from
sepsis, gas gangrene and recurrent trips to theatre.
Simple wound scoring systems are used, for both documen-
tation (photographs can be helpful) and clinical decision-
making purposes. If there is a cavity, the wound needs open-
ing (or unbridling¼ debridement). The International Committee
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 SURGERY FOR MAJOR INCIDENTS

EPRR action card for blast injury

Figure 2

SURGERY 39:7 396 Ó 2021 Published by Elsevier Ltd.

 SURGERY FOR MAJOR INCIDENTS
of the Red Cross (ICRC) has a simple six parameter scoring
system;

entry wound 1e4 (size of wound in cm)

exit wound 0e4 (size of exit wound in cm)

cavity 0e1 (can it accommodate two of the surgeon’s
fingers? (yes or no))

fracture 0e2 (no fracture/simple fracture, hole, insignifi-
cant comminution/significant comminution)

vital structure injury 0e1 (dura, pleura, peritoneum, major
vessel injury (yes or no))

metallic fragments 0e2 (none, 1  fragment, multiple
fragments).
A typical blast wound might be expressed as E4 X0 C1 F0 V1
M2
Debridement
The greater the tissue damage, the more extensive and complex
the wound excision should be.14 All dead, dying and grossly
contaminated tissue must be removed, leaving behind only
healthy tissue that is capable of resisting infection, so long as the
Figure 3 Example of arterial shunting for temporary stabilization of
vascular injury.
SURGERY 39:7
wound is left open. An attempt to excise all wounds and frag-
ments through multiple incisions is not normally necessary. Blast
injuries generate a large amount of metal fragmentation, and
these should only be removed if they are intra-articular or within
the CSF (where they may cause heavy metal arthropathy or
neuropathy) or risk damaging other structures by their prox-
imity. A non-inflated proximal limb tourniquet is recommended
to prevent ischaemic damage, while allowing for vascular control
in the event of heavy bleeding. In proximal or junctional injuries,
a decision needs to be made early as to whether more definitive
vascular control is required.15
All wounds require vigorous scrubbing and copious irrigation.
For small wounds, skin excision (of a millimetre or two) and
wound decontamination should follow. Larger wounds may
require generous skin excisions in the direction of the long axis of
the limb. The aim is to explore tissue planes removing contam-
ination, and assess damaged tissues. Different tissues respond
variably to blast trauma; skin is resilient to damage, so only
completely destroyed, heavily lacerated, or significantly
degloved skin needs be removed. Subcutaneous fat, with its
relatively poor perfusion, low resistance to infection, and
frequent structural damage should be generously removed. An
example of debridement can be seen in Figure 4. Muscle should
be assessed according to colour, consistency, contractility and
capillary bleeding. Resection should be attempted from good-to-
bad tissue removing all dead muscle and preserving fresh glis-
tening, oozy, red healthy muscle. Unhealthy muscle is a limp,
dry, friable, grey colour. Only healthy muscle contracts, and if,
when pinched with forceps there is no contraction, areas of
muscle should be excised. The surgeon must consider that
neuromuscular blockade diminishes this reaction.
Remove the hamburger, leave the fillet steak.
For deep wounds, the deep fascia should be excised along the
length of the skin incision in order to estimate track size and
tissue damage. A large blue-black clot is a reliable sign of major
vessel damage. Before further exploration is performed, consider
proximal vascular control. All dead and contaminated bone
should be removed to prevent both acute life-threatening sepsis,
and also to aid subsequent reconstruction. Both ends of damaged
bone need to be delivered into the wound for inspection and
debridement. Non-viable fragments of bone should be removed,
and the tug test is useful to distinguish bone with insufficient soft
tissue attachments. (A small piece of bone is very gently tugged
with forceps. If the force of the tug is enough to strip the bone
away from the soft tissues, then they were never sufficient to
support the bone in the first place.) Joints that have been
breached will always need washing out via a mini-arthrotomy.
Bony stabilization
Bony stabilization is mandated to reduce further neurovascular
injury, soft tissue deformation, cytokine release, and pain. It also
allows easier casualty handling. Initial stabilization will likely be via
external fixation, although skeletal traction or plaster of paris may be
used in a significantly injured patient. Definitive stabilization (in-
ternal fixation) is usually avoided in the unstable patient who is at
risk of infection. External fixation is most suited to:

unstable fractures with bone loss

fractures with significant soft tissue injury
397 Ó 2021 Published by Elsevier Ltd.
 SURGERY FOR MAJOR INCIDENTS
Figure 4 (a) blast injury before debridement. (b) after debridement showing generous excision of
degloved skin and devitalized fat.

polytrauma

fractures with neurovascular compromise

patients requiring transfer or handling.
Factors making external fixation more stable and more suc-
cessful are:

two bicortical pins placed either side of the fracture, out of
the zone of injury

near-far, near-far pin placement principle

rods placed closer to the bone

multiplanar configuration of pins and rods

cross links between rods

thicker diameter pins and rods

>1-cm skin incisions (small skin incisions can cause local
pressure necrosis, which can lead to infection, which can
then lead to loosening of pins in some situations).
Fasciotomies
There should be a very low threshold to perform limb fascioto-
mies in blast trauma. If the operating surgeon is considering it,
the procedure should be performed. Fasciotomies should be
generous, and decompress the full length of all compartments.
There are four compartments in the lower leg, three in the thigh,
two in the upper arm and three in the forearm.
We now include the method of fasciotomy described by the
British Orthopaedic Association and the British Association of
Plastic, Reconstructive and Anaesthetic Surgeons (BOA and
BAPRAS).16
BOA and BAPRAS fasciotomy guidelines: fasciotomy incisions
are made 1.5 cm lateral to the lateral border of the tibia, and 2 cm
medial to the medial border, avoiding the perforators at 5, 10 and
15 cm from the medial malleolus. It is essential to avoid incisions
crossing the (imaginary) line between them. The anterolateral
incision is extended through the anterior compartment to reach
the lateral compartment behind. The medial incision gives access
to the superficial posterior compartment, and is extended
through this compartment to reach the deep posterior compart-
ment. Thus four compartments are decompressed through two
skin incisions.
It is possible that an unfamiliar surgeon may not fully
decompress all four compartments with this method, particularly
if there is anatomical disruption. Surgeons should be aware of this
fact and take intraoperative measures to confirm their landmarks.
SURGERY 39:7
In the thigh lateral and medial incisions are appropriate. In the
upper arm both compartments are released through one lateral
incision. In the forearm the flexor compartment is decompressed
via a ‘lazy-S’ incision from the antecubital fold down to (and
including) carpal tunnel release. The extensor compartment
incision starts at the lateral wad in the pronated forearm, and
reaches the center of the wrist dorsally.
After debridement, all wounds should be thoroughly irrigated.
Wounds can be treated with (preferably) topical negative therapy
(TNP) dressings if available, or conventional dressings. The
traditional paradigm is to return to theatre in 48 hours for a
second look to check the adequacy of the initial debridement and
remove further non-viable tissue.
Definitive wound closure should only be attempted when
there is no further evidence of infection, and antibiotics should
continue until wound closure. Anti-fungal treatment may be
required especially for difficult to debride, complex wounds
sustained in woody areas or market places.
Lower limb amputation
Soft tissues
The anterior and lateral compartments of the leg are tightly
bound to the tibia and fibula so do not survive blast injury well.
They are best treated by excision at the level of bony amputation.
The posterior compartments (particularly gastrocnemius) are
less well attached, so better survive transmitted energy. It is
important to continue ample proximal debridement, as contam-
ination may extend far from the external wound. Maximal skin
preservation will help in subsequent definitive closure. Fasciot-
omies should always be performed in a debrided compartment.1
The three neurovascular bundles should be identified. The
main arteries should be ligated with double ties, while veins
can be ligated with single ties. Nerves can be cut under gentle
traction, and allowed to retract proximally, thus decreasing the
risk of neuroma development. It is recommended to cut nerves
with a scalpel rather than diathermy to minimize postoperative
pain; however, no studies have conclusively proved this to
be true.
Bone
A tibial stump shorter than 5 cm does not usually produce a
functional result. If the bone is in continuity and alive, it should
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 SURGERY FOR MAJOR INCIDENTS
Figure 5 (a) Debridement illustrating ‘chicken drumstick’ method of supporting soft tissues.
(b) After TNP dressing.
be left sticking out after debridement, as this ‘chicken drumstick’
will support the soft tissues14 (Figure 5). If the bone is short and
tissues long, the bone should be left again, because dieback will
occur as the injury evolves. Sometimes non-salvageable body
parts can still be used to harvest other tissue such as nerves, skin
and bone graft.
The tibia should be cut transversely, and the medullary cavity
curretted and washed out to remove any debris that may have
been forced into it. The fibula should be resected 2 cm proximal
to the tibia. The ideal final bone length is 20 cm. All bone ends
should be tidied with a rasp, and the sharp anterior tibial crest
also smoothed down. The plane between gastrocnemius and skin
should be left alone if possible, as this carries perforating vessels
and cutaneous blood supply. Soleus protects gastrocnemius
somewhat, and therefore this plane is usually clean.
Closure
At 3e5 days closure should utilize the long posterior flap.
Debulking of soleus and gastrocnemius may sometimes be
necessary so that the flap sits appropriately over the end of the
bone. The muscle should be attached to the end of the bone with
the use of sutures through two holes drilled in the distal tibia.
The skin is closed over the top of a drain, the stump is dressed
with fluffed gauze and crepe dressings, and a backslab is used to
hold the limb in full extension for a few days. The danger is of a
fixed flexion deformity rendering the stump functionally useless,
so physiotherapy is essential and should commence a few days
following wound closure. The drain should be removed at 48
hours.
Further considerations
Blast-injured patients with extremity injuries will require
specialist rehabilitation, which is most effectively delivered early
in care, and as part of a multidisciplinary approach.17 Most iso-
lated trans-tibial (and trans-femoral) amputees go on to live
SURGERY 39:7
normal lives. With modern rehabilitation techniques and
adequate resources, many amputees can demonstrate favourable
functional and emotional outcomes. Servicemen who have sus-
tained amputations secondary to blast injury have functional
outcomes comparable to age-matched healthy controls. In one
study 78% of unilateral amputees, and 52% bilateral amputees
were able to cover distances comparable to members of the
general population in the 6-minute walk test.17
Heterotopic ossification
Heterotopic ossification (HO) is described as abnormal bone that
forms within the planes of soft tissues. Risk factors for developing
HO include young age at time of injury, male gender, concurrent
head injury, blast injury, systemic inflammatory response at time of
injury, and there seems to be a tendency for HO to affect the lower
limb rather than upper limb. It is generally appropriate to excise HO
once it is fully corticated (on CT imaging), usually around 18
e24 months. Care must be taken to protect other structures in close
proximity or enveloped by the HO, and further investigations such
as MRI is often indicated. Non-steroidal anti-inflammatories such as
indomethacin 50 mg twice-daily for 4 weeks following initial surgery
can reduce the risk of developing HO.
Summary
Blast causes injury by distinct mechanisms. Understanding
wounding in the context of these mechanisms highlights the
importance of resuscitating the patient as a whole, with partic-
ular consideration of potentially hidden lung damage, spinal
trauma and pelvic fracture. Damage control resuscitation using
blood products, and rapid effective surgery should occur
concurrently with the aim of reducing the effects of the ‘lethal
triad’. These complex wounds require multiple operations and
are best managed at consultant level within an organized, multi-
disciplinary team. These teams should train together in prepa-
ration for the next terror event in the UK. A
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 SURGERY FOR MAJOR INCIDENTS
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