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Okay, thank you very much. Indeed. I'm actually going to just gloss over quite a large number of concepts of subjects. So the first thing I'd say before we get into the surgery is healthcare workers, surgical teams, you're incredibly precious to your communities. Your ability to look after your casualties is going to be limited by the level of resources you've got and the, and the circumstances you're working under and the number of casualties are going to be looking after. It's probably important as you as surgeons, as leaders, make your team aware that it can be quite painful and quite difficult to know that you could deliver a better level of care because you have the skills and the ability, but you don't have the equipment, you don't have the time and you don't have the space. So that that's something that we, we talk about as moral injury and that can be quite debilitating. And so that's something that surgeons and leaders, it's worth explaining to your team. They've got every times when it's going to hurt you because you're not gonna be able to look after people in a way that you know that you can, I don't need to labor this obviously, before you can get onto looking at reconstruction options, you need to think about preventing and treating infection before you get on to preventing and treating infection. It's all about the blood. You, you must keep as much of this blood in the patient as possible and you must keep as, as much of the blood in your hospitals blood bank as possible because it's incredibly precious resource. If hemorrhage is so bad that you need vascular control, don't do what they've done in this image here and try to get vascular control locally within the zone of injury. We've best to step out of the zone of injury and get proximal vascular control with a separate incision. And then that allows you to then get control within the zone of injury in a much more safer and measured way. And I almost never use tourniquets in my, in my civilian practice. But I think under austere environments and you should probably that should be fairly standardized technique just to try and reduce ongoing blood loss. So the next sort of sweeping generalization is it's very easy to get very focused on weapons systems. And you often hear people talk about someone who was shot with a high velocity rifle. It's just important just to read the wound and not get too fixated on what what the weapon might have been. It's a truism that high energy weapons can produce low energy transfer wounds that need multiple other and low energy transfer wounds might be very minimal debridement or potentially even know surgical treatment at all. This is a QR code that will give you an open access to a paper that we wrote on the subject to some of our experience, giving a scientific basis to some of these rules and they are generalizations and ballistics have a habit of making everyone look stupid when they claim to be an expert. But typical features of high energy transfer would obviously be very significant tissue description. Other features, bone strike, factual fragmentation. Typically, each one of those bone fragments has become a second, has been accelerated and energized and become a secondary missile in itself. So you're expecting anticipating far more tissue destruction deep within the wound. So that would be an injury that you potentially need to be a lot more aggressive about in your debridement. Similarly, bullet fragmentation, that's typically, and if the bullets been destroyed, if the jackets come off the bullet, that's typically a sign of significant amount of tissue damage. And so you need to be more aggressive with those ones. This is an example of someone who was shot with a high energy weapon, but it was through and through wound, minimal dish you damage. And essentially they all they had was a scrub. Although some features of energy transfer, this wasn't actually a very high energy transfer wound and essentially required know sort of true surgical treatment. The decision to amputate or decision making around amputation is challenging. It's emotive, it's difficult and it's often quite pressured. I think first thing to say is don't approach the injury or the limb or the patient with the question in mind or do I need to amputate this limb in the theaters? You would normally exercise all the devitalized and heavily contaminated tissue in the way you would with any other wound and just keep doing that until you've got clean vital tissue that's likely to survive. And then look at it and then you'll have a much clearer indication. If you start with an idea that you have to make a plan as to whether or not this is a agitation or a reconstruction, you'll be second guessing yourself and it makes it a lot harder the next point I'd make. And again, I appreciate this is probably very well known but devitalized loose fragments of bone is essentially proto Osteomyelitis in a contaminated battlefield wound. We know that essentially leaving in the wound is just providing a bacteria food or a sequestral in the future. The question of how much bone can be safely removed before it becomes a critical defect. And one that has to be either reconstructed using circular frames or mascular techniques that we can talk about later, it's very difficult. I mean, this is a gunshot wound, a high energy transfer wound that most people would say is probably getting on to a critical defect, right tibia. And in young healthy adults, they don't smoke, it healed up fine. What I would say about using P M M A spaces to occupy, avoids and to allow later reconstruction. I think in the setting where a lot of people are working now, I think that's a really great solution to a very difficult today problem. Admittedly, it just makes it a tomorrow problem. But I think that's a very safe way to temporize bone loss and critical defects. This is example of a high energy transfer from a handgun round. So making that point as well that this was a Canadian who has dropped by police officer with a nine mill handgun, typically a low energy weapon but produced a very high energy transfer injury, lots of loose bone fragments, it needed to be excised and he went on to have a maculae technique and reconstruction. This again is just an example. We were sort of when we think about masculine. We typically think about diet facil um segmental injuries. But this is a patient of mine who was, I think it was a forklift truck. So not a not a conflict injury, but essentially the initial ct scan on presentation shows a lot of tissue destruction to his mid foot and a lot of this bone just fell out of his foot. When we took him to theater, he ended up for soft tissue coverage and that it was quite a significant surface area of tissue loss in either the latissimus dorsi reconstruction. So with such a huge hole I was able to put on all of the little plates that I like to put on that you can see here in the in the middle photo, he ended up with a substantial proportion has mid foot gone. And this is a pair oh a spacer that was replaced subsequently with bone graft from a a Ria aspirate from his femur. That's obviously a very good way of getting a lot of bone graft. And so even in an atypical area, not a diagnosis, he's actually got a pain free foot that looks like a foot. He's not going to win any Olympic races, but he can walk around without pain. So it can give you a solution. And you can imagine when I was at this stage on the left here, I I didn't have a clue how we were going to cope with this and how we were going to reconstruct him. So it is a very nice way of making it tomorrow's problem. So I'd also talk a little bit about stepping back from some of the core medical issues that we're, we tend to be a bit more comfortable with when making decisions. And I've talked here about tissue excision and how radical and how aggressive you might want to be about a wound to Bryggman. But this is also quite, there's some crossover with doing fasciotomy is and compartment releases. So there's other factors that might influence your decisions. So if the patient's physiologically very unstable and they either can't take multiple surgeries or they can take a very long surgery, then the solution to that is just to be more aggressive in the first instances. And if you've got a choice between, you're not sure if this tissue is borderline or not, then it's probably gonna be cut out. That's true. Also, if your hospital is very sick. So if your hospital is overwhelmed by casualties and you can't be very confident that if the day after an operation, your patient becomes pyrexic and becomes septic and sick, that you can take them back to theater immediately. If that isn't the case because your hospital has a large number of casualties and more than it can cope with, then you might not get more than one chance every three or four days to take any individual patient the theater. So that one chance has got to really count. So that's going to lend you to being a bit more aggressive than you might want to be. The other thing is that the patient's about to be transferred. And if you're anticipating that your patient might be away from an operating theater for the next 36 hours or so, then again, you've got to be more aggressive with your, with your debride mints or have a lower threshold. Again, these go hand in hand a lower threshold for doing compartment releases potentially as we discussed before. If you think if you're suspicious that there's a high energy transfer wound, then again, you, you've obviously got to be a bit more, bit more radical, bit more aggressive than your tissue excision. This is a bit of a strange one. If you're seeing people being injured in not on a traditional frontline, they may get to your hospital incredibly quickly. And so we all know these military wounds produced by military munitions and weapons, they have a tendency to evolve quite a lot. Most of that evolution happens in the 1st 12 hours, but it continues over the next 234 days. It's possible that if you get to some of these wounds and you take the theater too early, they're still very much evolving and tissue that looks viable at six hours might be dead by 12 or or 18 hours. So that's something to bear in mind if you're getting a very fresh wound. The same is true of a later delayed presentation because not only you're going to be dealing with the necrotic and potentially a pop ptotic tissue, but you're also going to be dealing with secondary effects. So, wounds that were contaminated at one minute are going to be colonized by two or three hours and they're going to be frankly infected within 24 hours. So again, in late presentations, you're going to have to be a bit more aggressive with your deprive mints going back to difficult decisions about amputation. Again, after we've decided that limb injury is gonna necessitate an amputation. The next thing immediately fixate on is is this level of amputation. So the eventual height of amputation is essentially determined by the level that you can close the stump at and get a manageable healthy stump much more so than the bone. What I would say is that you can leave bone attached in place for the first and maybe second debridement operation. And you only need to make that final bone cut at the stage of final coverage. Because essentially the bone coverage, the unnecessary bit of bone that you know is going to be excised, that is essentially protecting the often metaphysis, heel bone from becoming colonized with bacteria. So if you only cut that off at the time where you can cover it with clean viable perfused tissue, you prevent the end of your bone, your end of your amputation stump, getting colonized over a few days and a few returns to theater before you've even closed the wound. In terms of some of the experience that we've had, we feel rather than we can necessarily prove, we feel that through the amputations which aren't commonly done in UK Villian practice, we think they do a lot better than a low transfemoral above the amputation. Obviously, that depends a lot on how well your prosthetist can get a good socket fit for a through knee, but we, we've certainly found them better. And obviously, a through knee allows potentially and weight bearing as opposed to a sort of hydrostatic transfer of forces from a transformer or a trans tibial as a rule. Obviously, the longer the residual limb, the amputation stump is the superior, the mechanical lever is. So you want to leave as much tissue as possible. Now, one way to do that is to do serial debride mints from within the zone of injury and reconstructing the end of the stump from within the zone of injury. The downside is that typically requires a greater number of operations, a greater risk of complications and infection. And although the stump will be longer, it might be more regular and have a lot more scar tissue. The alternative strategy is to amputate proximal out of the zone of injury. I mean, healthy tissue, one would anticipate that that normally takes fewer trips to theater, fewer, take backs, fewer complications. And although the stump is gonna be a lot shorter, it's probably going to be higher quality stump with more and more healthier tissue. On the end, war wounds have contaminated over and above what you would normally expect to see in your civilian practice. And you're going to do a staged sequence of operations to render a dirty uncontrolled traumatic war wound into a wound that can either be closed or really constructed. I'd like you to adopt what we would call an Ortho plastic approach and we're going to leave all are war wounds open in a damage control environment that, that always starts with a social wash. You're gonna be stopping the bleeding and that requires a proximal control or a torn okay. You may have limited access to blood and blood products and you may want to conserve those for those people with thoraco abdominal and injury. You need an adequate exposure and therefore you need to make adequate wound extensions. We talk about having a systematic approach to the wound. I will divide it into a clock face if I got a tonic a off. So I go from deep to superficially so that I don't cause bleeding in the skin that cascades down into the wound. Excuse my picture. If there's a tourniquet on, there are start from superficial, too deep. So I got complete control. I work around the clock from 12 all the way around to 12. We're going to create a tunnel, not a funnel and we're gonna exercise everything that's dead and everything that's heavily contaminated. Fat is poorly vascularized and the dye often needs to be debrided and then you cannot afford to leave any contaminated muscle behind because muscle is the ideal Petrie dish for those type of environmental bacterias that are going to go on to cause gas gangrene with the consequence of gas gangrene, myofascitis. Effectively, you're looking at amputation to save life and we want vast quantities of irrigant drinking water is appropriate. You don't need to use sterile saline. And if you don't have much of it, and we want low pressure pressure irrigation devices, drives bacteria into the wound bed. Therefore, at 72 hours, you get much, much higher wound bed contamination. And compared to low Bob, and you really want to keep your organisational and your institutional experience. So you need some good documentation to assess the neurovascular states than in photograph. If that could accompany or be sent to the higher echelons of care that's really important and you want to divide, do not close dress. And then the other thing is to have some discussion before deciding you can reach out for decisions. Report the British Orthopaedic Association backers are published guidelines about how they would want the wound extensions. In terms of the tibia, the green here marks the subcutaneous border, the tibia, the blue on the medial aspect of the leg is 15 millimeters behind the subcutaneous medial border of the tibia. You look at the red cross is that are there those are said to represent the perforating vessels that lie for 12, 16 or 5, 10, 15, depending what literature you read. And they lie in the posterior skin flat and therefore that keeps that posterior skin flat, reliable and makes it suitable to act as a local distantly based media fashion, cutaneous flat to cover defects on the subcutaneous border of the tibia, on the lateral side of the leg, make your incision, approximately two centimeters lateral to the tibial Crestor, the subcutaneous border of the lateral tibia that takes you right the way into the anterior compartment to decompress the perennial or lateral compartment by accessing it through the anterior. Other surgeons make their incision more laterally so that you come down onto the sector itself. And therefore, you can physically see the difference between the anterior and the perennial of the lateral compartment. And you make a hate shaped incision across that. So you cross it. And if you get direct vision by doing that, you create a degree of the gloving and tissue injury, which in the context of having a war wound to the same limb, puts extra burden on the skin and put an extra burden on the wheels. So therefore, in the context of an open fracture or in the context of a war wind to that, Lim, I really would advise you to do the the approach which two centimeters get anterior compartment across into the paradigm and confirm that by feeding the fibula under direct vision, the key learning points I would tell you for this is make sure the limbs reduced before you do the official. If the limbs askew or slightly rotated distantly at the level of the fracture, it can be very difficult to line up the things and then you come to reduce the limb with the external fixator in very large people or legs, which are incredibly swollen. It can be difficult to work out how much skin that you need. If you make your skin bridge to narrow, it will act as a by pedicle flap. And therefore you can move it across and graft the second defect going forward. But try and keep about hands breath minimum or eight centimeters across the anterior aspect of the tibia. The extensions give you access to the back of the wound, give you access to the muscle are allowed to debride it properly. And at the same time, this highlights the perforating lesson. The other thing that you must comment on in your op note and for the future surgeons is the degree of degloving on this posterior skin flat because obviously the skin is degloved. You're not going to be able to use it reliably for the local fashion contains flat reconstruction. You should be making a note of this routinely in your operating documentations that you get into the habit of always checking as well. So draft energized fragments are going to be deposited. The commonest form of extremity injury and extremity injury predominates in modern warfare. Now, you don't always have to operate on this. If you're in a resource normative environment, you can pick them out so they don't tattoo and you can give them a good scrub and leave them open if they're in the dermis or subcutaneous. The one exception to that I would say, which really does need a good surgical scrub is facial tattooing, which is really quite common. It creates a lifelong psychological problems and I would really advise you to address it as soon as possible. How long is too long to wait? I don't know. I would assume it's between about eight and nine hours, but as soon as you get them into theater the better and I would try to go up to 24 hours afterwards and then to improve the cosmetic appearance. There are some wounds which you don't need to operate on them at all. So small fragments that pass through the limb with no fracture, no other markers of high energy transfer, such as neurovascular deficit, confusion to the skin. If the lymph feels soft, the energy transfer has been minimal, then I think it's entirely appropriate to excise the wound energies and dress this do not close. Give them a course of oral antibiotics and arrange follow up. If you've got a fracture, neurovascular deficit, the limb feels swollen, tense is unduly painful. And obviously, I think you're committed to surgically exploring this. But operative a bribe mint comes with a price in terms of physiologically to the patient and in resources to your healthcare facility. Because what you want to do is I said before is with your sequence of excess extend debride reassess washout is create that untidy wound into a clean healed. And at the end, which allows the patient to have some form of prosthetic rehabilitation. So classically in the limb, you see situations like this, this has obviously got markers of high energy transfer and contamination limits, swollen gets tense, it's covered in dust. There's a ski me to the to the wound edges with necrosis and you can get a sense of that medial aspect of the limits really bulging. There's a tourniquet of light. And again, you see how by opening up the known in fasciotomy, the muscles barred in the lower limb, you just need to access the compartment itself. And then by making a full length and decision, you could space and allow the muscle to prolapse out and breathe. And obviously, on the medial side, you've got to take Cialis off the back of the tibia, you can feel that as you put your finger in there, there's a kind of arch around the back and that's got to come off to allow the vessels. You should be able to see the vessels fracture, neurovascular deficit, the flim feels swollen, tense, it's unduly painful. And obviously, I think you're committed to surgically exploring this. But operative debridement comes with a price in terms of physiologically to the patient and in resources to your healthcare facility. Because what you want to do, as I said before is with your sequence of access extend, debride reassess, washout is create that untidy wound into a clean healed. And at the end, which allows the patient to have some form of the prosthetic rehabilitation. So classically in the limb, you see situations like this, this has obviously got markers of high energy transfer and contamination limits swollen. It's tense, it's covered in dust. There's a ski me to the to the wound edges with necrosis and you can get a sense of that medial aspect of the limits really bulging. There's a tourniquet of light. And again, you see how by opening up the known in fasciotomy, the muscles barge in the lower limb, you just need to access the compartment itself. And then by making a full length and decision, you could space and allow the muscle to prolapse out and breathe. And obviously, on the medial side, you've got to take Cilias off the back of the tibia, you can feel that as you put your finger in, there's a, there's a kind of arch around the back and that's going to come off to allow the vessels. You should be able to see the vessels, how you dress it. Think dressing is relatively controversial subject something light gauze like which is not adherent would be ideal. There are certain advantages to having topical negative pressure in some wounds. But again, just dressing a wound with fluff gauze wrapping it up provided it's been adequately divided is a safe thing to do. You might choose to use an interface dressing such as Mettetal adaptic touch gel, Annette vascular in gauze over those structures which too delicate neurovascular bundles, raw bonin's, etcetera or cartilage, otherwise just fluff cause is perfectly adequate. And there's really good video on this in the International Committee for the very cross website about how they would like to treat it okay. But, and in the upper limb, this is how the fact shot to me is really, this is kind of one way of doing it. And this is the way that I would advocate from a military perspective which preserves potentially three different flats. And my key point about this was to look at the individual epee. Um I assume for each muscle, topical negative pressure that William also has the advantage is that you can sculpt it and mold it and place the hand into a position of safe demobilisation in a way that is more difficult to do withstand a plaster of Paris techniques. Just be mindful though is that when you put a limb completely encased in topical negative pressure, when it comes out, it looks macerated, it looks like you've had the hand in a bath two or three hours and don't be upset by that. So that's kind of like a get you in guide. So what I would advise you to do from the from the next evidence, identify those key and Timoptic structures. There's those surgical explosions and orthopedics by hock and field devore, which is one of the great text you may have to go outside your comfort zone and find those neurovascular bundles proximal to the war wound and then chase them through, look at them throughout the whole extent and then see them that they're on injured as well. By doing that. You're identifying the neurovascular injury at the time. And if there's a nerve injury, you can document it even though you may not want to do anything about it. Our practice has been not to tag the nerves because it creates another area of fibrosis and it may preclude you doing probably, you know, prepare but I take it some centers are keen for you to tag them to aid future identification as well. The deglove skin, remember I said, just leave it where it wants to sit. Deglove skin is incredibly fragile and maybe precious to you if you stretch it to pull or move it in a way that doesn't want us to do cause it further skinned a crisis as you put pressure on subdermal Texas and I'd like to introduce you. Now these no matter how good your divide mint is, if the energy transfer from blast of ballistic injury has been such, you will have a concept of a wounded evolution. Either wound is changing albeit slowly and therefore you're going to have to have a repeated look at the room in the second look, monitor addressing the ongoing areas of sepsis or further tissue. The crisis. I don't want there to be excessive Paris to strip pick. I want to deliver the bone ends by adequate extensions and I feel it's my job as the plastic surgeon to be able to in an Ortho plastic approach to give the orthopedic surgeon the ability to look at the whole bang. We pull that bone if it's attached, leave it there, consider where you're going to put your pins for how you're going to stabilize them, them in the upper limb. There's only a very few occasions which I think you're compelled to use an external fixator. And I think plaster of Paris, topical negative pressure or a decent dressing is more than adequate for almost all injuries to the two and the upper limb in the lower limb stabilizing. A formal factor is lifesaving with an external fixator, a typical fixator. So have a really careful think about where the zoning injury is making a Felicia pins. I've written briefly about tough tissue reconstruction considerations and damage control environment. Previously, Rudy you can do even though there's thoracoabdominal, the control of hemorrhage going on, you can make real real differences to people. Get some concurrent activity going on. Have a look at the back, have a look at the perineum. Decide amongst you who does the eyes first. You've got everything against you for this, for sepsis. You've got abbreviated surgery, some of the massive transfusion who may be cold and a high degree of contamination. So everything stacked against you to try and influence as much as that if you can get them warm, reduce the burden of contamination, product or solicitation to minimize their coagulopathy and minimize the ongoing blood loss and abbreviated surgery, unpleasant to quit. I blast injury is the biological shrapnel and this has been seen both in civilian trauma and also in military trauma. So you need to have a protocol and the public Health England. One is a pretty good place to start about how you're going to deal with that. There's a psychological component that too, just looking for it and being aware and being appreciative is key I female. But it is you got to look after hepatite, you know, screen for HIV, the tetanus also speak to the patient as well. And there are other guidelines which are from the NHS which are really helpful up. I found both not in terms of team organization and how you might cope with those events where you are suddenly overwhelmed with casualties either by particular tiger uh to transfer the movement of casualties between facilities. But I think when you're receiving someone in, from, from another facility, you've got to look under every address and you've got to look as soon as you reasonably can. So what would I told myself when I first started? Well, I would have gone really, I would have really stressed the importance of microbiological sampling and if, if you have the ability to do it, I would do it now or the beginning of the procedure at the end, what you're leaving in that wound that may go on to cause mischief is what I'm really interested. Then the other thing is you're gonna be fatigued, you're gonna be working outside your comfort zone and you're going to be tired. And therefore what you want to do is minimize the amount of thinking you have to do. And we have, this is called bundles of care, spinal injury, bundle, open fracture, bungle, try and tie everything up. You don't want to be thinking, obviously, everyone will be thinking about the individual application of the surgery to the, to the patient. Everything else that goes along with it, you want to just bundle up. So if you've had a traumatic amputation, a massive transfusion, you've been injured in a, in an agricultural environment in the field of fighting, then you just want to, are we going to start anti fungal straight away? Is that part of the bungle? Are we just going to do this? And that is just the algae sick wonder is this the antibiotics bundle just put them together in, in your individual facility, work out what your abundance going to be for each and that just takes the pressure off. You gives you the ability to manage everyone in, in a common fashion. I would leave the nerves long initially at the initial deployment and I wouldn't do any traction directed to your opponent. It gives you so much more options later to one when they go back to the, the definitive care and I wouldn't have cut the machine. I would have kept better notes, better photographs. And the final thing that I would do the posterior winds first. Yeah. If you get the obstacle treaty, turn them, do those rooms first. Dress them then over, then address everything in the limbs back this anterior. And then if they become unwell, it's much easier for the new sister to manage. You haven't forgotten those posterior winds because at the end, you're tired at the end when there's a great desire to get on to the next case, flipping them and doing those posterior room to be the last thing you want to do. And it's easier to miss something. The butter crease in the perineum perianal that will go on to cause significant mischief to into two union patient's really, I want, this is a patient who's on our award amendment and I think I have an array of different techniques that you would want that you would like to use and apply them. So he's got pedicle DLD for his arm, which was subtotally amputated. He's got a free flat for his Angkor. That's the sinusitis split screen class. And he's got artificial dermal matrix over his transforming, he lost his leg as part of the damage control procedure whilst his arms being shunted and then we made up with physiologically able to, to correct it. And it allowed him to have a definitive surgery really quite quickly