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I'm going to start by talking about the the basics of ballistic injuries. And the reason I'm going to do that is because there are differences in children's injuries which are explained by the basic principles. So I'm going to start with that, even though you are familiar with them, they're going to just go over some reasons why Children are different from adults, talk about the initial management and the definitive management of children's war injuries. And then finally you talk about amputation and growth. So most of the injuries that we see either due to a projectile, something that's come a long distance and and hit the casualty or due to a blast injury where an explosion has happened in the vicinity of the patient. So when you read military textbooks, quite often, they spend a lot of time talking about the velocity of bullets. And I think it's important to remember that you're not treating the missile or the injury, you are treating the wounds that the patient receives and that that may be related to the methadone is um of injury, but it is specific to the patient. So we'll start with projectiles. So very simply they start a long way away and they hit the target and the amount of the damage caused by a projectile is caused by the transfer of its energy. It's kinetic energy to the target. And what you're seeing frequently now are shell fragments or shrapnel bits of an exploding device which are just of random shape and indiscriminate what you're probably not seeing and hopefully won't see much of is bullet injuries. But I'll just go over how they differ because there are some very specific things to realize about a bullet wound that that may affect the way you treat them. So a fragment injury, it's uh the amount of damage it caused depends on the size of the fragment and how fast it's going. So here is a, a small injury caused by uh a detonator which is low energy but has been sufficient to penetrate the skin. So in contrast, a large shell fragment from a large explosion is capable of taking off somebody's legs as, as a 15 year old girl and who just lost both legs instantly. And obviously where, where the fragment hits, where in the anatomy is, is very important. The fragment will give most of its energy on impact with the patient bullet though are designed to travel long distances by having a minimum friction with the air and so long as they remain in a stable flight, they don't cause much damage because they don't cause much friction once the bullet is hits something and loses its energy is, is stopped. Or if it fragments, then suddenly the energy of the bullet is is is released in a small explosion. And obviously where it hits is important, a move on to this. So this is the what happens when a bullet is fired into material which is the same density as the human body for time, it just drills through and doesn't cause much damage and then it tumbles and causes an explosion. So if we look at this section where it's moving where it is in stable flight, this bullet has moved through this girl's leg and has caused very little damage. And if the bone is intact and there's been little energy transfer, you don't need to expend resources on operating on this wound. A similar case bullet has gone in here, come out here and has just made a small hole in the spinous process of the cervical spine. So minimal energy transfer and therefore it has not much caused much damage. If we look at the explosive effects though, such as this bullet that has trans first a person or this bullet which has hit an object, then the damage is considerable but very localized blast injuries. Uh So the although this is a dramatic injury, the amount of energy is relatively small and localized. Whereas in a blast injury, the they transmit a high energy, various forms of energy and to multiple sites. So if you look at an explosion, we have thermal energy burns, we have the wind of the, the blast and also this shell of acoustic energy, which is the shockwave. So while we understand very well, what burns do and what kinetic energy does the shock wave is something we don't understand very well, but which probably causes a lot more damage than then we uh understand. So you may have seen landmine, patient's or other blast injury. Patient's where tissue that looked as if it was viable when you operate on, it dies after two or three days afterwards. And this we think is probably due to the effect of the shock wave in a blast injury. So just a series of pictures which I think of self explanatory about a small explosive device, the shockwave will pass through the patient, the blast wave and the heat will then start to cause local damage. And then there are fragments thrown off which act as projectiles, the blast wave on a landmine or a small sub munition, blast up the bone and strips away the tissues causes burning to the tissues and also the effects of the shockwave. So in Children, the important thing here is the fact the damage to the periosteum, which is one of the main differences in children's injuries as well. Come to later, the typical landmine injury, the foot has been removed, but the damage will have gone all the way up almost to the knee damage to the opposite leg and then fragments to the perineum and also to the face. Okay. So two Children, why are Children different? Well, these things are obvious but important. They're small, they are soft, they are elastic, they're stretchy and they grow. So the same injury that causes a localized trauma to an adult will cause multiple injuries to a child because of the their size. So a small, very small blast injury which might cause local damage to an adult can cause devastating injuries to a child. So here's a case that I saw a child who stood on a submunitions from a cluster bomb had little tiny marks on the chest and abdomen. The injuries were caused by fragments of plastic, only a few millimeters across which blew off a toe and made little holes in the tibia that went through into the bone. So all these look like minor injuries, but the and the abdominal injuries seemed to be superficial. But the next morning, this child has peritonitis and had eight bowel perforations from little bits of plastic. It's very difficult to detect these. But if you see an injury which has caused even small damage to bone, then assume that it it it may have caused bigger injuries to viscera. So bullet injuries that it will hit hard adult bone cause this shattering effect. But when it hits soft children's bone, the effect on the bone is different. So a bullet or fragment, we didn't know which has come through here, splinted the bone and then tumbled into the other leg causing to injuries. But the bone is flexible and it splits as opposed to fragmenting. The other consideration is the skin and skin in the child is very much more elastic. And so, although this looks dramatic, this is a bullet wound that's gone through and through. These skin edges may very well survive. And it's, it's worth just leaving skin to see in a child, particularly to see whether it survives rather than excising it all. So again, relatively soft bone, the the bullet instead of shattering, the bone has passed through it into the other bone but has passed through that as well causing what looks like devastating injury. But actually, the the bone that the amount of damage is not as bad as it looks a big difference in the growing skeleton is the periosteum. This is the the with the depth of the periosteum on a child compared to that on an adult. While we all recognize that periosteum has an important role, supporting bone in an adult in a child, it actually creates bone. So again, when operating, preserve as much periosteum as possible, we know this this hierarchy of management. You save life before you save limb. And then in orthopedics, we say you save limb before you save a joint. And then children's orthopedics, you say you say the joint before you save growth. So we always look after growth plates, but only after you've done the more important point. So the initial treatment for any of these injuries is first to control bleeding, then control contamination by exposing the fracture, wide exposure, excise devitalized tissues, but try and leave as much skin as possible, then leave the wounds open with a addressing that an exclusive dressing or negative pressure dressing for 3 to 5 days and stabilize fractures by whatever means, the simpler, the better and that gives the time, give the time then allow the child to resuscitate to uh to be, be made better before we consider any further surgery. If you need a tourniquet, it should be applied as close to the wound as possible. This tourniquet has been applied much further up the leg and if it's on for too long, then we'll require an amputation which is closer to the joint in Children. It's very important to that they lose as little blood as possible. However, it's also quite often possible to control bleeding in a child with simple elevation and pressure, which may be as effective as a tourniquet. If you have the resources to do that, if you need a tourniquet, of course, you need a tourniquet. Removing the loose fragments of bone is of course very important and it is a question of making sure you've removed anything that is has no blood supply while especially in Children, leaving anything that has, that has soft tissues. So you may be left with something like that looks like this. But in a child, as I'll illustrate uh in a minute, then the periosteum may fill in the gaps over time. So this is just a an illustration. But this is what we, we observe. This is a bone periosteum cortex and the medulla of the bone, the fragment goes through and creates um damage to the periosteum, destroy fragments, the bone and this is what you operate on. It's important not just to remove the loose fragments, but anything else that doesn't have a blood supply. And what you're left with then is a sleeve of periosteum with fragments of bone attached to it which over time reforms the bone. And we can see this in even thema fractures treated on simple traction that the bone will reform to a surprising extent. So while that works for fragment injuries, blast injuries are of course, completely different because in this case, everything is destroyed, including the periosteum, which is what makes the difference for children's bone healing. So after the surgery, um then bandage and put uh inclusive dressings on the injured part. And another great thing about Children is they do tend to recover so much more quickly than adults when you're approaching the bone. Uh top tip, you standard surgical approaches where possible. So in this uh a proximal femur injury, the wounds, the uh yeah, the wounds are not in the line of uh standard approach but use that standard approach to approach to expose the bone so that it is extensile and you can, you are in a safe place. So errors that we see as both not excising enough of the damaged tissues or doing the opposite and sometimes both in the same patient and the other. Um the other sin is immediate wound closure of any ballistic wound. So here's a some this person had a large skin excision, but the all the deep damaged tissues have been left uh undisturbed. And on the other hand, this is a case of the young girl who had small wounds, which could have been approached through a longitudinal incision instead of which uh over enthusiastic excision of skin has been done. Uh which is something we see surprisingly often. So particularly with Children with elastic skin, which survives blast injuries and, and uh fragment injuries surprisingly well leave what skin you can and I'm sure you've seen the effect of closing a war wound too early. You will simply end up with an infected wound. It's much safer to leave everything open until you're sure it is clean. The definitive treatment team up with your plastic surgeons try and avoid putting metal wear into particularly in Children until you're absolutely sure things are clean. I'll consider traction for fema fractures because they can heal very quickly uh with fragment wounds. And finally, external fixation, I think is the the best method for stabilizing tibia fractures in this situation. So this is a very simple traction frame. I know it's very old fashioned, but it's a safe method of treating uh projectile wounds in particular, which can heal quickly. So skeletal fraction through the tibia and after only four weeks, you have abundant callus, I'll just run through another few cases, uh shotgun injury to a tibia treated with a ring fixator with uh for four months, uh mangled extremity. And again the principles of saving life, then limb, then the joint in order to save the limb, the growth plate has been has had to be ignored in in terms of yeah, stabilizing the bone in a child because of the plastic surgeons won't let us near them sometimes. Then a plaster, simple plastic cast may be sufficient for initial treatment of the tibia. The growth plate unfortunately didn't survive but the child is alive, the joint working and we can do limerick construction at a late some years down. The line. Traction on bilateral femurs is perhaps asking too much but external fixators work in a very young child. This child was the fragment injury saw earlier four or five years old, we did uh simple soft tissue wound debridement and then pins in plaster, very old fashioned. And on this side, the bone was pushed inside uh the proximal fragment to stabilize it. And a simple plaster of Paris on top and they healed if you are feeling more ambitious than intramedullary fixation of a femur is of course possible. But I would suggest that after debridement using external fixator for at least two weeks to ensure that the wound is clean. Before implanting metal wear. For unstable injuries, you can reinforce intramedullary fixation with external fixators. If more stability is required, uh forearm, of course, the ulnar is easy to uh stabilize with an external fixator. And if the radius wound is not involved in the wound, then consider a hybrid fixation. I've never put a, never been happy putting an external fixator on the, on the radial shaft, I just can't do it. Um I'd just like to go quickly through uh some rules for amputation in Children. This is a standard classic blast injury, but the heel pad was largely intact and attached to the posterior soft tissues. Unfortunately, this child was treated as if they were an adult and had a proportionally appropriate amputation through the proximal tibia. That this is an error in a young child for some reasons, which I'll explain. So if you amputate a uh a bone through the bone in a child, the remnant doesn't grow as much as it would if the bone had been intact and it gets worse off the end of the stump very often grows a spike of bone. So this isn't normal growth. It's, it's uh intramembranous growth which goes through the tissues. And so the it continues to grow out until a child can't wear a prosthesis So if you can, a better approach is to amputate through a joint and you can then at a later date, manipulate growth if you want to keep the stump a little shorter for adult life. So this sort of this preserves the length, it preserves growth and this is an end bearing, comfortable stump for a child. Other ways of keeping stump. This is a child who lost both legs to a landmine but also had a femur fracture rather than amputate through the fracture, which is uh what is often done, the whole femur has been stabilized through the through the amputation. Uh This child also had a fema uh femoral neck fracture due to the the actual load, but it was left eventually with a stump that could take a prosthesis. Finally. Um what amputations uh whereas this would be probably not acceptable in an adult Children can function very well or surprisingly well on partial foot amputations. And that is a useful thing to take them through their growing years. But what you will often find then is as they become as they get to adolescence and adulthood, then because the bone has ossified that they are heavier that the half foot is not tolerated and they may then wish to have a definitive amputation at a high level. But there are certain advantages particularly to a younger child of having a life without a prosthesis. Amputation rules goes distal as possible, preserve as much length as possible in a child because the, the remnant will not grow as long as you expect. If you can possibly go through amputate through a joint instead of through the bone in a young child, please do. Sometimes it's worth employing plastic surgery to make this possible. Don't throw away skin in a child. It's, um, it's, it's difficult to replace and it usually survives where you don't think it might. And despite what it says in some textbooks, you can skin graft the end of the amputation, pin a child. And uh it's, it's, if it preserves length, then do so. It is said in the UK, sometimes you can't split skin graft the end of the amputation. But you can, you, you definitely can, we have done it in adults too, but you can very definitely do it in a child. Um And it, of course, it's not ideal but it, if it preserves length, if it allows you to amputate through a joint, if it allows you to keep the knee joint, for instance, then it is definitely worthwhile. So as you know, it's all about energy transfer, but it's different in a child because of the, the the different properties of a child being more elastic, being more stretchy multi system injuries, more common in Children because of their size, blast wounds are horrible as you well know, and they get worse and Children lose the advantage of their periosteum in blast wounds and have all the same problems that adults do. I'm interested by the influence of, of shock wave of the acoustic trauma which can cause unexpected cell death, immune problems. Um and, and probably promotes uh these unusual infections you get in blast wounds. So, uh an area for research and finally, in Children just consider, try and preserve growth where you can but bearing in mind the priorities and, and try not to damage the growth plates if you can avoid it.