Hospitals and medical facilities in civil practice generally have better access to resources, including medical equipment, skilled personnel, and rehabilitation services. In disaster zones, resources are often scarce, and medical facilities may be overwhelmed. Orthopaedic surgeons must work with limited resources, adapt to challenging conditions, and make quick decisions to address immediate life-threatening injuries.

Triage: the more critical is permanent marker and paper

Various criteria can be used to classify situations [15,16,17]. Analysing and comparing disaster protocols can be challenging, with some classifications incorporating multiple criteria, potentially increasing complexity.

The important thing for triage is to have a permanent marker and paper. One of the authors remembers receiving a bus of 30 people alone in Africa; the reality is that when you are alone, you don’t have time to use all the classification tables for triage. You also don’t have time to check patients several times. So, after the patients’ examination, the most important thing is to take a sheet of paper, staple this sheet to the patient’s clothing, or write directly on the patient’s skin, what you found and what you are going to do. Once you have done what you have to do, for example, an amputation, the second most important thing is to write on the dressing the day and time of the amputation for the patient in question. It will be helpful for the following surgeon or yourself if you remain alone after 24 h!

Amputation: doing it is more challenging than talking theory

One of the authors was for 30 years at the head of the department of one of the largest polytrauma centres in France. The decision to amputate is always tricky, and most of the surgeons (except vascular surgeons) have no real amputation experience. At the end of the twentieth century or the beginning of the twenty-first century, even in hospitals receiving a lot of polytrauma patients, the frequency of amputation does not exceed 15 amputations per year, even during the periods of civil attacks, as in the Bataclan [18]. For comparison, Larrey, Napoleon’s surgeon, carried out more than 100 amputations per day to save soldiers during the Russian campaign, and this was without anaesthesia. We must remember that if the surgeon does not have experience of humanitarian disaster, previous earthquake, or war practice, the most experienced surgeon after 20–30 years will have less than 200 amputations in his experience, i.e., the equivalent of three days of Surgery for Larrey during the Russian campaign. In a survey in France, 95% of orthopaedic surgeons had never performed amputation, and 99% never in children.

The rules established in the nineteenth century by Larrey [9] have changed much less than one might think and deserve to be repeated. Given the impossibility of determining the precise boundaries of traumatic tissue damage and the risk of local and often generalised surgical infection, the use of any method of closing the wound surface is inadvisable. The stump should remain open. In case of doubt about the risk of infection, a guillotine method of amputation and/or disarticulation of the distal part of the limb is a first step before revision of amputation. This method allows prompt truncation of limbs in the first treatment phase and without blood loss. Subsequently, after the stabilisation of the general condition of the patient, a revision of the level of amputation can be discussed.

The main surgical treatment option for crush syndrome is amputation [1]. Mortality and crush syndrome severity are correlated with thigh injuries. In the case of crush syndrome, amputation is a lifesaver, and fasciotomy should not be preferred. This procedure ought to be the last resort that is usually done above the fracture in case of crush syndrome.

Amputation for an open fracture without crush syndrome is different from an amputation related to a crush syndrome. For an open fracture, the surgeon must follow principles of maximal sparing of viable tissues in the injured limb and maximally possible preservation of the length of the extremity. Amputation in children should not adhere to the generally accepted level of limb truncation. This is due to continued growth in this segment and the possible delay in the growth of the upper limb. Attention to the preservation of growth cartilage is necessary in children. It is crucial, for example, to amputate in the ankle joint, to be certain to preserve the distal growth plate of the distal tibia.

Amputation in civil practice is guided by established medical ethics, patient consent, and legal frameworks. The process involves collaboration between the patient, his family, and the medical team. In a disaster zone, the situation’s urgency may require medical professionals to make rapid decisions, but here also, religious and family consent should be researched if the patient is not able to answer.

Usually, there is no external fixation or very few on the site of disaster

Stocks of external fixators are large worldwide, but only in manufacturers’ cupboards. Experience has shown that the external fixators are often not where they need to be! Even in developed countries and even in places where one would think that they are in large numbers, like capital cities, the Bataclan experience showed to one of the authors (head of the department) that the reserves of external fixatives in civilian hospitals were low: no possibilities to make more than five assemblies using an external fixator in the same night in the same hospital. To have external fixators delivered on the weekend may take 30 h for a hospital in a European capital, that is to say, the same time as to return from the international space station (Fig. 1). It doesn’t seem that this has changed in the last ten years. There seem to be more stock external fixators now, but no one knows precisely where they are! The unfortunate rule of experience and innovation also applies to disasters: “Experience is the sum of the mistakes one can make in one’s life, but usually it is not transferable, and each generation must repeat its experience”. “Innovation is sometimes simply a new experience that we are doing”.

Fig. 1

Difference between kilometric and hourly distances

Don’t forget plaster and debridement!

In 970, Abu Mansur Muwaffak, a Persian pharmacologist, suggested in his pharmacology book that for fractures and other bone injuries, applying plaster to the limb would be beneficial [19]. Trueta [20] later innovated by introducing the concept of open fracture care using plaster of Paris. Trueta challenged prevailing opinions by asserting that the primary risk of infection was in the muscle rather than the bone. His recommended approach involved debridement of the wound, excision of bruised tissue, drainage with sterile absorbent gauze, and allowing the wound to heal by secondary intention, followed by the application of a plaster cast to the limb. Additionally, the technique of using pins in plaster, especially for open fractures, was a simple method applicable worldwide, as plaster is commonly found in medical kits.

Antibiotic resources are limited, and bacterial contamination is a constantThe medical kit

It may sometimes have a tourniquet [21] and a wide range of antibiotics. However, the risk of infection is accentuated by the combination of several factors: in a hostile environment, the transmission of pathogens is facilitated because the immune defences of the injured are immediately weakened due to stress and shock. Furthermore, we must not forget that the active medicinal ingredients may have become ineffective simply because the cold chain was broken during transport or simply during the storage of these medicines, which have sometimes travelled with difficulty several hundred or even thousands of kilometres.

Watch out for aggressive bacteria in open fractures

Bacteria like viruses, have no borders, and wanting to believe that in some areas of the world, bacteria have not yet developed resistance to antibiotics is undoubtedly a utopia.

A bacteria can develop resistance through mutations or the acquisition of resistance genes that give the resistance to one or more antibiotics. Bacteria can exchange genes. These exchanges are particularly problematic in the case of genes making the bacteria that host it resistant to antibiotics. Indeed, the acquisition of resistance by mutation is rare (one bacteria in a hundred million). But resistance genes can be exchanged between bacteria at a very high frequency (up to one bacteria in 100). Estimation shows that the typical adult human body [22] consists of about 38 trillion bacteria (half cells, half bacteria); therefore, exchanging resistance genes for bacteria in a humanity of 8 billion people is simple and quick! Antibiotic resistance is not specific to the “disease-causing” bacteria. It also affects the beneficial and non-pathogenic bacteria that colonise us and constitute our microbiome which are essential to our good health. These resistant bacteria then represent a reservoir of resistance genes which can be transmitted to pathogenic bacteria.

It is a global phenomenon. Antibiotic resistance affects all countries and is also present in animals and the environment. Antibiotic-contaminated environments, veterinary care, and human medicine all contribute to the rise in resistance. Humans, animals, and the environment can all contract resistant bacteria and genes through direct contact, as well as through ingestion of food or water. The “European Center for Disease Control and Prevention” (ECDC) has calculated that throughout Europe 33,000 deaths could be caused [23] by infections with bacteria resistant to antibiotics. The CDC in Atlanta reports an equivalent excess mortality in the USA. Data is lacking for low-income countries [24]. Still, the increase in resistance in these countries, combined with the lack of access to safe antibiotics—when they are needed—is likely responsible for many deaths.

Contaminants in crush injuries can come from various sources, including soil, vegetation, and microorganisms present in the environment. The risk of contamination may be higher in situations where individuals are trapped beneath debris for an extended period. The environmental conditions following a landslide, including the presence of mud, water, and other debris, can significantly contribute to bacterial contamination in crush injuries. Prolonged entrapment under rubble may increase the risk of acute compartment syndrome [25] and secondary infection.

The risk of contamination underscores the importance of appropriate medical care and time. Antibiotic administration as early as possible, wound cleaning, and surgical debridement are common strategies to mitigate the risk of infection in open fractures. Despite early treatment (in the first hours), most of them will become infected and often not be suspected [26, 27], as in many situations in surgery [28]. The precise strategy, however, might change depending on the particulars of every injury scenario and external fixation used after the acute period [29, 30]. Antibiogo, a smartphone app that assists non-expert laboratory technicians [31] in low-resource settings in measuring and interpreting Antibiotic susceptibility tests (AST) may help clinicians prescribe accurate antibiotics in a second instance.

Early and careful debridement is as important as antibiotics

A recent international study [32] from 61 countries confirms the statement of Trueta [19] done in 1939 about debridement. Examining 10,651 fractures, the likelihood of infection rose by 0.17% with each six h delay in debridement. Gustilo-Anderson type-III injuries exhibited a higher infection probability, increasing by 0.23% every six h, compared to 0.13% for Gustilo-Anderson type I or II injuries. The infection risk also varied between tibial and femoral fractures, with a 0.18% increase every six h for tibial fractures compared to 0.13% for femoral fractures.

Mobile phones and artificial intelligence are not efficient on the first day

Addressing the challenge of the geographical separation between local surgeons and surgical experts is paramount. Whilst mobile phones may seem like a solution, the unpredictable nature of disaster medicine introduces regular disruptions in telephone signals, hindering effective communication. Moreover, critical situations amplify urgency, leading to potential interpretation errors and cognitive biases. The language barrier, arising from differences in mother tongues amongst those involved, further complicates decision-making exchanges, adding a layer of confusion.