War is changing; modern conflicts appear likely to be fought in urban or remote environments, producing different wounding patterns and placing non-combatants in the line of fire. Military medical skills training and available resources must reflect these fundamental changes in preparation for future conflicts.

We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.

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We report on the survival of 145 patients presenting to a single centre with a pathological metastatic fracture of the proximal femur. The single surviving patient had a follow-up of 17.7 years. Mean survival for the 144 patients who died was 332 days (range 2 to 3053 days), being longest for those with myeloma (662 days), lymphoma (> 633 days) and breast tumours (477 days) and lowest for lung tumours (110 days). The most common sites for the primary tumour were breast (36%), prostate (23%) and lung (17%). 47% of fractures were intracapsular, 28% trochanteric and 25% subtrochanteric. 99% of the fractures were treated surgically with a mean hospital stay of 19 days. The commonest fracture healing complication was further fracture of the femur around or immediately below the implant which occurred after 9/144 (6.2%) of operations. The difference in survival of patients related to the primary tumour site is of relevance in planning surgical treatment and discussing prognosis with patients.