A fractured peace: a changing pattern of violence

Since the paramilitary cease-fire in Northern Ireland in August 1994 we have seen a change in the pattern of so called ‘punishment attacks’. Shootings with low velocity handguns have been replaced by severe beatings to the extremities from multiple assailants using iron bars or similar weapons. In the 18 months prior to the cease-fire there were 177 punishment shootings, which were usually relatively minor and did not require any plastic surgical expertise. Between August 1994 and November 1996, however, there were 461 punishment beatings. These beatings result in much greater morbidity and require considerable orthopaedic and plastic surgical input. In the Northern Ireland Plastic and Maxillofacial Unit we have treated 18 patients with a mean age of 22.9 years (range 16–32 years) who have been the victims of punishment beatings. These patients sustained multiple injuries, all with severe soft tissue involvement; 70% had compound fractures. The majority of patients had multiple wounds. Four patients with compartment syndrome as a result of their injuries required fasciotomies. Soft tissue reconstruction included split skin grafting (4 patients), fasciocutaneous flaps (4 patients), adipofascial flaps (2 patients), local muscle flaps (2 patients) and free muscle transfers (2 patients). Six patients required more than one procedure for soft tissue reconstruction because of multiple injuries. Each patient had a cumulative mean time in theatre of 6.7 hours. The mean hospital stay was 22.2 days (range 2–52 days). This change in the pattern of injury has led to an increased use of plastic surgical resources. Patient morbidity is significantly greater than when guns are used, and permanent disability is often the result.