J Am Acad Orthop Surg, Vol 18, No 2, February 2010 Maj W. G. P. Eardley, MB ChB, MSc, MRCS (Ed) RAMC and Col M. P. M. Stewart, MB ChB, QHS, FRCS (Glas), FRCS (Tr & Orth), L/RAMC From the Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, West Midlands, UK (Dr. Eardley), and the Department of Orthopaedics and Trauma, James Cook University Hospital, Middlesbrough, UK (Dr. Stewart). Complex hand wounds are an unfortunate consequence of conflict. Increased battlefield survival rates have resulted in an evolving range of ballistic hand trauma encountered by deployed surgical teams, requiring increased knowledge and understanding of these injuries. In the civilian setting, the combined threats of gun crime and acts of terrorism warrant appreciation for such injury among all surgeons. Surgeons often have to relearn the management of ballistic hand trauma and other aspects of war surgery under difficult circumstances because the experiences of their predecessors may be forgotten. Current evidence regarding these injuries is scarce. Ballistic hand trauma is rarely isolated. The demand on surgical resources from combat injury is significant, and it is imperative that a phased strategy be followed in this setting. Minimal, accurate débridement and decompression with early stability are crucial. Delayed primary closure and an awareness of future reconstructive options are fundamental.