A FRACTURED PEACE - A CHANGING PATTERN OF VIOLENCE

Since the paramilitary cease-fire in Northern Ireland in August 1994 w e have seen a change in the pattern of so called 'punishment attacks'. Shootings with low velocity handguns have been replaced by severe bea tings to the extremities from multiple assailants using iron bars or s imilar weapons. In the 18 months prior to the cease-fire there were 17 7 punishment shootings,(1) which were usually relatively minor and did not require any plastic surgical expertise. Between August 1994 and N ovember 1996, however, there were 461 punishment beatings.(1) These be atings result in much greater morbidity and require considerable ortho paedic 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 be atings. These patients sustained multiple injuries, all with severe so ft tissue involvement; 70% had compound fractures. The majority of pat ients had multiple wounds. Four patients with compartment syndrome as a result of their injuries required fasciotomies. Soft tissue reconstr uction included split skin grafting (4 patients), fasciocutaneous naps (4 patients), adipofascial flaps (2 patients), local muscle flaps (2 patients) and free muscle transfers (2 patients). Six patients require d more than one procedure for soft tissue reconstruction because of mu ltiple 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). Th is change in the pattern of injury has led to an increased use of plas tic surgical resources. Patient morbidity is significantly greater tha n when guns are used, and permanent disability is often the result.