Massive Transfusion Protocols in Orthopaedic Trauma: Lessons from the Battlefield

Background and Aims: Uncontrolled haemorrhage remains a leading cause of preventable mortality following traumatic injury. Orthopaedic trauma—particularly injuries involving the pelvis, femur, and complex extremity wounds—contributes substantially to exsanguination and early trauma-related deaths. Objectives: This narrative review aims to describe the evolution of massive transfusion protocols (MTPs) from military to civilian trauma care, examine their integration into orthopaedic trauma practice, and outline future directions in haemorrhage control and resuscitation science. Methods: A narrative review of the literature was conducted focusing on the development of MTPs during recent military conflicts and their subsequent adaptation to civilian trauma systems, with particular emphasis on implications for orthopaedic trauma management. Results: Over the past two decades, MTPs have transformed trauma resuscitation by promoting early balanced transfusion strategies using predefined ratios of red blood cells, plasma, and platelets. These approaches have replaced earlier practices dominated by crystalloid resuscitation and delayed plasma administration. In orthopaedic trauma, early haemorrhage control and damage control orthopaedics have become integral components of damage control resuscitation. Battlefield-derived principles have expanded the role of the orthopaedic surgeon beyond skeletal stabilisation to include active participation in haemorrhage management within multidisciplinary trauma teams. Conclusions: The translation of military resuscitation strategies into civilian practice has significantly influenced modern orthopaedic trauma care. MTPs have reinforced the central role of orthopaedic surgeons in early haemorrhage control and interdisciplinary trauma management. Ongoing refinements in resuscitation strategies and transfusion science are expected to further optimise outcomes in patients with severe orthopaedic injuries.