MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II

MEDICAL DEPARTMENT, UNITED STATES 4RMY

SURGERY IN WORLD WAR II

ORTHOPEDIC SURGERY

in the

MEDITERRANEAN THEATER

OF OPERATIONS

Editor in Chief Colonel John Boyd Coates. Jr., MC

Editor for Orthopedic Surgery

Mather Cleveland, M. D.

Associate Editor

Elizabeth M. McFetridge, M. A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON D. C., 1957
SURGERY IN WORLD WAR II

Prepared under the direction of

Major General S. B. Hays

The Surgeon General, United States Army

Historical Unit, Army Medical Service

Colonel John Boyd Coates, Jr., MC, Director

Major I. H. Ahlfeld, MSC, Executive Officer Captain J. K. Arima, MSC, Special Projects Officer

Donald O. Wagner, Ph. D., Chief, Historians Branch

Willa B. Dial, Chief, Editorial Branch

Josephine P. Kyle, Chief, Archives and Research Branch

II azel G. Hine, Chief, Administrative Branch

Advisory Editorial Board

Michael E. DeBakey, M. D., Chairman

Frank B. Berry, M. D. John B. Flick, M. D.

Brian Blades, M. D. Frank Glenn, M. D.

J. Barrett Brown, M. D. M. Elliott Randolph, M. D. Sterling Bunnell, M. D. Isidor S. Ravdin, M. D.

Norton Canfield, M. D. Alfred R. Shands, Jr., M. D.

B. Noland Carter, M. D. Howard E. Snyder, M. D.

Edward D. Churchill, M. D. R. Glen Spurling, M. D.

Mather Cleveland, M. D. Barnes Woodhall, M. D.

Daniel C. Elkin, M. D. Robert M. Zollinger, M. D.

Colonel Joseph R. Shaeffer, MC (ex officio)

Colonel John Boyd Coates, Jr., MC (ex officio)
ORTHOPEDIC SURGERY

in the

MEDITERRANEAN THEATER

OF OPERATIONS

by

Oscar P. Hampton, Jr., M. D., F. A. C. S., Colonel, MC, USAR

Assistant Professor of Clinical Orthopedic Surgery

ashington University School of Medicine St. Louis, Mo.

Foreword

Orthopedic surgery in the Mediterranean (originally the North African)

Theater of Operations developed by process of evolution. One would almost

be justified in saying that the surgery which was first performed was pioneering in character. Certainly, one is justified in saying that the early endeavors

culminated in superb treatment of combat-incurred injuries of the extremities.

The Mediterranean theater thus served as testing ground for the principles

and techniques which were applied with such success in the later campaigns

in this theater and by which these injuries were treated in the European

Theater of Operations in 1944 and 1945.

When United States Army troops invaded North Africa in the fall of

1942, almost no medical officers with previous experience of combat-incurred

injuries of the bones and joints were on active duty in the theater, and no

official, definitive policies had been established for the management of these

wounds. It was inevitable, therefore, that these combat-incurred injuries

should be managed by the principles and techniques then employed in peacetime practice and that they should be managed, also, by individual variations

of these principles and techniques.

brief experience showed that the methods employed, however satisfactory they might have been in the circumstances of peacetime practice, were

not satisfactory in time of war for variety of reasons; namely, (1) the logistic

situation in North Africa; (2) the timelag, which was frequently quite prolonged; and (3) the nature of most combat-incurred wounds, which were

devastating to degree entirely unknown in peacetime.

The new policies of management, which were based on the staged treatment of battle-incurred wounds, were first applied to soft-tissue wounds. By

the end of 1943, year after the beginning of combat in this theater, the practice was well established of managing this type of wound by initial and reparative surgery overseas, with reconstructive procedures reserved for Zone of

Interior hospitals. By the spring of 1944, it had become accepted practice to

use the same methods in the management of compound (open) fractures.

Before the war ended, they were also applied to wounds of the joints.

The most important consideration in the management of compound fractures and wounds of the joints was that of sound surgery. The sulfa drugs

were useful until penicillin became available. Penicillin proved extremely

valuable in the prevention and control of invasive infection. Both chemotherapy and antibiotic therapy, however, were always regarded as adjunct

measures. They were never considered as substitutes for indicated surgical

procedures.
VIII FOREWORD

Dr. Hampton’s comprehensive coverage of orthopedic surgery in the

Mediterranean theater during World War II is the result of careful planning.

Through the foresight of Col. Edward D. Churchill, MC, chief consultant in

surgery to the theater surgeon, surveys of special types of combat-incurred

injuries and other lesions of the hones and joints were planned and carried out

while the war was still in progress. The analyses of these surveys and the

conclusions drawn from them add materially to the value of this record.

It is fortunate that the subject of wartime orthopedic surgery is so

thoroughly covered in this volume. The errors made early in the war in the

management of combat-incurred injuries of the bones and joints are frankly

recorded, as they should be, to prevent the making of the same errors in the

event of another war. The validity of the principles of management which

were established in the Mediterranean theater was proved in actual combat.

They are still valid. These are the principles which must govern the management of mass casualties should total war ensue in the future. Details of

management may change. Principles of management are permanent.

The story that is told in this volume is record of hard experience. It

is story that should be generally known. For this reason, hope that this

book will find its way into the libraries of medical schools and that the principles which it sets forth will be incorporated in the curricula of these schools.

The medical students and young physicians who are our future medical officers

will find the history of orthopedic surgery in the Mediterranean theater

helpful introduction to the management of combat-incurred injuries of the

bones and joints.

S. B. Hays,

Major General, United States Army,

The Surgeon General.
Preface

In World War II, as in all previous wars, wounds of the extremities,

great number of which involved the bones and joints, constituted the bulk of

the surgical load. In the Mediterranean (previously the North African)

Theater of Operations, of 111,125 wounded or injured in action it is estimated

that 79,000, more than 71 percent of the total number, sustained wounds of the

extremities. significant proportion of these required orthopedic management.

Incidentally, the number of wounds of the extremities in this theater approximately equaled the total number of wounded or injured in action (79,526) in

the entire Korean conflict.

These figures are not surprising. In the Mediterranean theater, United

States Army ground forces experienced the longest period of continuous ground

combat which they had known since the War Between the States. With only

very brief interludes, in the early and late summer of 1943, they were in constant contact with the enemy from November 1942 until May 1945. They

fought from the shores of Casablanca across North Africa to Bizerte. After

short respite, they conquered Sicily. After another interlude, they invaded

Italy and fought up to the Swiss border.

The medical history of the Mediterranean theater parallels the tactical

history. The steady flow of battle casualties through forward and fixed

hospitals from November 1942 until May 1945 provided concentrated

experience in military surgery, unusual opportunities for the observation of

results, and, on indications, changes in both concepts and methods. These

changes are described in detail in the chapters of this volume. In brief, the

management of compound skeletal injuries in the early days of this experience

was based upon the concepts of plasma for shock, sulfonamide drugs for the

prevention of infection, and the closed plaster method for the management of

fractures and wounds. As the result of continuing observation of the results

obtained in the theater, each of these concepts was discarded.

Long before the fall of Rome on June 1944, the prevailing concepts were

that the most important preventive measure against wound infection was

adequate debridement at initial wound surgery; that whole blood was crucial

in the management of wounded men; that penicillin, used systemically, was an

important measure in impending or established infection; and that wounds left

open at initial surgery need not heal by granulation but, instead, that it was

surgically feasible to perform delayed closure of clinically clean wounds over

fractures, following which good results could be anticipated.

The delayed primary closure of soft-tissue wounds by suture, including

wounds associated with compound fractures, was not, of course, an entirely

new concept. It had been practiced to some extent in World War I. In that
PREFACE

war, however, the criterion of low bacterial count on repeated cultures of the

wound before delayed closure was undertaken not only made the method

impractical for general use but also, because of the repeated dressings necessary, was an invitation to secondary infection. In World War II, closure was

predicated upon only clean clinical appearance of the wound several

after the initial surgery. The method was, therefore, more widely applicable.

The lessons of World War had, in large measure, to be learned again in

World War II. Lives and limbs will be saved, and countless extended periods

of morbidity will be avoided, if the lessons derived from the Mediterraneantheater experience with musculoskeletal injuries as set forth in this volume are

put into practice without delay in any future war.

Oscar P. Hamptox, Jr., M. D.
XI

Acknowledgments

This reasonably complete and comprehensive record of the experience in

orthopedic surgery in the Mediterranean Theater of Operations reflects the

efforts of number of medical officers who served in that theater during World

War II. They include

Brig. Gen. (later Maj. Gen.) Albert W. Kenner, Brig. Gen. Frederick A.

Blesse, and Maj. Gen. Morrison C. Stayer, who at various times served as

theater surgeonand who had the overallresponsibilities for the medical activities

of the theater; and Col. (later Maj. Gen.) Joseph I. Martin, MC, Surgeon,

Fifth U. S. Army.

Col. Edward D. Churchill, MC, Chief Consultant in Surgery, Office of the

Surgeon, Mediterranean Theater of Operations, who guided the transition

which took place in the theater in the management of wounds of the soft tissues

and then in the management of wounds involving the bones and joints, and

which provided the pattern for the subsequent management of these injuries

in all overseas theaters.

Col. Frank B. Berry, MC, Chief, Surgical Service, 9th Evacuation Hospital,

and later Consultant in Surgery, Office of the Surgeon, Seventh U. S. Army,

whose observations on, and advice concerning, the problems of serious wounds

of the extremities was invaluable.

Col. Howard E. Snyder, MC, Consultant in Surgery, Office of the Surgeon,

Fifth U. S. Army, who effectively taught the principles of good initial surgery

in all the hospitals of that army.

Maj. Champ Lyons, MC, Consultant in Wound Infection, Chemotherapy,

and Penicillin Therapy, Office of the Surgeon, Mediterranean Theater of Operations, who did so much to emphasize that penicillin therapy was merely an

adjuvant to good wound surgery and should be used to obtain better surgical

results.

Appreciation is also expressed to the late Brig. Gen. Fred W. Rankin,

Chief Consultant in Surgery, Office of the Surgeon General, and his assistants,

Col. B. Noland Carter, MC, and Col. Michael E. DeBakey, MC. They were

all most helpful in the followup survey on the results of delayed internal fixation

of compound battle fractures in the Mediterranean theater and on other problems of management of casualties with wounds of the bones and joints which

were carried out in Zone of Interior hospitals.

Acknowledgment is also made to the various surgeons and orthopedic surgeons in the Mediterranean theater who made the special surveys upon which

several of the chapters in this volume are based.

Finally, acknowledgment is made to the chiefs of orthopedic surgery in the

general and station hospitals in the communications zone in the theater and
XII ACKNOWLEDGMENTS

to the general and orthopedic surgeons in the forward hospitals, all of whom

aided so materially in the development of the program of initial and reparative

surgery for compound battle fractures which was in effect at the end of the war.

very substantial and indispensable contribution to this volume, in

field widely separated from that covered by the author and by the medical

officers on whose work he has drawn for the content of the book, has been

made by Melvin J. Hadden, HMC, USN, who, under the direction of Mr.

Herman Van Cott, chief, Medical Illustration Service, Armed Forces Institute

of Pathology, prepared the very excellent layouts for the illustrations and supervised artwork and preparation of illustrations for printing.

Appreciation is expressed to The C. V. Mosby Company for their cooperation in providing printing media for several illustrations appearing in this

volume which also appeared in the book “Wounds of the Extremities in Military

Surgery” by Oscar P. Hampton, Jr., M. D.
XIII

Prologue

The principle that underlies all surgical management of battle

fractures and wounds of major joints was relearned in the field

in North Africa and Italy. When Serjeant-Chirurgeon Richard

Wiseman who attended Charles II in his wanderings on the

continent of Europe in the 17th century wrote on the “Cure

of Gun-shot Wounds,” he turned to Latin version of Hippocrates. Omne quod contusion, necesse est ut putrescat,

in pus vertatur, it was written. “What is contused must

necessarily putrefie, and be turned into matter.” This is the

ancient principle that surgeons reared under the aseptic mantle

spread by Lister must come to know when they are called upon

to deal with the soiled and torn flesh of gunshot wounds.

“But,” said the young surgeon, “I cannot take responsibility

for opening knee joint in tent with dirt floor!” “Why

not,” is the reply, “when the joint already contains devitalized

cartilage and mud from foxhole?”

distorted version of Trueta’s teaching which omitted his

emphasis on the careful excision of dead tissue was false

starting point, but facts disclosed by experience soon replaced

unsound ideas. Skeletal pins fixed in plaster do not withstand

transport. Packing the wound with vaseline gauze causes

necrosis and macerated flesh. Splinting for transport is

different art from splinting for the maintenance of reduction.

Unpadded plasters abrade the skin. An evil smell and gas

bubbles do not necessarily spell clostridial myositis. These

and many more detailed lessons emerged as the product of grim

experience and came rapidly to the surgeons of the Mediterranean theater. They are set forth in this volume dealing with

gunshot wounds of the extremities.

Edward D. Churchill, M. D.

Contents

Page

FOREWORD VII

PREFACE IX

ACKNOWLEDGMENTS XI

PROLOGUE XIII

Chapter

Introduction

II Administrative Considerations

Evolution of the Consultant System

Visits to Medical Installations

Assignment of Personnel 12

Facilities 14

Hospital Administration 25

Graphic Records 27

Accumulation of Data 28

III Splinting in the Combat Zone 29

Classification of Military Splinting 29

Emergency Splinting 31

Transportation Splinting 39

IV The Management of Compound Battle Fractures 53

Part I. The Evolution of the Program of Staged Management

Concepts and Practices Before World War II 53

United States Experiences With the Closed Plaster Method 55

Development of the Program of Reparative Surgery 58

Application of the Reparative-Surgery Program to Compound Fractures- 61

Part II. The Initial Surgery of Compound Fractures

Surgical Timing 64

First Aid 66

Preparation for Initial Wound Surgery 67

Appraisal of the Wound 71

General Principles and Practices 72

Technical Considerations 74 Management of Bone Fragments 78

Fracture Management 80

Postoperative Regimen 80

Evacuation 80

Part III. The Reparative Surgery of Compound Fractures

Preoperative Preparation 82

Technical Considerations 83

Postoperative Management 103

Results 103
XVI CONTEXTS

Chapter Page

Regional Compound Fractures 115

Part I. Compound Fractures of the Humerus, Radius, and Ulna

General Considerations 115

Problems of Management 115

General Principles of Management 116

Compound Fractures of the Humerus 121

Compound Fractures of the Radius and Ulna 133

Conclusions 137

Part II. Compound Fractures of the Femur

General Considerations 137

Survey of Results, Spring, 1944 139

Source Material 140

The Program of Reparative Surgery 141

Technical Considerations 142

Appraisal of Results 157

Conclusions 159

Part III. Compound Fractures of the Tibia and Fibula

The Reparative-Surgery Program 160

Analysis of Cases, 1944-45 161

Wound Management 162

Fracture Management 164

Evaluation of Results 173

Part TV. Compound Fractures of the Foot

Wound Management 181

Fracture Management 182

Postoperative Management 183

VI Delayed Internal Fixation of Compound Battle Fractures—A Followup Study

in the Zone of Interior 185

Technical Considerations 187

Survey of Results 188

Conclusions of the Survey 197

Analysis of Unfavorable Results 200

VII External Skeletal Fixation of Fractures in the Communications Zone 203

Analysis of Cases 203

VIII Wounds of Joints 211

Historical Note 211

General Considerations 213

Wounds of the Knee Joint 215

Wounds of the Hip Joint 237

Wounds of the Smaller Joints 243

IX Amputations 245

Indications 246

Technical Considerations 247

Analysis of Cases 260

Noncombat Orthopedic Lesions 271

General Principles of Management 272

The Management of Painful Backs and Feet 274

Surveys of Management of Noncombat Orthopedic Lesions 276

Internal Derangements of the Knee 277
CONTEXTS XVII

Chapter Page

Non combat Orthopedic Lesions—-Continued

Joint Mice (Osteochondritis Dissecans) 280

Recurrent Dislocations of the Shoulder 287

Fractures of the Carpal Scaphoid Bone 290

XI Disposition of Patients From Orthopedic Services of General Hospitals 295

General Principles of Disposition 295

Sample Hospital Experience 297

APPENDIX 299

INDEX 345

Tables

Number

Timing of splinting of compound battle fractures in relation to objectives and

facilities 30

Relationship of shock and blood loss in 67 battle casualties 69

Blood replacement before and during initial surgery in 100 compound fractures. 70

Results in relation to procedure and wound healing in 147 compound fractures

of humerus 131

Results in relation to technique and status of fracture in 147 compound fractures

of humerus 131

Results in relation to technique, wound healing, and status of fracture in 147

compound fractures of humerus 132

Location of Kirschner wire for skeletal traction in 613 compound fractures of

femur 149

Methods of fracture management in 1,063 compound fractures of femoral shaft. 157

Techniques of internal fixation in 284 fractures of femoral shaft 157

10 Appraisal of wound healing in 825 compound fractures of femoral shaft 158

11 Fracture management in 622 compound fractures of tibia and tibia and fibula.. 167

12 Fracture management in relation to level of tibial injury in 621 compound fractures of tibia and tibia and fibula 167

13 Severity of injury in relation to location of fracture in 132 compound fractures

of tibia and 80 of tibia and fibula 178

14 Results in relation to severity of injury and technique of wound management in

132 compound fractures of tibia and 80 of tibia and fibula 179

15 Results in relation to severity of injury and technique of fracture management

in 132 compound fractures of tibia and 80 of tibia and fibula 180

16 Combined results of wound and fracture management in relation to severity of

injury in 132 compound fractures of tibia and 80 of tibia and fibula 180

17 Results of internal fixation on obligate indications in 135 compound fractures. 193

18 Results of internal fixation on elective indications in 165 compound fractures 193

19 Results of internal fixation in relation to indications in 67 compound fractures

of humerus 193

20 Results of internal fixation in relation to indications in 31 compound fractures

of radius and ulna 194

21 Results of internal fixation in relation to indications in 146 compound fractures

of femur 194

22 Results of internal fixation in relation to indications in 88 compound fractures

of tibia and fibula 194

396961 °—57
XVIII CONTEXTS

Number Page

23 Composite results of internal fixation in relation to technique and location of

fracture in 332 compound fractures of long bones 195

24 Results of internal fixation in 29 compound fractures with established wound

infection 196

25 Essential data on 14 fractures treated by external skeletal fixation 205

26 Essential data on 27 fractures treated by external skeletal fixation 205

27 Essential data on 25 fractures treated by external skeletal fixation 206

28 Sites of amputation in 1,379 separate operations on United States Army troops. 263

29 Sites of amputation in 1,389 separate operations on German prisoners of war 264

30 Agents of wounding and causes of amputation in 1,271 United States Army

troops 265

31 Agents of wounding and causes of amputation in 1,332 German prisoners of war. 266

32 Complicating injuries in 1,000 United States Army amputees 266

33 Indications for amputation in 1,344 operations following wounds or injuries in

United States Army troops 267

34 Indications for 843 primary and 243 secondary amputations in United States

Army troops 267

35 Indications for 962 primary and 427 secondary amputations in German prisoners

of war 268

36 Combinations of levels in 85 multiple amputations in United States Army casualties 269

Illustrations

Figure

First aid in field 15

Scenes at first-aid stations 16

Scenes at collecting station 18

Arrival of casualty at admission tent of clearing station 19

Ambulance transportation of wounded 20

Scenes in field hospital 21

Scenes in evacuation hospital 22

Evacuation hospital 23

General hospital 24

10 Improvised battlefield splinting for fracture of femur 33

11 Emergency splinting for fractures of forearm and about elbow and wrist 35

12 Emergency splinting for fracture of humerus 36

13 Emergency splinting for fractures of lower third of leg and ankle 37

14 Emergency splinting for injuries of thigh, knee joint, and leg 38

15 Improvised techniques of splinting after initial wound surgery 42

16 Modification of elephant-tusk splint for fractures about shoulder jointand elbow. 44

17 Plaster Velpeau bandage for injuries of shoulder joint, arm, or elbow 45

18 Shoulder spica for injuries about shoulder joint and of arm 46

19 Transportation splinting of compound fracture of femur with hip spica 48

20 Modified Tobruk splint 50

21 Transportation splinting for fractures of lower extremities 52

22 Staged surgery of wound of calf 60

23 Staged surgery of wound of right arm 61

24 Reparative surgery of wound of left axilla and shoulder 62

25 Initial wound surgery of soft-part wound 75

26 Staged surgery of wound of thigh 76
CONTEXTS XIX

Figure Page

27 Initial surgery of wound of thigh 77

28 Appearance of wound at completion of initial surgery 78

29 Correct excisional surgery in infected compound comminuted fractures of left

tibia and right femur 85

30 Management of compound comminuted fractures of femur and patella by delayed internal fixation 88

31 Reparative management of wound of thigh with associated compound fracture

of femur 90

32 Management of compound comminuted fractures of right tibia and fibula by

delayed internal fixation ..

92

33 Staged management of compound comminuted fracture of femur 94

34 Management of compound comminuted fracture of femur by delayed internal

fixation 95

35 Staged surgery of bilateral compound fractures of shaft of femur 96

36 Management of compound fractures of tibia and fibula by internal fixation 104

37 Comminuted compound fracture of right humerus with radial-nerve paralysis 106

38 Compound comminuted fracture of right humerus with loss of bone 108

39 Staged management of associated humeral-radial fractures and nerve injury by

shortening of bone 111

40 Reparative management of fracture of tibia 112

41 Management of compound comminuted fracture of femur by balanced-suspension skeletal traction 113

42 Management of compound fracture of right tibia by staged surgery and modified

closed plaster technique 114

43 Management by delayed internal fixation of compound comminuted fracture of

humerus, with loss of bone and laceration of median and ulnar nerves 118

44 Management by delayed internal fixation of compound comminuted fracture of

humerus with segmental loss of bone and laceration of radial nerve 120

45 Splinting for paralysis of radial nerve 121

46 Comminuted fracture dislocation of right shoulder, comminuted fractures of

humerus and both bones of forearm, with injuries of median and radial

nerves 124

47 Hanging cast for fracture of humerus 126

48 Shoulder spica cast for fracture about shoulder joint 127

49 Unsuccessful management of compound comminuted fracture of right radius

and ulna 135

50 Management of compound comminuted fracture of radius and ulna by delayed

internal fixation 136

51 Suspension traction in 90-90-90 position for compound fracture of femur 143

52 Management of compound oblique fracture of femur by delayed internal fixation. 144

53 Internal fixation of displaced fracture of medial femoral condyle 147

54 Two-wire skeletal traction for battle fracture of femur 150

55 Balanced-suspension skeletal traction by half-ring leg splint and Pierson attachment 151

56 Navy traction for fracture of femur 152

57 Modlin modification of Navy traction for fracture of femur 153

58 Linch modification of Navy traction for fracture of femur 154

59 Skeletal traction by 90-90-90 suspension method for fracture of femur ... 155

60 Anteroposterior and lateral roentgenograms showing fracture of tibia with loss

of bone 166

61 Skeletal traction in fractures of both bones of leg 168

62 Roentgenologic results of skeletal traction in cast 169
XX CONTEXTS

Figure Page

63 Management of compound comminuted fractures of tibia and fibula by delayed

internal fixation 171

64 Management of compound comminuted fractures of tibia and fibula by delayed

internal fixation 172

65 Management of compound comminuted fractures of tibia and fibula 174

66 Management of comminuted fracture of tibia and fibula, by plating of fibula 176

67 Management of fractures of fibula and tibia, with loss of bone, by plating of fibula. 177

68 Management of compound comminuted fracture of radius, with loss of bone and

median-nerve palsy, by external skeletal fixation ...208

69 Management of segmental compound comminuted fractures of tibia and fibula

by external skeletal traction 209

70 Staged management of wound of left knee joint 218

71 Staged management of penetrating wound of knee joint with comminuted

fracture of femur 220

72 Management of early suppurative arthritis of knee joint 222

73 Management of early suppurativearthritis of knee joint 224

74 Management of suppurative arthritis of knee joint 226

75 Management of suppurative arthritis of knee joint 228

76 Management of suppurative arthritis of knee joint 230

77 Management of suppurative arthritis of knee joint 232

78 Management of suppurative arthritis of hip joint 238

79 Management of suppurative arthritis of hip joint 239

80 Management of suppurative arthritis of hip joint 240

81 Destructive injury of entire left leg 246

82 Bilateral traumatic amputations of legs 247

83 Bilateral injuries of lower extremities 248

84 Traumatic amputation of right leg, multiple penetrating wounds of left leg 250

85 Amputation stump of left forearm 251

86 Technique of open circular amputation 252

87 Application of skin traction after amputation of leg 253

88 Plaster cast with elastic traction 254

89 Traumatic amputation of right leg, compound fracture of bones of left leg 255

90 Open circular amputation through middle third of forearm 256

91 Healed stumps after amputation by open circular technique 257

92 Closure of amputation stumps 258

93 Closure of amputation stump 259

94 Closure of amputation stump 260

95 Amputation by open flap technique, with closure of flaps at reparative surgery. 261

96 Amputation through leg near site of election, with preservation of posterior

viable flap of skin 262
CHAPTER

Introduction

The combat experience in the Mediterranean area lasted from November

1942 until May 1945. During this period of approximately 30 months, battle

casualties were treated by the officers of the United States Army Medical

Corps in the various echelons of the theater. Casualties were often heavy,

and they continued to be received, in smaller numbers, even during the infrequent periods when combat activity was diminished.

During the period from January 1942 to June 1944, admissions to United

States Army hospitals in England were limited to casualties from the Army

Air Forces and few British casualties received from the Mediterranean

theater. Ground forces were engaged in combat in the European theater, and

battle casualties were heavy only between D-day, June 1944, and V-E Day, May 1945.

The medical officers in the Mediterranean theater thus had much longer

experience in the treatment of battle casualties than the medical officers in

the European theater and had correspondingly greater opportunities to gather

data for the evaluation of their techniques of treatment.

The Mediterranean theater, with relatively small number of troops and

relatively few hospitals, was extremely fortunate in having assigned to it

considerable number of affiliated general hospitals. Many able young

orthopedic surgeons were on the staffs of these hospitals. Col. Edward D.

Churchill, MC, consultant in surgery to the theater surgeon, stimulated and

encouraged his junior officers to record and analyze their surgical experiences.

Lt. Col. (later Col.) Oscar P. Hampton, Jr., MC, consultant in orthopedic

surgery for the theater, was indefatigable in spreading throughout the hospitals

of the theater the principles upon which the surgery of wounds of the bones

and joints is based.

During the war and immediately thereafter, Colonel Hampton, with the

assistance of many of his colleagues, collected invaluable data on military

orthopedic surgery. The studies which were the result of these investigations

and which are presented in this volume form an unusually complete and comprehensive analysis of orthopedic surgery in an overseas theater.

Mather Cleveland, M. D.,

Formerly Colonel, MC, AUS,

Editor for Orthopedic Surgery.

CHAPTER II

Administrative Considerations

During the approximately 2,500-mile advance by United States Army

troops from Casablanca in North Africa, where landings were made in November 1942, to Como on the Swiss border of Italy, which was reached early in

May 1945, continuous flow of casualties were treated in United States Army

hospitals. This was the largest continuous combat experience for United

States troops since the War of the Rebellion.

Many of these casualties had suffered bone and joint injuries. All of

them were treated under conditions without parallel in any previous war.

They were treated initially by concepts and methods prevailing in civilian

practice, many of which were soon found wanting in the circumstances of military surgery. Similarly, some of the techniques which had been employed

surgeons of Allied armies already in the field and which were adopted by United

States Army surgeons were also found wanting. Increasing experience and

repeated critical evaluation of results frequently led to the modification of

concepts originally accepted and methods originally used and sometimes led

to their replacement by entirely new measures. Modification and replacement

of the techniques originally used were, however, matter of evolution; they

were not accomplished by directives.

The regimen for the management of bone and joint injuries which was in

effect at the end of the war was based upon program of staged management

which was applicable to all wounds and which had evolved from continuing

experience. Neither of its component parts, initial surgery and reparative

surgery, was new, nor was the combination of the two components new. Such

program had been recommended by some surgeons and employed in some

cases in World War I. It was not until the spring of 1944, however, that the

scope and timing of the program were fully developed in World War II and that it was universally applied. This program was applicable to most wounds of

the soft tissues and was of major importance in the management of bone and

joint injuries, the end results of which depended, as much as upon any other

single factor, upon the initial management and later reparative management

of the compounding soft-tissue wound.

EVOLUTION OF THE CONSULTANT SYSTEM

Officers and enlisted men of the Army Medical Department assigned or

attached to combat elements furnished the only medical support for the North

African landings November 1942, but mobile and fixed hospitals, staffed with
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

their intrinsic professional personnel, were established soon afterward. It was

not until March 1943, however, that the consultant system began to function

in the theater, with the arrival of Col. Edward D. Churchill, MC, consultant

in surgery to the theater surgeon. There was lapse of another months

before, on the recommendation of Colonel Churchill, consultant in orthopedic

surgery was appointed.

By the time the consultant in this specialty was appointed, it had become

apparent that orthopedic surgery was sufficiently important in its own right

in this active theater of operations to require more direct attention than

consult ant in surgery could spare for it from his other duties. This was because

(1) large proportion of all combat-incurred injuries involve the bones and

joints and (2) large proportion of these wounds present major problems of

management.

The landing at Salerno on the Italian mainland by the Fifth U. S. Army

in September 1943 had resulted in considerable increase in all casualties and

in corresponding increase in the number of bone and joint injuries. At the

same time, certain personnel problems became apparent. Shortly after the

landings in Italy, 11 general hospitals and several large station hospitals designated to operate in Bizerte, Oran, and Naples, arrived from the Zone ofInterior.

Previous experience had already revealed the need for supervision of the management of casualties with bone and joint injuries. In particular, it had showed

that orthopedic surgeons without previous military experience, however wide

their experience in civilian orthopedic practice might have been, required

orientation in the principles and techniques of military surgery.

Maj. (later Col.) Oscar P. Hampton, Jr., MC, chief, orthopedic section,

21st General Hospital, was therefore placed on duty in the Office of the Surgeon, North African Theater of Operations, as acting consultant in orthopedic

surgery. His mission was (1) to visit the newly arrived general hospitals;

(2) to appraise the professional qualifications of their orthopedic staffs; (3) to

acquaint their staffs with previous experiences in the theater in the management of combat-incurred bone and joint injuries; and (4) to record observations which might lead to improvement in the management of these injuries.

When this mission was concluded, in December 1943, Major Hampton was

dispatched to the Fifth Army, then fighting near Cassino, to communicate to

forward surgeons the observations he had made in the base area, with particular reference to the quality of initial wound surgery and transportation

splinting. Throughout the war, the exchange of experiences between hospitals of forward and rear areas was to prove one of the most profitable functions performed by all consultants.

After February 1944, when the position of consultant in orthopedic surgery to the theater surgeon was made permanent, Lieutenant Colonel Hampton

continued to function in that capacity under the consultant in surgery until

the consultant staff of the theater was deactivated in September 1945.

Neither the II Corps, which operated in Africa, Sicily, and Italy, nor the

Seventh U. S. Army, which operated in Sicily, Italy, and southern France,
ADMINISTRATIVE CONSIDERATIONS

ever had an officer assigned as consultant in orthopedic surgery. When Capt.

(later Maj.) Floyd H. Jergesen, MC, of the 2d Auxiliary Surgical Group, was

placed on temporary duty in the office of the surgeon, Fifth U. S. Army, late in 1943, to make special study of gas gangrene with Maj. (later Lt. Col.)

F. A. Simeone, MC, he was also appointed acting consultant in orthopedic

surgery to the Fifth Army and served in this capacity until after the CassinoRome campaign in May and June 1944. Thereafter, as in the Seventh Army,

the surgical consultant to the Fifth Army supervised the management of bone

and joint injuries.

In retrospect, delay in the appointment of consultant in orthopedic

surgery for the Mediterranean theater appears to have been wise. At the

time of the North African landings, as has already been pointed out, few if

any of the medical officers in the United States Army had had any experience

with battle-incurred bone and joint injuries. Furthermore, none of the orthopedic surgeons who participated in the landings had served as observers with

the Allied armies before the entrance of the United States into the war. Sound

policymaking was obviously impossible until some experience in military

injuries had been achieved. During the first months of combat, therefore,

the surgeons in charge of the orthopedic sections in the various fixed hospitals

worked out their special problems, observed the results of different methods

of management, and in many instances recorded the data upon which sound

future recommendations could be based. When consultant in orthopedic

surgery was finally appointed, comprehensive plans for the management of

combat-incurred injuries were being evolved, and the experience in the theater, as far as it had gone, could be transmitted in an organized fashion to newly

arrived personnel.

Whether the decision not to appoint consultants in orthopedic surgery to

the armies was equally wise is more open to question. basis for the decision was that even serious wounds of the extremities were usually, from the

standpoint of initial wound surgery, second-priority cases, and that orthopedic

surgeons were usually assigned to the evacuation hospitals in which the forward surgery of bone and joint wounds was chiefly performed. The policy

of assigning orthopedic surgeons to evacuation hospitals may have been wasteful of trained personnel, as will be pointed out shortly (p. 13). The appointment of consultant in orthopedic surgery to each army would have eliminated the need for trained orthopedic surgeon in each evacuation hospital

and would have meant considerable saving in specialized personnel, who

were always in short supply. There would have been other advantages in

the appointment of an orthopedic surgeon to each of the armies. Such

consultant, moving continuously from hospital to hospital, could have done

much, in his supervisory role, to improve the initial surgery of wounds of the

extremities. He could also have played an important role in the education

of medical officers who had had no previous experience in military surgery

and who, in many instances, had had no previous experience in bone and

joint injuries.
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Functions of the Consultant

Both as acting consultant in orthopedic surgery and in his permanent

capacity, the consultant in orthopedic surgery routinely advised the theater

surgeon, through the consultant in surgery, on variety of matters, such as the

following: (1) The personnel assignments to orthopedic-surgery sections, including not oidy those of trained orthopedic surgeons but those of other surgeons

and other medical officers who had to assume the management of bone and

joint injuries; (2) the organization and functioning of orthopedic sections;

(3) the quality of the management of bone and joint injuries; (4) changes in

concepts and techniques of orthopedic surgery, both as the consultant in orthopedic surgery personally observed these changes and as they were reported to

him in Ids official capacity; (5) the results being obtained; and (6) future

planning.

Some of the consultant’s time was necessarily spent at headquarters in

administrative work, but most of his time was spent in the field. With the

approval of army surgeons, frequent visits were made to hospitals in the combat

zone, particularly during offensives, when the flow of casualties was heavy.

Methods of management were observed, and suggestions for improvement

were made to the consultant in surgery for each field army. These suggestions

chiefly concerned the principles of debridement and the application of transportation splinting as preliminary to the further treatment of casualties in

the communications zone.

One of the chief problems in forward areas was the training of surgeons

who had to care for casualties with bone and joint injuries but who had had no

previous experience to qualify them for this duty. As continuing effort, this

was the responsibility of the chiefs of surgery in the various hospitals, but it

was also major responsibility of the consultants in surgery for the theater and

the armies, and of the theater consultant in orthopedic surgery.

The consultant in orthopedic surgery utilized his time chiefly in the hospitals

of the communications zone, where fractures and other conditions of the bones

and joints could be segregated and where more definitive management of these

injuries was accomplished. This was in contrast to the situation in the hospitals

of the army area, where bone and joint injuries were, for the most part, part

of the general surgical problem. The major portion of the consultant’s time

was spent in hospitals close to the rear boundary of the army. These were the

installations in which casualties were received from forward hospitals at the

time when precise definitive surgery was necessary and could be most effectively

carried out.

The general plan was to visit each fixed hospital for several days at time,

actually living with the orthopedic staff, observing their work in the operating

room, following them on ward rounds, discussing general and special problems

in both formal and informal sessions, suggesting and implementing such changes

in policies and practices as special circumstances might require, and rendering

whatever other aid was requested. These were tours of inspection, it is true,
ADMINISTRATIVE CONSIDERATIONS

but the major emphasis was upon their instructional aspects. The most

practical way to achieve this objective was to study, with the medical officers

assigned to the orthopedic section, the cases under treatment at the time of the

visit.

These studies were comprehensive. They included the historyofwounding,

details of previous treatment, roentgenologic examinations, progress to date,

plans for future care, anticipated disposition, and possibilities for later reconstructive surgery. It was always emphasized that, while the management of

orthopedic problems was necessarily conducted by inclusive rides in time of war,

the objective in each case was individual—to obtain the best result that could

be obtained for the particular patient under consideration.

Improved techniques observed in one hospital were communicated to other

hospitals as the consultant visited them in their turn. When new regimens

were in process of introduction, when the volume of work was excessive, or when

specific clinical observations had to be made for future planning, the consultant

in orthopedic surgery frequently remained in one hospital for week or more,

integrating himself, for all practical purposes, into the hospital staff for this

period of time, in order to accomplish results more quickly.

Although in all of these tours some attention was given to elective surgery,

its performance was generally discouraged (p. 271). Emphasis was placed

upon the necessity, in all military surgery, for the prompt return of the soldier

to duty and upon the lack of justification for the use of hospital-bed space by

any man whose future combat usefulness could not be assured.

Special educational efforts had to be undertaken when such radical changes

were in the making as (1) the application of reparative surgery to compound

fractures, in the spring of 1944 (p. 58); and (2) the extension of the program to

wounds of the hip joint some months later (p. 242).

VISITS TO MEDICAL INSTALLATIONS

The activities of the consultant in orthopedic surgery in the Mediterranean

theater can best be illustrated by his (summarized) reports to the theater

surgeon of two typical visits of instruction, one in September and the other in

October and November 1944.

September 1944

This tour, which began September and ended 26 September 1944, covered

the following hospitals:

Army hospitals.—Army hospitals visited included the 8th, 38th, and 94th

Evacuation Hospitals and platoons of the 33d Field Hospital. The matters

examined, which were later discussed with Lt. Col. (later Col.) Howard E.

Snyder, MC, consultant in surgery, Fifth U. S. Army, were as follows:

1. Amputations were discussed in the light of Circular Letter No. 46, 29

August 1944, Office of the Surgeon, North African Theater of Operations,
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

United States Army. Emphasis was placed upon the importance of good skin

traction and the use of the elastic cord which had become available for this

purpose.

2. The results of the methods then in use for handling wounds of the knee

joints were reported. Emphasis was placed upon the importance of good im- mobilization in the forward area by the use of single hip spica casts, or, at

at least, Tobruk splints. Emphasis was also placed upon the instillation of

penicillin after the joint had been closed at operation and upon aspiration, with

reinstillation of penicillin, through window in the cast 24 to 48 hours after

operation.

3. It was recommended that injured hands be immobilized in the position

of function and that good occlusive dressing be applied. It was also recommended that trial be given to the so-called boxing-glove type of plaster cast

over mechanic’s waste and sheet cotton. This method was then being tested

in number of hospitals, and its more extensive use was suggested.

4. It was pointed out that immobilization and the use of an occlusive

dressing in wounds of the soft parts treated in forward areas were essential

for successful reparative surgery in rear hospitals.

64th General Hospital.—This hospital, which was visited 11-15 September,

was the only general hospital at Leghorn, Italy. It was very busy with battle

casualties. Some few were admitted for initial wound surgery. Others were

received from evacuation hospitals. Many patients were admitted from station

hospitals with large outpatient clinics. The casualties included both United

States and British naval personnel. Although relatively few seriously wounded

men were being admitted at this time, the treatment of many of the injuries

was very time consuming. Arrangements for handling fresh battle casualties

were excellent, and the work was well integrated with the reparative phase of

the hospital work.

Surgery on fracture cases was observed in the operating room, and ward

rounds were made. In general, reparative surgery was satisfactory. There

had been some modifications in the program, the evaluation of which could be

made only at later date. few fractures had been managed by internal

fixation. Results in the few wounds which had been closed at initial wound

surgery were not considered satisfactory, and staged procedures were advised.

The sections of Circular Letter No. 46 which applied to orthopedic surges

were discussed.

It was noted at this hospital that several soldiers of the 92d Infantry

Division had received tetanus antitoxin instead of tetanus toxoid. wound

adjacent to the knee had been sutured in the battalion aid station with the

foreign body still in situ. These and related observations were reported to

Colonel Snyder,

Hospitals in the Rome area.—The 33d General Hospital was not receiving

patients at the time of this visit, and all remaining patients were already preSee appendix, pp. 326-331.
ADMINISTRATIVE CONSIDERATIONS

pared for transfer to other hospitals. The more serious fracture cases were

examined on the wards. Under the stress of closing the hospital, number of patients with fractures of the femur had been boarded for the Zone of Interior. Their transportability seemed doubtful, and it was suggested that notes be made

on their records to warn the next receiving hospital that further definitive care

might be needed before evacuation. The reparative-surgery program had been carried out well in this hospital,

with strong (perhaps excessive) emphasis on internal fixation.

The 12th General Hospital had an excellent program of reparative surgery

in accordance with theater recommendations. The orthopedic section had an

extremely conservative attitude toward the internal fixation of compound

fractures.

The 12th General Hospital made number of suggestions, including the

following:

1. That dry fine-mesh gauze be substituted for vaseline gauze in all

echelons.

2. That hand injuries observed in forward areas be put up with mechanic’s

waste between the fingers as well as over the entire hand in the application

of pressure dressings. There was skepticism about the value of the boxingglove plaster cast, but it was regarded as worthy of trial.

3. That simple interrupted sutures be used for delayed primary closures,

instead of vertical mattress sutures.

The 6th General Hospital was visited for only half day, and the number

of cases observed was necessarily limited. The reparative-surgery program

was in full use, with satisfactory results. At meeting of the surgical staff,

Circular Letter No. 46 was freely discussed. Objection was raised to the “no

deviation” clause under amputations, and case was described in which each

dressing produced hemorrhage until skin graft was applied; then healing was

prompt. The staff concurred in the principles laid down in this circular but

felt that occasional exceptions should be permitted. It was suggested that,

if and when good surgical judgment seemed to call for deviation from the

stated policies, the deviation should be permitted but full explanatory notes

should be added to the record.

In the light of the 60-day holding policy, the section on duration of traction

for fractures of the femur was also questioned. It was agreed that Circular

Letter No. 46 gave the hospital staff authority to maintain traction as long as

patient’s condition required it.

At the 73d Station Hospital, planeload of battle casualties had been

received from France the night before. Many of the injuries were serious,

including fractures of the femur and wounds of the knee joint. Arrangements

had been made to transfer the most seriously wounded patients to general

hospital. Several fractures of the femur were in traction on the wards. It

was suggested that in the future, if such patients were transportable, they be

sent to general hospital as soon as possible after admission. Some excellent

results were seen in this station hospital, but tendency was noted to hold, as
10 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

possible category (limited duty) dispositions, patients who would almost

certainly require category dispositions. The whole question of dispositions was discussed with the chief of the surgical section.

It was noted in all the general hospitals visited that many patients who

had received penicillin in the evacuation hospitals were being received without

the proper notification (“On Penicillin,,

in the appropriate place on the jacket

of the Medical Field Record, as prescribed in Circular Letter No. 36, July

1944, Office of the Surgeon, North African Theater of Operations, United

States Army. This omission was reported to Colonel Snyder.

October-November 1944

These visits of inspection, which began 15 October and ended 19 November, covered the Continental Advance and Delta Base Sections.

Continental Advance Base Section.—The 46th General Hospital was

visited 16-24 October and again 17 November. The surgical service, on the

first visit, was heavily loaded with both United States and French battle

casualties. French casualties were reaching the hospital without initial wound

surgery. Efforts to perform initial surgery on the French casualties and reparative surgery on both French and United States casualties had taxed the surgeons to the limit, and reparative surgery had been possible to only limited

degree. Formal and informal conferences were held with the surgical service,

laboratory service, and commanding officer, and the North African Theater of

Operations, United States Army plan of reparative surgery, which consisted

of surgery, blood replacement, and penicillin therapy, was described in detail.

The reception of the plan was enthusiastic. At the request of the orthopedic

surgeons, number of patients were operated on to demonstrate the principles

of the program. Many case histories were obtained, and serial photographs

were arranged for. On the return visit to this hospital, 17 November, the

new program was found to be functioning adequately.

The 36th General Hospital was visited 25-28 October, 30 October-1

November, and 16 November. At the time of the first visit, the surgical service

was functioning with incomplete physical facilities, and the orthopedic section

was particularly handicapped. Improvement was noted on the return visits,

which were made at the request of the recently installed chief of the orthopedic

service, for consultation on number of cases of various types. This officer

was doing an excellent job.

The 21st General Hospital was visited 29 October. The surgical service

was not yet ready for admissions, but the facilities planned for the orthopedic

section were the best yet seen in the theater. The orthopedic staff, as the

result of an extensive experience, was already competent in reparative surgery.

The 180th Station Hospital was visited November. At staff meeting,

the entire program of reparative surgery was presented and was followed by

prolonged question-and-answer session.

See appendix, pp. 321-326.
ADMINISTRATIVE CONSIDERATIONS 11

The 35thStation Hospital was visited November, when the weather prevented travel to the Delta Base Section, as planned. Reparative surgery was

discussed at length with the chiefs of surgery and orthopedic surgery. The

hospital was busy with minor battle casualties and bad received some severely

wounded patients from two plane crashes and number of roadside accidents.

Many patients were seen on the wards in consultation. The professional work

was good.

Delta Base Section.—The 43d General Hospital was visited 3-6 November,

10-11 November, and 13-15 November. The surgical service was overloaded

with United States Army casualties and German prisoners of war. Reparative

surgery was in progress on the wounds of the soft parts. The chief of the

orthopedic section was then hospitalized; later, he had to be evacuated to the

United States, and new chief of section was subsequently appointed by the

hospital commander. Formal and informal conferences were held, and many

patients were seen in consultation. Some were operated on, by request, to

demonstrate the principles of the reparative-surgery program. Considerable

progress was being made on orthopedic work in this hospital.

The 3d General Hospital was visited November. Orthopedic surgery

was being conducted along the same principles as had been previously employed

at this hospital. Some cases were well handled, but the management of others

did not measure up to the theater standards. This situation was reported to

the Delta Base surgeon.

The 78th Station Hospital was visited November. This hospital had

received casualties from the Airborne Task Force, the most severely wounded

of whom had received initial surgery at the 514th Clearing Company. Ward

rounds were made and problems discussed. Transfers to general hospitals were

being made correctly.

The 70th Station Hospital was visited 12 November. Surgery on the

usual good station-hospital level was being performed.

The 80th Station Hospital was visited 12 November. The chief of surgery

appeared to be doing an excellent job. All phases of reparative surgery were

discussed with him. Several special problems, among them fractured femurs,

were observed and discussed on the wards.

The 514th Clearing Company was visited November. This station now

had roentgenologic facilities, and its equipment was considered satisfactory.

Two surgical teams, one from the 36th General Hospital and one from the 43d

General Hospital, were attached to this Company. Operations had numbered

32 in September, 58 in October, and 16 to date in November. The work did

not justify the attachment of two surgical teams, and the Delta Base Section

surgeon was so informed. He planned to return the team from the 36th

General Hospital to its proper station. The teams were advised to split all

plaster casts (unsplit casts having been observed at the 78th Station Hospital)

and to utilize elastic cord, supply of which was on hand, for skin traction on

amputation stumps.
12 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Additional activities.—The consultant in surgery, Seventh U. S. Army, was

informed of the observations made in rear hospitals on the surgery performed

in forward hospitals. Case reports were furnished to him, and ward rounds

were made with him at the 36th and 46th General Hospitals. At his request,

information was supplied to the surgeon, Sixth Army Group, concerning the

observations which had been made on casualties being evacuated by train and

air from Army holding stations to Continental Advance and Delta Base Sections, and from Continental Advance to Delta Base Section.

ASSIGNMENT OF PERSONNEL

When the landings were made in North Africa, in the fall of 1942, the

exact role to be played by qualified orthopedic surgeons in an overseas theater

was still to be determined. This was chiefly because the exact surgical missions

of the various echelons of medical care in the staged management of the wounded

had not yet been clearly defined.

Only few of the evacuation hospitals which arrived early in North Africa

had orthopedic surgeons on their staffs, though many had general surgeons

experienced in the management of fractures. The initial experiences led to

the decision that each such hospital should have an orthopedic surgeon on the

staff. This was not because it was expected that all wounds of the extremities

would affect bones and joints or because it was considered essential that an

orthopedic surgeon should perform all initial surgery in bone and joint injuries,

which was an obvious impossibility. The chief reason for the decision was

that qualified orthopedic surgeon should be available in each evacuation

hospital for consultation on such special problems as wounds of the joints,

complicated fractures of the femur, injuries which might require amputation,

and similar serious problems. It was felt that the orthopedic surgeon, with

his specialized knowledge and wider experience in plaster techniques, would be

extremely useful to the general surgeons who would necessarily perform most

of the initial surgery in evacuation hospitals. It was also intended, of course,

that, as time permitted, the orthopedic surgeon should himself handle injuries

of extreme severity, such as compound comminuted fractures of the femur and

penetrating wounds of the knee and hip joint.

Another reason orthopedic surgeons were assigned to forward hospitals

had to do with the management and disposition of soldiers with non-battleconnected complaints, such as internal derangements of the knee, painful backs,

and foot disabilities. Manpower, especially combat manpower, was always in

short supply, and it was essential that as many of these soldiers as possible

should be returned to duty as promptly as possible, without the loss of time

and effort which would be expended in their transfer to general hospitals. On

the other hand, it was equally important that men who really needed treatment

and who could not be promptly returned to duty should be evacuated to
ADMINISTRATIVE CONSIDERATIONS 13

hospitals in the rear without delay. These decisions were often delicate and

could best be made against background of orthopedic training and experience.

For these reasons, many of the younger, well-trained and capable orthopedic surgeons, who had had previous experience in civilian traumatic surgery,

were transferred to evacuation hospitals as soon as they arrived in the theater

on the staffs of general hospitals. This proved to be wise plan as long as

policies concerning the management of bone and joint injuries were still in

state of flux. The anticipated effectiveness of these trained orthopedic surgeons

was fully realized, and they made important contributions to the increasing

efficiency of initial wound surgery. They themselves, however, were seldom

content with these assignments, and requests for transfers to general hospitals

were frequent, on the ground that as trained orthopedic surgeons they would

be more useful in the performance of reparative surgery and definitivereduction

of fractures than they were in evacuation hospitals, where initial surgery was

limited to debridement, gross alinement of fractures, and transportation

splinting.

Although the weight of these arguments was fully realized, the policy of

assigning orthopedic surgeons to evacuation hospitals continued the same in

the Mediterranean theater throughout the war. In retrospect, this inflexibility

does not seem to have been altogether wise. As policies of surgical management in forward areas became standardized and as surgeons in these areas

became experienced in the management of wounds of the extremities, the

original need for orthopedic surgeons in evacuation hospitals became much

less pressing. At this time, in view of the shortage of trained orthopedic personnel in rear hospitals and the demands of the regimen of reparative surgery

for trained men, it would probably have been wiser to utilize in general hospitals

many of the surgeons assigned to evacuation hospitals. The assignment of

consultant in orthopedic surgery to each army (p. 5) would further have

reduced the need for experienced orthopedic surgeons in hospitals in the army

areas.

Orthopedic surgeons who were heads of orthopedic teams were occasionally

attached to field hospitals in the division area in Sicily and in the early days

of the fighting in Italy, but this practice as misuse of qualified personnel

and was soon discontinued. Injuries of the bones and joints were seldom, in

themselves, of sufficient urgency to require treatment in field hospitals, and

the few which were could be cared for by the well-trained general surgeons

attached to these installations. Orthopedic surgeons, on the other hand, were

seldom equipped to treat the serious wounds of the chest and abdomen which

constituted the chief work in field hospital, and they cmdd not, therefore,

handle proportionate share of casualties with these injuries or of casualties

with multiple injuries involving the chest and abdomen as ell as the extremities. For these reasons, orthopedic teams were used only in evacuation hospitals

after early 1944.

396961°—57
14 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

FACILITIES

In World War II, before casualty with bone and joint injury reached

general hospital in the communications zone, he had passed, successively,

through battalion aid station, collecting station, clearing station, and an

evacuation or held hospital. The care he received in the division area was

limited to measures designed to supplement the first aid he had

received on the battlefield and to make him transportable to the evacuation

hospital. Classification as to transportability was major responsibility of

the clearing station. No special orthopedic equipment other than splints was

therefore usually required in these echelons of medical care (figs. 1, 2, 3, 4,

and 5).

Soldiers with wounds of the extremities, as already noted, were usually

second-priority casualties. They were therefore not transferred to the held

hospital adjacent to the clearing station unless shock, the presence of tourniquet, traumatic amputation, an abdominal wound, severe chest wound, or

an impaired airway required immediate attention.

Definitive initial surgery in the evacuation or held hospital was directed

toward the management of the soft-tissue injury, not the bone injury, except

for gross alinement of fractures and immobilization for transportation. Plaster

of paris and auxiliary supplies and splints were therefore the only special

equipment required for bone and joint injuries in the evacuation hospital (hgs.

6, 7, and 8). fracture table was essential equipment, and the portable fracture table provided by Medical Supply (Item No. 7099300) proved entirely

satisfactory.

Materials for internal hxation of fractures, overhead fracture frames, and

material for the management of fractures in balanced-suspension skeletal traction were authorized items of supply in evacuation hospitals. They were all

superfluous items at this level. They are used in the dehnitive management

of fractures, which is the mission of hospitals in the communications zone,

though not of installations in the army area.

In the general hospital in the communications zone (fig. 9), where fractures

were reduced and other definitive care provided, desirable special facilities

included, at minimum—-

1. An operating room, at least 20 by 25 feet, to accommodate two operating

tables and large table for sterile supplies. It was also desirable to have an

adjoining room in which patients could be anesthetized and in which the

transportation casts applied in the evacuation hospital could be removed.

2. ward of 75 to 100 beds, to be used as femur (traction) ward. It

was essential that this ward be equipped for the taking of roentgenograms with portable apparatus and desirable that it be near the X-ray department.

3. Other wards of 75 to 100 beds. When it was practical, it was best to

admit patients to these wards according to the nature of their injuries, but

anatomic subdivision was not always possible because of multiplicity of wounds

and the variations in the bed status. The principle of segregation of special
ADMINISTRATIVE CONSIDERATIONS 15

AFIP CA-4340-D

Figure 1. First aid in field, Fifth U. S. Army, Italy, December 1943.

injuries, however, was sound and preferably was adhered to as circumstances

permitted.

4. plaster room, about 20 by 30 feet, equipped with three plaster tables;

fully equipped table for dressings; and storage cabinets for splints, accessory

materials, and sterile supplies. This plaster room was preferably located

adjacent to the principal orthopedic ward. It was used for the changing of

plaster casts as well as for minor surgical procedures, usually without anesthesia.

Essential items of supply in general hospital included an adequate number

of overhead fracture frames, Army half-ring leg splints, and materials for

balanced-suspension skeletal traction and for internal fixation of fractures, as

well as materials for the application of plaster-of-paris casts.

5. Facilities for the examination of ambulatory patients from other wards

and of outpatients. The plaster room could be used for this purpose, if necessary, but this was less desirable than provision for special consultation and

examining room.

Braceshops. —Although tables of organization included qualified bracemaker in the personnel of all numbered general hospitals, tables of equipment

provided little equipment for braceshops when these hospitals first came into

the North African theater. It soon became evident, however, that there was

definite need for few braces, special splints, belts, and similar items in an

overseas theater which functioned on 90- to 120-day holding policy.
16 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

U. S. Army photos

Figure 2.—Scenes at battalion aid stations in World War II. A. Litter bearers bringing

casualty into Fifth U.S. Army battalion aid station in Italy. B. Infantrymen at

Fifth U.S. Army battalion aid station in Italy waiting for evacuation. They had been

dug out of wrecked building which had collapsed after being hit by shell.
ADMINISTRATIVE CONSIDERATIONS 17

U. S. Armyphotos

Figure —Continued. C. Administration of first aid to infantryman in Fifth U.S. Army

battalion aid station in Italy. This man, like the casualties in B, had been dug out

of wrecked building which had collapsed after being hit by shell. D. Administration

of plasma to wounded German prisoner outside of Fifth U.S. Army battalion aid station

in Italy, April 1945.
18 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

U. S. Army photos

Figure 3.—Scenes at collecting station on Anzio beachhead, March 1944. A. Infantryman, wounded by enemy artillery, being carried into collecting station after transportation to the station in the back of jeep. B. Wounded infantryman being given

plasma at medical collecting company.
ADMINISTRATIVE CONSIDERATIONS 19

U. S. Army photo

Figure 4.—Casualty being taken into admission tent of clearing station,

Fifth U.S. Army, Italy, November 1943.

The first braceshop to function in North Africa was set up at the 21st

General Hospital, late in 1942, soon after the hospital was established at Bon

Hanifia, the site of former spa, some 65 miles south of Oran. Many of the

tools were secured from the well-equipped machine shop that had been part of

the former bathhouse and hotel facilities. Other tools, as well as supplies of

steel, leather, and salvaged canvas, were obtained from the engineering and

quartermaster departments in the base section.

As this shop was the only equipped braceshop functioning at this time in

the Mediterranean Base Section, requisitions were forwarded to it, through the

office of the base surgeon, from other hospitals in the area. Eventually, the

volume of requisitions became so large that this shop was formally designated

as braceshop for the entire base section. This proved an efficient and economical plan. As might have been expected, the orthopedic staff at the 21st General

Hospital made the fullest use of the braceshop, but orthopedic surgeons in other hospitals in the base section were also assured of the braces and belts

which they needed without the expenditure of large overhead in their own

hospitals. There was no waste of personnel. Requisitions from other hospitals in addition to his own kept the bracemaker at the 21st General Hospital

busy at all times and justified the maintenance of fully equipped and staffed

shop. The requisition and provision of material were also simplified and

expedited by the operation of single shop rather than multiple shops.

When the 21st General Hospital was moved from North Africa to Italy,

the braceshop at the 46th General Hospital served the hospitals in the medical

center at Oran by the same general plan. The bracemaker in charge had had
20 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

U. S. Army photo

Figure 5.—Ambulance transportation of wounded, Fifth U.S. Army, Italy,

April 1945.

an extensive experience in civilian life, and bracemakcrs from other hospitals

in the area at times worked under his direction. In Italy, the braceshop at the

21st General Hospital served the general and station hospitals in the medical

center at Bagnoli, just outside of Naples, as well as the orthopedic section of its

own hospital.

shop planned for the 24th General Hospital and intended to serve the

medical center at Bizerte did not become operational, as this hospital and the

other hospitals the braceshop was intended to supply moved to Italy shortly

after the equipment for the shop had been issued. Hospitals not served by

area braceshops continued to operate their own small shops, to meet their

special needs. In these isolated hospitals, the bracemakcrs usually served as

orthopedic technicians, with bracemaking an incidental assignment

The output of the theater braceshops consisted chiefly of canvas belts for

support of the back, metal braces for personnel returning to limited duty, and

individual splints and appliances. Standard splints were repaired and altered,

and shoes were also altered. Since patients with fractures which would not

permit return to duty within the period of the theater holding policy were

evacuated to the Zone of Interior while they were still in plaster, there were

few calls for the type of brace which would be needed during reconstructive

surgery and rehabilitation.
ADMINISTRATIVE CONSIDERATIONS 21

U. S. Army photos

lint re 6. Scenes in 33d Field Hospital, Fifth U.S. Army, Italy, September 1944. A. Removal, in operating room, of bandages placed on patient by medical aidmen in field. B. Dressing of wounds of distal portion of foot following initial surgery and application of cast for fractures of the bones of the leg.
22 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

U. S. Army photos

Figure 7.—Scenes in 8th Evacuation Hospital, Fifth U.S. Army, Italy, January 1944.

A. Wounded soldiers lying in receiving room of hospital. B. Winterized wards of

hospital. Winterizing was accomplished by building up wooden sides inside the side

walls of the ward tent to the height of the caves and placing wooden frames, with

doors, at the ends of the tent. Wooden floors were also provided. C. Operation of

initial surgery for wounds of the extremity in progress.
ADMINISTRATIVE CONSIDERATIONS

AFIP CA-4340-A; U. S. Army photos

Figure 8. A. 94th Evacuation Hospital, Fifth U.S. Army, Italy, December 1943. B. Operation by orthopedic team from 2d Auxiliary Surgical Group at 94th Evacuation

Hospital, Fifth U.S. Army, Italy, December 1943. Cast is being applied after initial

surgery for compound fracture of the left femur, caused by shell fragment. Note use

of portable fracture table.
24 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

U. S. Army photos

Figure 9.—24th General Hospital, Florence, Italy. A. Exterior view of headquarters and

surgical buildings. B. Operating room. C. Large surgical -ward, serving especially

for patients in traction.
ADMINISTRATIVE CONSIDERATIONS 25

HOSPITAL ADMINISTRATION

Assignment of cases.—When the North African Theater of Operations

was established, the assignment of responsibility for compound fractures was

somewhat confused. Some chiefs of surgery felt that, as in World War I,

these injuries should be the responsibility of general as well as orthopedic

surgeons and should be treated in general surgical as well as orthopedic sections.

In several hospitals, the chiefs of surgical sections elected to assign casualties

with bone and joint injuries alternately to general surgical and orthopedic

sections.

These policies proved unwise and unsound. The general surgeon and

the orthopedic surgeon frequently had wise counsel and skilled assistance to offer each other in the management of combat wounds, but only brief experience was necessary to demonstrate that the best results were obtained when

hone and joint injuries were managed exclusively in orthopedic wards. Almost

without exception, this was the policy in effect in all general hospitals in the

theater by the spring of 1944.

Segregation of bone and joint injuries, as already noted, was neither

necessary nor practical in evacuation hospitals, where initial surgery as

limited to management of the compounding wound. In properly operated

fixed hospitals, however, it was found best for orthopedic sections to receive

all casualties with fractures and joint injuries except, for obvious reasons,

those with associated fractures of the ribs, skull, and maxillofacial bones.

Fractures of the bones of the hand were also exceptions to this policy in hospitals in which general surgeons experienced in the management of hand

injuries were attached to the staff. Otherwise, these injuries were managed

on orthopedic wards.

Patients with concurrent wounds which relegated fractures to place of

secondary importance were admitted to the general surgical or other appropriate wards, but personnel from the orthopedic section assumed responsibility

for the bone and joint injuries. Failure to provide permissible treatment of

the fracture would have resulted in needless deformity and might even have

caused spreading, life-endangering infection.

Orthopedic surgeons also had the responsibility for all acute, recurrent,

and chronic conditions affecting the function of the bones and joints of the

extremities and of the back and shoulders.

Consultations were answered on request from the remainder of the surgical service and from other services in the hospital. Examinations were

carried out on the ward or in the outpatient department, according to the

status of the patient.

Caseload.—The proportion of the hospital census represented by the

orthopedic caseload varied according to the total hospital census, which might

be unusually high because of medical conditions or for other reasons. As

rule, during an active campaign, the orthopedic section accounted for about

25 percent of the hospital population and for about 35 to 40 percent of the
26 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

surgical census. After the campaign ended, these proportions usually increased

because of the long periods of hospitalization required by casualties with

fractures.

To take care of this load ideally in 1,000- or 2,000-bed general hospital,

the following personnel was necessary:

1. chief of the orthopedic section, who was responsible to and worked

under the administrative control of the chief of the surgical service. Technically, classification of B-3153 was desirable, though, when their training,

initiative, and industry warranted it, these assignments were often given to

officers with classification of C-3153. Many of these officers rapidly attained

the higher rating, particularly if they had had some previous civilian experience

in acute trauma of the extremities. Many of them did outstanding orthopedic

surgery in North Africa, Sicily, and Italy.

If the chief of the orthopedic service were to perform his duties competently, he had to exercise his supervisory and executive functions to the

fullest extent. They were not so exercised when he dissipated his time and

effort by assuming the duties of ward officer on any special ward. It was

essential, instead, that he keep his time free for ward rounds, supervision of

junior officers, emergency consultations, observation of seriously ill soldiers,

and operating-room duties. At times, he had to spend the entire day in the

operating room. The best section chiefs were those who utilized their time

in this fashion.

2. senior ward officer, to serve in twofold capacity, as assistant chief

of the orthopedic section and as ward officer on the traction ward. As the

reparative program for compound fractures developed (p. 53), it became

extremely important to have on each service an experienced orthopedic surgeon, or general surgeon with special experience in traumatic surgery, who

was qualified to make quick decisions when the pressure of work was too

heavy for the chief of the section to make them all. These decisions frequently

had to be made in the operating room.

The assistant chief of section was usually either C-3153 or C-3150

(general surgeon), though officers with classifications, who were interested

in traumatic surgery, frequently advanced, sometimes rapidly, to the higher

rating. In the Mediterranean theater, it proved perfectly satisfactory for

general surgeons to assume the management of fractures and joint injuries,

provided that they functioned as members of the orthopedic staff, under the

supervision of the chief of the orthopedic section. It was, however, neither

desirable nor practical for general surgeon to have the responsibility of

fracture management if at the same time he had the responsibility for abdominal and chest injuries and for other unrelated injuries.

3. Junior ward officers. These officers had classifications of D-3153 or D3150, but, as in other categories, it was possible for officers with general-duty

classifications to advance to specialty categories if they were interested in traumatic surgery. Each junior ward officer usually carried patient load of 75
ADMINISTRATIVE CONSIDERATIONS 27

to 100 patients, the number varying with the size of the hospital and the number of admissions after campaign.

When convalescent sections were set up in general hospitals, it was found

to be highly desirable for each ward officer to continue to supervise his own

patients as they were transferred to these sections. This duty increased the

officer’s caseload, but, as convalescent casualties required only minimum of

care, the burden seldom proved excessive, and the continuity of care thus

secured was well worth the extra effort.

4. Technicians. qualified, industrious group of enlisted technicians

was indispensable for the smooth functioning of an orthopedic section. Their

training in plaster and splinting techniques was the responsibility of the chief

of the orthopedic section in each hospital. An orthopedic section caring for

400 to 500 patients required at least technicians and also required the services

of bracemaker (p. 15). Properly taught technicians readily mastered all the

principles and details of plaster, splinting, and skeletal-traction techniques.

With experience and under minimal supervision, they could apply plaster

casts, including spicas; erect Balkan frames (see fig. 9C); arrange pulleys for

skeletal traction; and perform numerous similar duties, thus leaving medical

officers free for strictly medical tasks. Technicians also made plaster bandages,

if stock supplies were not available.

It was the usual practice for the best qualified man in the group to serve

as the chief technician. Among his other duties were the storage, maintenance,

and supply of splints, accessories, and pi aster.

Outpatient dispensaries.—After short experience with the operation of

outpatient dispensaries in general hospitals, it became clear that these dispensaries should be kept to an absolute minimum and should be chiefly used

for seeing ambulatory patients in consultation and for periodic observation of

convalescing patients. Any other plan handicapped the smooth functioning of

the orthopedic section because it required the withdrawal from it of muchneeded personnel. Outpatient clinics attached to station hospitals were

better prepared to take care of the type of work ordinarily seen in civilian orthopedic clinic, and it was particularly desirable and convenient for them

to exercise this function in base sections.

GRAPHIC RECORDS

Early in 1944, the Army Pictorial Service provided, informally, photographers to assist the consultant in orthopedic surgery in recording methods of

splinting and other orthopedic procedures and in securing illustrations of the

results of wound and fracture management. These illustrations proved very

useful for instructional and demonstration purposes.

Later, the 3d and 6th Medical Composite Detachments, Museum and

Medical Arts Service, supplied both photographers and artists as the need

arose. Photographs and drawings were thus accumulated to show variations
28 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

ill traction and splinting methods, serial wound management, the technique

of special operations, and various other items. In many instances, it was

possible to make complete case studies from the first observation of the casualty

in forward hosiptal, before initial surgery, to the end results of management

in base hospitals, before disposition. Motion pictures were also made, some of

them in color.

ACCUMULATION OF DATA

Throughout the period of active fighting, as well as after the war ended,

several different plans were followed to accumulate data on casualties with

bone and joint injuries. The following methods were used;

1. Throughout the period of active fighting, efforts were made to stimulate

the interest of the various chiefs of orthopedic sections in accumulating factual

information on small groups of cases according to their special interests.

2. In relatively quiescent periods, arrangements were made through the

theater surgeon for several chiefs of orthopedic sections in general hospitals

to travel about the theater to visit other general hospitals and to gather data

on subjects of special interest to them and to the theater consultant in orthopedic

surgery. These trips also served to acquaint the surgeons making the surveys

with techniques and methods employed in other hospitals.

3. After the war ended, arrangements were made through the theater

surgeon to have additional surveys made by other orthopedic surgeons, who

visited most of the hospitals and studied their records on special orthopedic

problems.

4. Still other medical officers were placed on temporary duty in the Office

of the Surgeon, to study disposition-board proceedings and other records available in that office, in an effort to gather as much data as was possible on several

special orthopedic problems and on the results of the treatment employed

for them.

The data thus collected furnish some of the supporting information in

various chapters of this history.
CHAPTER 111

Splinting in the Combat Zone

CLASSIFICATION OF MILITARY SPLINTING

The exigencies of military surgery in World War II required, as already

noted, that all care of battle casualties be rendered in phases, in installations

located, equipped, and staffed for various specific missions. The splinting of

bone and joint injuries was similarly timed. It was necessarily interrupted

for each phase of surgical management. It was carried out with material and

facilities that varied according to the mission of the installation at which the

care was rendered. It was provided again, with new objective, after each

phase of treatment had been completed.

By process of evolution, splinting in overseas military surgery in World

War II (table 1) was eventually classified as follows:

1. Emergency or first-aid splinting, which was provided within the divisional area of the combat zone as an integral part of resuscitation and to render

the casualty transportable to hospital equipped for surgery.

2. Splinting after initial wound surgery, which was provided in an evacuation hospital or, as indicated, in field hospital. It was not intended to obtain

or maintain reduction of fractures. Its objective was to facilitate transfer of

the wounded soldier to fixed hospital in the communications zone.

3. Splinting after reparative surgery, which was applied in fixed hospital

in the communications zone. It was sometimes designed to achieve reduction

of fractures. It was always designed to maintain reduction and to provide

prolonged immobilization. As matter of convenience, it will be discussed

under the headings of the management of regional and special injuries.

4. With an occasional exception, such as fractures of the femur and of

the hand, splinting for transportation to the Zone of Interior did not represent

special type. The casts applied after reparative surgery were sometimes

changed before the casualty was returned to the United States, for reasons of

cleanliness or because the casts had become too loose to be effective. As

rule, however, the definitive splinting applied for the fracture in the fixed

hospital served until the cast was removed in the hospital in the Zone of Interior in which treatment would be continued.

396961°—57
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Table

1.

—Classification

of

splinting

of

compound

battle

fractures

by

phase

of

management,

in

relation to

timing,

objectives,

and

facilities

Phase

of

management

Time

after wounding

Anticipated duration

Medical

installation

Surgical

personnel

Methods

Materials,

facilities

Emergency,

transportation

0-12

hours.-.

4-24

hours...

Battlefield,

battalion

aid

Medical

aidmen

Improvised,standard... ...

Improvised,

halfand

fullto

forward

hospital.

station.

ring

splints,

basswood,

wire

ladder

splints,

slings.

Battalion

aid,

collecting,

General-duty medical

offiInspection,

adjustment,

reclearing

stations.

cers.

placement.

Initial

surgery,

transporta8-36

hours... 1-10

days

Field,

evacuation

hospiGeneral,

orthopedic

sur- Plaster casts,

skin

traction

X-ray

facilities,

plaster,

tion

to

fixed

hospital.

tals.

geons.

(amputation), metal

standard

splints.

splint

(occasional).

Reparative

surgery, main5-10

days

21-120

days..

General,

special

station

General,

orthopedic surSkeletal

traction,

plaster

X-ray

facilities,

plaster,

tenance

fracture reduohospitals.

geons,

physiotherapists.

casts,

internal

and

exterstandard

splints, Klrschner

tion.

nal

fixation,

metal

splints,

wires,

Steinmann

pins,

walking

irons,

simple

Balkan

frames,

bone

plates,

braces.

screws,

external-fixation apparatus,

braceshops.

21-120

days.

Plaster

casts,

simple

metal

Do.

Interior.

splints.

En

route

to

Zone

of

Interior.

10-14

days...

Changes

of

cast

Plaster. None.

Army

general

hospitals,

Orthopedic

surgeons, physPlaster

casts,

special

indiComplete,

brace

and

prostive.

special

centers.

ical

and

occupational

vidual

splints

and

prosthetlc

shops.

therapists.

theses.

After

partial or

complet

bony

union.

Only

if

necessary.
SPLINTING IN COMBAT ZONE 31

EMERGENCY SPLINTING

Historical Note

In World War I, splints and other appliances used by the United States

Army Medical Corps were not standardized until late in 1917. board appointed by General Headquarters, American Expeditionary Forces, to investigate and report upon the advisability of standardization suggested that

manual of splinting be prepared for the use of medical officers. The manuscript was approved by the commanding general, American Expeditionary

Forces, September 1917, and weeks later the Manual of Splints and Appliances for Use of the Medical Department of the United States Army was

delivered to supply depots in France. The printing of the manual, as well as

the manufacture and procurement of the recommended splints and other

appliances, was then the responsibility of the American Red Cross.

second board of officers was appointed in October 1918 to revise the

manual on splinting and to examine the necessity for changes in the splints

and other appliances in use. Although the board completed its work in only

few days, the second edition of the manual was not ready for distribution

until February 1919, more than months after the end of World War I.

No significant changes seem to have been made in the methods prescribed

in this manual until 11 September 1940, during the prewar mobilization of the

United States Army. This was 15 months before the entry of this country

into World War II. The manual issued at this time (Medical Field Manual,

FM 8-50, Splints, Appliances, and Bandages) served as the textbook for the

training of officers and enlisted men of the Army Medical Department during

the period of mobilization and for the first years of United States participation

in World War II.

The methods described in this manual were based on the use of the splints

standardized in the Army Tables of Equipment (then called the Basic Equipment List) before the beginning of mobilization. These methods were naturally

modified in the light of experience in overseas theaters, but no formal revision

of the manual was issued until 15 January 1944.

Splinting is mentioned only incidentally, and with almost no details, in

Orthopedic Subjects, one of the Military Surgical Manuals prepared by the

Committee on Surgery of the Division of Medical Sciences of the National

Research Council, which appeared in 1942.

Improvised splinting was not mentioned in the manuals prepared in World War I. It seems to have been included for the first time in the second

(1931) edition of the Military Medical Manual. It was only briefly discussed

The Medical Department of the United States Army in the World War. Washington; Government Printing

Office, 1927, vol. XI, pt. 1, pp. 549-590.

Orthopedic Subjects. Prepared and edited by the Committee on Orthopedic Surgery of the Committee on Surgery

of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals. Philadelphia

London: W. B. Saunders Co., 1942.
32 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

in this edition and was mentioned with similar brevity in each of the subsequent

editions of this manual, including the sixth, which was issued in 1944.

The Medical Field Manual (FM 8-50) issued in 1940, also contains no

mention of improvised splinting. The 1944 revision, entitled “Bandaging and

Splinting,” contains no direct text references to improvisations, but illustrations show the use of sticks as splints for the forearm and the use of coat and

shirttail as slings. Soldiers Handbook (FM 21-100), issued 23 July 1941,

contained brief but excellent paragraph on the subject. First Aid for Soldiers

(FM 21-11), issued April 1943, contained detailed description and many

excellent illustrations of improvised methods of splinting. Long before this

date, however, intensive and thorough instruction in improvised methods had

been given to Medical Department enlisted men of the Regular Army, both

before and during the period of mobilization and after the entry of the United

States into the war.

Equipment

Standard United States Army equipment for emergency battlefield splinting in World War II included hinged half-ring leg splints; hinged full-ring arm

splints; wire ladder and basswnod splints; and triangular, roller, and Carlisle

compressed bandages.

This equipment, while it was generally efficient, was extremely cumbersome.

Throughout the war, the desire was repeatedly expressed, and the need as

clearly evident, for light, readily adjustable, easily transportable, universally

applicable splint which medical aidmen could use on the battlefield. At the

end of the war, this need had not yet been satisfied.

General Considerations

The emergency splinting of fractured extremity had as chief objective

the preparation of the wounded man for his transportation, with minimum

discomfort, from the battlefield to hospital in which he would receive surgical

care. It was also an important part of first-aid management. It minimized

or prevented shock in bone and joint injuries. Itreduced the need for narcotics.

It was thus an essential step in the resuscitation which had to be accomplished

before surgery could be undertaken.

Reduction of the fracture was not an objective of emergency splinting.

The purpose of emergency splinting was to prevent additional damage to the

soft parts by fragments of bone and to keep the patient as comfortable as

possible while he was on his way to the evacuation hospital. The criteria of

its success were therefore comfort and relief from pain during transportation.

Medical aidmen, during their training, were always instructed that it

was desirable, when possible, to “splint ’em where they lie” and to use standard

methods of splinting. As practical matter, neither of these instructions was

ahvays possible of accomplishment. For variety of reasons, itwas sometimes

more expeditious to bring the wounded man to the battalion aid station on
SPLINTING IN COMBAT ZONE 33

AFIP 45-5oa

Figure 10.—Improvised battlefield splinting for fracture of femur.

board is secured to the trunk by the wounded man’s own belt and to the

injured right lower extremity by several turns of bandage.

litter. The chief of these reasons was that delay on the battlefield might

have resulted in additional hazards to the casualty as well as risk to the aidmen

themselves. In the battalion aid station, the environment was safer; better

equipment was available; and the splinting, which could be applied deliberately,

was frequently more precise and more accurate than splinting applied nearer

the front. None of these reasons, however, was an indication for failure to

splint the wounded man on the battlefield whenever that was possible.

Improvised splinting, as already mentioned, was taught along with

standard methods during the period of training. The ingenuity of the United

States Army medical aidman, when he found himself in circumstances of stress,

often went beyond his formal teaching. fractured lower extremity (fig. 10),

for instance, was bandaged to rifle, to handy board, or to limb from

nearby tree. fractured upper extremity was held against the chest by the

field jacket after the upturned shirttail had been fashioned into sling. These

and other improvisations proved extremely satisfactory, and, when they were

adequate, they, like more conventional splinting, were left undisturbed as the

casualty was evacuated through the successive echelons of the division medical

battalion.
34 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

If for any reason either improvised or conventional splinting did not seem

adequate, it was adjusted or replaced at the battalion aid station. All splints were carefully inspected at each subsequent installation and were

adjusted as necessary, but they were not removed or replaced except for good

reason. Even if it was necessary to remove the dressing and inspect the

wound, it was seldom necessary to remove the splinting to accomplish this

purpose.

Regional Emergency Splinting

Upper extremity.—Well-padded coaptation basswood or wire ladder splints furnished satisfactory emergency splinting in injuries of the bones and

joints of the forearm and hand (fig. 11). It was promptly learned that sling composed of triangular or roller bandage must be added to keep the patient

comfortable (fig. 11C).

Difficulties frequently developed when the hinged full-ring arm splint was

used under battlefield conditions for fractures of the humerus. This splint

proved undesirable in almost every respect. Many of the wounded soldiers complained of constant discomfort when they were put up in it with traction

applied by means of hitch placed about the wrist and fastened to the end of

the splint. The full elbow extension produced by traction predisposed to

angulation of the fragments, and the angulation, in turn, introduced risk of

damage to the brachial artery and the main nerve trunks. Still another dangerous possibility from pressure of the ring was injury, which might be irreparable,

to the axillary contents.

For these various reasons, the hinged full-ring arm splint was employed

less and less during the course of the Tunisian campaign, but it was still occasionally used in the theater, in spite of instructions to the contrary, until

December 1944, because new units coming from the United States had been

taught to apply it.

Eventually, this splint was completely replaced for fractures of the arm

and shoulder joint by two other methods which were simple to apply and which

provided maximum relief of pain and discomfort. Both held the elbow in

about 90° flexion.

1. In the first of these methods, Carlisle pad was placed in the axilla

and triangular bandage was applied as sling to hold the elbow at, or almost

at, right angle. second triangular bandage was used to bind the arm, in

this position, against the chest, and was reenforced by few turns of roller

bandage. During the latter part of World War II, this simple method came

to be considered the method of choice for emergency splinting of fractures of

the humerus and for fractures about the shoulder.

2. The second method of emergency splinting (fig. 12) required the use of

padded wire ladder splint extending from the tip of the shoulder down the

posterior aspect of the arm and forearm to the hand. The arm was held at

the side, with the elbow almost at right angle; then the splinted arm and

forearm were bandaged against the chest by roller or triangular bandage.
SPLINTING IN COMBAT ZONE 35

AFIP FC-44-3, C-44-66, C-44-657

Figure 11.—Emergency splinting applied for fractures of forearm and about elbow and

wrist. A. Basswood coaptation splints used for fractures of forearm and wrist. Wire

ladder splint used for fractures of forearm and about elbow. Note free use of Carlisle

pads, loop of roller bandage for sling, and reenforcing turns of bandage which are added

if shock or concurrent injuries make it desirable that soldier travel as litter case. B.

Basswood splint (applied in battalion aid station) for compound fracture of forearm.

C. Sling added to complete emergency splinting in compound fracture of forearm.

D. Wire ladder splint and sling applied in clearing station for fracture of forearm by

small-arms fire.

Lower extremity.—Either single or double wire ladder splints, well padded,

were used for fractures of the foot and ankle (fig. 13). Often single splint

was sufficient it was passed down the back of the leg, around the heel, and up

the plantar surface of the foot. If false motion or instability at the site of the

fracture was present with single splint, second was passed down one side

of the leg, around the plantar surface of the heel, and up the other side of the

leg. The foot was splinted at right angles to the leg, and roller bandages were

used to hold the splint or splints in position.

The half-ring leg splint proved, on the whole, quite satisfactory for fractures of the leg, knee joint, thigh, and hip joint (fig. 14). Three triangular

bandages served as slings for the fractured portion of the extremity and two

others for the intact portion. The foot was held almost at right angle by

foot support, and the distal end of the splint was elevated by another foot
36 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Figure 12.—Methods of emergency

splinting, either of which is satisfactory, for fracture of humerus. Fractures in this location cause considerable pain, and effective splinting is

essential for the patient’s comfort during evacuation to hospital. A.

Technique of application of double

triangular bandage and wire ladder

splint reinforced by Velpeau bandage. B. Emergency splinting with

wire ladder splint and sling for battleincurred compound fracture of humerus. C. Wire ladder splint applied

for emergency splinting of compound

fracture about elbow. Note reinforcing bandages about body.

AFIP FC-44-2, C-44-654, Fd-44-10
SPLINTING IN COMBAT ZONE 37

Figure 13.—Emergency splinting for injuries of the lower third of leg and

ankle. A. Emergency splinting with

double wire ladder splint for injuries of

foot and ankle. Note free use of padding,

which is essential to protect bony prominences from pressure. Note also that

foot is held at angle of 90°. B. Double

wire ladder splint for emergency splinting

for compound fracture of the lower tibia.

C. Single wire ladder splint applied for

emergency splinting for compound fractures of lower third of tibia and fibula.

AFIP FC-44-4, C-44-652, Fd-44-10

support, this one being turned downward. Late in the war, single gadget

slipped over the end of the splint took the place of both supports. standard

webbing strap was placed about the heel and ankle and fastened to the end of

the splint, thus providing moderate fixed traction. The strap was applied

with the shoe on, but the shoelaces were then loosened or cut, to allow for

possible swelling of the ankle and foot.

casualty was not comfortable during evacuation in the half-ring leg

splint unless the distal end of the splint was elevated and made secure. This

was accomplished by fixing the lower half of the foot support used to maintain

elevation of the distal end of the splint in the bar by which the splint was

attached to the stretcher. The bar was standard equipment.

number of other precautions were necessary when the half-ring leg

splint was used:

1. Deflexion or unfolding of the hinged half ring, with sagging of the

upper end of the splint, was likely to result in painful drag on the thigh.

This could be almost entirely prevented if care was taken to see that the half

ring was folded completely into tlie 90° position when the splint was applied.
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Ca-45-736, Ca-45-738, Fd-45-55

Figure 14.—Emergency splinting with Army half-ring leg splint for injuries of thigh, knee

joint, and leg. and B. Fixation of splint by litter bar. This accessory proved

valuable adjunct for comfortable emergency splinting. C. Application of Army halfring splint with traction, at collecting station, for compound fracture of middle third

of tibia. Basswood coaptation splints had been used for emergency splinting.

D. Substitution, in clearing station, of standard splinting (traction in an Army

half-ring leg splint) for the improvised splinting shown in figure 10.
SPLINTING IN COMBAT ZONE 39

2. If the injury was near the hip or the knee, the splint was bent 15°

to 20° at the knee before it was applied, so that those joints would be put up

in some degree of flexion.

3. In fractures of the lower third of the femur, the popliteal vessels had to

be protected against injury from the sharp bony fragment likely to project

posteriorly. The risk of injury to the popliteal artery was decreased if the

extremity was put up in slight flexion at the knee instead of in complete extension.

4. Pressure necrosis, which was possibility underneath the strap crossing

the foot, was guarded against by avoiding strong traction. Strong traction,

as matter of fact, was not required, since the objective was merely to immobilize the fracture, not reduce it. The results were therefore accomplished

by moderate or even minimal traction. It was necessary to inspect the strap

at each halt in the line of evacuation, to be sure that pressure had not become

excessive.

TRANSPORTATION SPLINTING

Theroutine use of plaster of pans for transportation splinting in the evacuation hospitals of the combat zone in World War II was major advance over

the methods of splinting used in World War I, when for all practical purposes

only the splints and appliances described in the manual issued in 1917 (p. 31)

were provided in forward areas and plaster was seldom used.

Medical planning for World War II contemplated the use of plaster in the

forward zone, partly because United States surgeons were fully trained in

plaster techniques and partly because these methods had been used with

satisfaction in forward installations during the Spanish Civil War as well as

in Allied forward hospitals before the entry of the United States into the war.

Standard United States Army Medical Department equipment for hospitals

in the combat zone therefore included ample supplies of plaster of paris and

sheet wadding, in addition to standard splints. Portable fracture tables

became available after the Tunisian campaign in 1942-43, Up to that time,

some hospitals were supplied with Meyerding sacral rests. Those which did

not have them made use of wooden blocks, tin cans, and other improvised

substitutes, which were more or less satisfactory. The chief objection to

these improvisations was that they were wasteful of personnel. At least one

person was required to hold each lower extremity while hip spica, for instance,

was being applied.

It should be remembered that the First U. S. Army functioned in World War for only about 11 weeks, from

September to 11 November 1918. The number of casualties during this period was large but amounted toonly small

fraction of those sustained in the European theater or Mediterranean theater during World War II. There was no consultant system in World War I, except on paper, until hostilities were almost concluded. Those of us who served in

World War I, have found, cannotrecall seeingany circulars or directions concerning the propersplinting forevacuation

of wounded. The Army ring splint was used to evacuate patients from field hospitals to evacuation hospitals, and, in

smany instances, it was doubtless reapplied before theywere sent to the rear from evacuation hospitals. Plaster-of-paris

plints, however, were also used. recall applying them myself,and have checked with fellow medical officer who

served in nearby evacuation hospital and who spent his entire time applying plaster-of-paris splints to immobilize

fractures for evacuation. [Editor’s note.]
40 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

General Considerations

The objective of transportation splinting in forward hospital was to

maintain gross normal alinement of the injured extremity, to immobilize the

adjacent joints in the position of function, and to accomplish these purposes

without causing nerve or circulatory damage or causing pain by pressure on

bony prominences.

Some of the techniques used in the hospitals of the combat zone early in

the North African experience proved completely unsatisfactory and dangerous

as well. Among them were skintight, unpadded plaster casts and skeletal

fixation with incorporation of transfixion pins or wires in the cast (p. 55).

The ideal transportation splint proved to be well-padded plaster-of-paris

cast which held the fracture in grossly normal alinement and which immobilized

the joints above and below the injury in the position of function. Once the

lesson was learned, no exceptions were permitted to the rule that all circular

plaster casts applied to the extremities must be split or bivalved in the operating

tent of the forward hospital before the patient was taken off the operating table.

There were two reasons why it was not safe to postpone this procedure: (1)

There were no ward officers in the usual sense of the term in forward hospitals,

and the splitting or bivalving of the cast was therefore the responsibility of

the surgeon, who could not count on time to leave the operating room to split

casts on the ward; and (2) theoretically, provision had to be made for tactical

situation which might demand immediate evacuation and allow no time for

such details as splitting casts.

Plaster casts for transportation purposes were made relatively thick and

heavy, to prevent breakage after they had been split or bivalved. Muslin

bandages were wound around them snugly after they had been split, to protect

their integrity and increase their stability.

After the cast had been applied, diagram was drawn on it showing the

location and general contour of the fracture (fractures), the location of the

wounds of entry and exit, and the extent of the skin loss. Those who cared

for the casualty in the course of his evacuation, as well as those who received

him in the general hospital, thus had readily available source of information

concerning his injuries.

The application of good transportation splinting often required the help

of several persons. single assistant could not possibly support lower

extremity in which both the tibia and fibula were fractured so that the fragments were kept in satisfactory alinement, while at the same time the foot was

kept in 90° dorsiflexion, in neutral version, and the knee in mild flexion. An

attempt to put the lower extremity in plaster with aid from single assistant

who grasped the toes and provided both elevation and traction almost invariably resulted in immobilization with posterior bowing, with the foot in plantar

flexion and inversion and the knee in complete extension. This is as pernicious

position as can be imagined for immobilizing an extremity with fracture

of the tibia and fibula. Properly, the plaster was applied for such an injury
SPLINTING IN COMBAT ZONE 41

while one assistant supported the fracture and another held the foot in correct

position.

Improvised methods (fig. 15) were designed to reduce the number of

helpers necessary after initial wound surgery, personnel shortages always

being problem. Thus the use of narrow, removable support of flexible

metal under the knee while the cast was applied to the lower extremity kept

the joint in slight flexion and made it possible for single assistant to support

the fractures of the lower leg in reasonably good alinement and at the same time

hold the foot in the position of function (fig. 15A).

plaster Velpeau or shoulder spica was extremely useful in transportation

splinting for injuries of the upper arm and shoulder but was difficult to apply

because of lack of standard equipment. The hinged full-ring arm splint, although unsatisfactory for the purposes for which it was intended (p. 34), was

very useful in the application of plaster about the shoulder (fig. 15B). The

end of the splint was placed on the operating table and the ring on some convenient available support, such as sawhorse. The patient’s head rested comfortably in the ring during the application of the cast. The splint was easily

pulled out from beneath the cast after the plaster had hardened. long,

narrow board or narrow strip of strong metal could also be used in this fashion

(fig. 15C), but it was less convenient for the surgeon and considerably less

comfortable for the patient.

If the hand was suspended from stand used for intravenous therapy by

roller bandage tied about the thumb and fingers, long arm plaster casts could

be applied for fractures of both bones of the forearm with the fragments in

reasonably good position and the wrist and elbow joints in the position of

function.

These are merely examples of some of the shortcuts and improvisations

employed. They were highly advantageous when casualties were heavy,

demands urgent, and surgical personnel in short supply. Numerous others

were devised as special necessities developed.

Regional Splinting

Arm and shoulder joint.—For several years before the war, the hanging

plaster cast had been popular in the United States for fractures of the humerus

and injuries about the shoulder joint. It was therefore natural that it should

have been rather widely used in the early stages of the North African campaign.

It soon became evident, however, that while this cast might be satisfactory in

civilian practice, it was not an adequate transportation splint in military

circumstances. Reports from general hospitals which received casualties put

up in hanging casts were always to this effect. Most patients with fractures

of the humerus were necessarily transported recumbent after initial wound

surgery, with the result that the traction produced by the weight of the cast in

the hanging position was lost and little immobilization was maintained during

transportation. Ambulance rides,over rough terrain helped to increase the
42 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-652, FD-44-9, C-45-759, C-44-542, CA-44-137

Figure 15.—Improvisations designed to save time and economize on personnel in application of splinting in evacuation hospital after initial wound surgery. A. Application

of plaster cast of lower extremity in evacuation hospital. Note narrow removable

support of flexible metal which is readily improvised and is exceedingly valuable in the

proper application of the cast. Note that the cast has been split down the outer side.

Note also data on cast. B. Use of hinged full-ring splint to facilitate application of

plaster Velpeau or shoulder spica. C. Application of plaster Velpeau or shoulder

spica is facilitated with patient lying on narrow metal strip, one end of which rests on

the operating table and the other on an improvised headstand. D. Application of

hip spica. The patient rests on portable fracture table placed on top of wooden

table improvised in fixed hospital. The same type of portable fracture table is

placed on standard folding operating table for the application of hip spica casts in

forward hospitals. E. Improvised canvas sling, stretched between crossbars fixed to

litter, for application of body cast or plaster Velpeau.
SPLINTING IN COMBAT ZONE

loss of immobilization and added to the patient’s discomfort. Because of

universally adverse criticism, the hanging cast was seldom used after the first

months of 1943.

In the early North African experience, fractures of the humerus were also

immobilized by the so-called U-plaster cast, which the British had used widely

in the Middle East. It was not satisfactory and was soon discarded. Another,

later method, which also never achieved popularity among United States

Army medical officers, was the so-called elephant-tusk splint (fig. 16), which

was introduced during the Italian campaign. Because it could be removed

and replaced, it was theoretically useful (1) in injuries of the arm or shoulder

associated with chest injuries which required thoracentesis and (2) in vascular

injuries which required repeated inspection of the entire arm and forearm.

The plaster Velpeau and the shoulder spica both proved excellent transportation casts, and one or the other was always used after the fighting for

Cassino and Anzio began in the winter of 1944. Both maintained the arm at

or near the side and the elbow at 90°. This position permitted transportation

with minimum discomfort.

The plaster Velpeau (fig, 17) was, for number of reasons, the better of

the two techniques: It provided maximum comfort. It was easy to apply and

remove. It fitted within the bars of the litter, which was an important consideration in comfortable transportation. If thoracentesis was necessary for

an associated chest injury, access to the chest could be provided by windows

cut into the cast. If radial-nerve paralysis was present, excellent temporary

support could be provided for the thumb and the proximal phalanges of the

fingers by extending the plaster sufficiently to hold them in extension. When

the plaster Velpeau was applied correctly, it was not necessary to split it, since

it did not completely enclose the arm.

There were, it is true, some theoretical objections to the use of plaster

Velpeau for transportation splinting. The chief was that the adducted position

of the arm at the side was unsuitable for fractures of the upper third of the

humerus. This was not sound argument, for two reasons. The first was that

surgeon in forward hospital was not concerned with the definitive reduction

of fractures. The second was that the comfort provided by the cast predisposed

to muscular relaxation, so that it was the exception, at the general hospital,

not to find the upper humeral fragment adducted and in reasonably good

alinement with the distal fragment.

The shoulder spica (fig. 18) provided just as comfortable transportation

as the plaster Velpeau in injuries of the arm and shoulder, but it had number

of disadvantages in forward hospital: The spica had to be applied with special

precautions, preferably with the arm in the position of internal rotation at the

shoulder and with the elbow and arm held anteriorly rather than laterally.

Otherwise, the cast would not fit within the bars of the litter or cot, and the

elbow would project and might be traumatized during transportation. Finally,

the spica required more personnel for its application, and the use of more

plaster, than the Velpeau.
44 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP FC-44-U

Figure 16.—Modification of elephant-tusk splint for fractures about shoulder joint and

elbow. This splint has only limited field of usefulness, but every military surgeon

should be familiar with it. The shoulder and elbow are points of stress, and the cast

most often breaks at these points. and B. Technique of application of elephant-tusk

splint. and D. Anterior and posterior views of completed splint.
SPLINTING IN COMBAT ZONE 45

AFIP FC-44-0

A. Diagrammatic showing of steps of application of plaster Velpeau. For several reasons,

this cast provides excellent transportation splinting for fractures of the humerus. It can

be constructed from only plaster slabs and or rolls of plaster bandage. There are no

points of stress, so breakage need not be feared. The entire hand, if desired, can be left free.

AFIP CA-44-612 AFIP FD-44-924

B. Plaster Velpeau used as transportation

splinting for compound fracture of lower

third of humerus. The hand in this case

projects farther forward than usual.

C. Plaster Velpeau applied in evacuation

hospital after initial surgery for compound

fracture in region of shoulder. Note data

on cast.

Figure 17.—Plaster Velpeau bandage for injuries of shoulder joint, arm, or elbow

396961 —57
46 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fc-45-2

A. Diagrammatic showing of shoulder spica so applied

that forearm and elbow are held forward and therefore

within bounds of litter bars. Note that the circular

portion of the cast about the arm has been split.

AFIP C-44-480

B. Shoulder spica applied in evacuation hospital, following initial surgery

for compound fracture of humerus with injury to radial nerve. Note support

temporarily provided for thumb and proximal phalanges of fingers. Note

also data on cast.

Figure 18.—Application of shoulder spica for injuries about shoulder joint and of arm
SPLINTING IN COMBAT ZONE 47

Forearm and elbow joint.—The preferred transportation splint for wounds

of the forearm and elbow joint was plaster cast extending from the upper arm

to the proximal palmar crease. It was so applied that the elbow was held at

90°, the forearm in mid pronation, and the wrist in slight cocknp. sling

provided additional immobilization and at the same time added to the patient’s

comfort. It was particularly important that the sling be supplied when the

casualty had no other injury. Under these circumstances, he would be treated

as walking wounded, and without sling the hand would be in the dependent

position and would rapidly become edematous.

If there was no radial-nerve injury, all casts applied to the upper extremity

were trimmed away to the proximal palmar crease, to permit active use of the

fingers and thumb. Particular care was taken to avoid restriction of motion

in the metacarpophalangeal joints. If radial paralysis was present, the plaster

was extended beyond the palmar crease, to support the proximal phalanges of

the fingers in some degree of extension, and the thumb was immobilized in

partial abduction and extension. The distal phalanges of the fingers ere

left free for active motion.

Thigh and hip.—Although the hinged half-ring traction splint was standard

United States Army equipment, it as seldom used in transportation splinting,

even during the early stages of the North African campaign.

During both phases of theTunisian campaign, United States Army medical

officers had ample opportunity to observe the British use of the Tobruk splint.

This splint, so named because it first came into use during the evacuation of

Tobruk, as practically always used by the British for transportation splinting

of fractures of the femur, and its use was recommended in the preparatory

United States Medical Department directives for the invasion of Sicily.

United States Army surgeons wdm served in Sicily never liked the Tobruk

splint for fractures of the femur. They found it difficult and time consuming

to apply and did not regard the immobilization provided as satisfactory.

For these reasons, the Tobruk splint was not generally accepted in the

Mediterranean theater during the remainder of World War II, even after

its application had been greatly simplified and it had proved highly effective

for transportation splinting in injuries of the knee (p. 49) and the low er third

of the femur.

In spite of the unpopularity of the Tobruk splint, every United States

Army military surgeon should have been familiar wdth it. It was far more

desirable than the hip spica when injuries of the large bowel for which

colostomy had been performed were associated with fractures of the femur.

It was particularly useful for fractures of the low er third of the femur and

wounds of the knee joint. It was also useful when either plaster or water

was in short supply or when speed of application W’as important.

(1) Circular Letter No. 13, Office of the Surgeon, North African Theater of Operations, 15 May 1943, subject:

MemorandaonForward Surgery. (2) CircularLetter No. 16, Office of the Surgeon, North African Theater of Operations,

June 1943,subject: Memorandaon Forward Surgery Especially Applicableto Amphibious Operations. (See appendix,

pp. 299-303 and 304-307, respectively.)
48 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-338

Figure 19.—Hip spica applied in evacuation hospital for transportation splinting of compound fracture of femur. The cast has been split along the outer side. Note that

knee spread is held to minimum, so that the cast fits within the bars of the litter.

Note also the data on the cast, including the highly informative diagram of the injury.

Early in the North African campaign, the single hip spica was widely used

for fractures of the femur and fractures about the hip joint. Later, the double

spica (fig. 19) came into general use. It was really spica and half, since the

cast on the uninjured side was carried only to the knee. On the injured side,

the cast extended from the foot to the costal margin. plaster slab extended

beyond the toes. The plaster was molded about the pelvis and was trimmed

low in front, to permit the injured man to sit semierect during travel. Knee

spread was held to minimum, so that the cast would fit between the bars

of the litter or cot on which the casualty was transported. Such spica cast

emerged as the recommended transportation splinting for fractures of the

femur.
SPLINTING IN COMBAT ZONE 49

Certain precautions were necessary in the application of the spica. In

fractures of the upper third of the femur, the hip and knee were both flexed at

35° to 40°, In fractures of the lower third, in order to guard against pressure

in the popliteal space by rotation of the lower femoral fragment, the knee was

flexed at 30° to 35°, which required compensating degree of flexion of the

hip. Care was taken to insure that the heel and buttock were held in the same

horizontal plane when the cast was applied. Otherwise, the upper rim of the

cast could produce uncomfortable pressure against the back or the abdomen

when the patient was recumbent in bed or on cot and the heel and buttock

necessarily assumed the same plane.

If the spica was bivalved from toes to hip, cross sticks were incorporated

between the thighs both anteriorly and posteriorly. As rule, itwas necessary

to split only the leg section of the spica, on the outer aspect, and single anterior cross stick was then all that was necessary.

Knee joint.—Satisfactory methods of transportation splinting for wounds

of the knee joint were slow in developing. Long leg casts were used in the

early days of the North African invasion and continued to be used by most

surgeons in forward areas until the spring of 1944. This technique was employed

in spite of the early British experience, which had showed that the hip spica

was preferable for such injuries, and in spite of reports from United States

Army general hospitals to the effect that casualties transported in long leg

casts often suffered great deal of pain.

The hip spica began to be used for injuries of the knee joint in the latter

part of 1943, but it was employed only sparingly until the spring of 1944.

Then its use was recommended officially, as part of the effort to improve the

results in wounds of the knee joint. The long leg cast, however, was easier

to apply and it continued to be used frequently, especially when casualties

were heavy. This was unfortunate, for, even when injury to the adjacent

bones was minimal, adequate immobilization of the knee was of paramount

importance in reducing the risk of infection. It was also essential if the

patient were to travel comfortably. These criteria could not be met by use

of long leg plaster cast.

It was eventually found that single hip spica, well molded about the

pelvis, with the hip and knee joints each held in 15° to 20° flexion, provided

the most satisfactory kind of transportation splinting for an injury about the

knee joint. The portion of the spica encircling the trunk was kept narrow

and did not extend above the costal margin, so that the soldier might sit

semierect without discomfort, as in spicas applied for fractures of the femur.

The simplified form of the Tobruk splint (fig. 20) could be used as

substitute for the plaster hip spica for wounds about the knee joint, and its

ease of application often made it desirable substitute. Because it had

proved so unsatisfactory in its original form for fractures of the femur, it

never became widely popular for this purpose in Fifth U. S. Army hospitals.

The simplified form of the Tobruk splint was, however, recommended for
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP FC-44-1

Figure 20.—Application of modified Tobruk splint. A. Application of adhesive tape for

traction; sheet cotton and plaster. B. Stabilization of half ring by loop of muslin bandage

incorporated in plaster.
SPLINTING IN COMBAT ZONE 51

wounds of the knee joint by the consultant in surgery, Seventh U. S. Army,

just before the invasion of southern France. In the original Tobruk splint, traction was provided by strips of adhesive

plaster passed down each side of the thigh and leg. long leg plaster cast,

which included the foot, was applied over these strips, which emerged from

the cast just above the malleoli. The injured extremity in the plaster cast was then placed in Thomas splint and the traction strips were tied to the

end of the splint. Traction was provided by means of windlass. Additional

turns of plaster were passed around the leg and the bars of the splint.

In the simplified Tobruk splint (fig. 20), the traction strips of adhesive

were placed down each side of the extremity, as in the original technique, and the limb, heavily covered with sheet cotton, was placed in an Army halfring splint. The traction strips were then passed around the footrest, which

supported the foot at about 90°, and were tied to the end of the splint. Tongue depressors passed between the traction strips just proximal to the distal end

of the splint served as windlasses to provide some traction. Several turns

of plaster were next applied loosely about the limb and the splint, from just

above the malleoli to the groin. They were molded about the uprights and

along the posterior and anterior surfaces of the thigh and leg. The distal

end of the splint was elevated by means of second foot support, which was

turned downward. figure-of-eight plaster bandage bound the foot to the

foot support. This precaution, which prevented rotation of the leg, increased

the patient’s comfort.

The full-ring Thomas splint would have been more satisfactory to use

with the Tobruk splint than the half-ring splint, hut the latter had been

standardized equipment since the beginning of World War II, and the fullring splint was not available in evacuation hospitals. Deflection of the half

ring at any time after it was applied caused the upper end of the plaster to

press against the thigh and produced considerable discomfort. This could be

avoided by fixed traction on loops of bandage passed through the half ring.

The ends of the loops of bandage were incorporated in the plaster about the

thigh and the half ring was thus stabilized in the correct position.

Surgeons of the forward hospitals of the Fifth and Seventh U.S. Armies

who used the Tobruk splint by the modified technique just described were

almost unanimous in stating that it can be applied more quickly and more

easily than hip spica.

Leg, ankle joint, and foot. -Fractures of bones of the leg, ankle joint, and

foot were put up in molded plaster casts (fig. 21). If only the bones of the foot

were broken, the cast was stopped at the knee. For injuries about the ankle

and for fractures of the tibia, fibula, or both bones, it was carried to just below

the groin. The foot was held at 90°, in neutral version, with the arches well

molded. plantar slab extended beyond the toes, to protect them from the

pressure of blankets and from other trauma during transit. Hyperextension of
52 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-663

Figure 21.—Transportation splinting in fractures of lower extremities.

Long leg cast applied in evacuation hospital, following initial surgery.

The cast has been split down the outer side, and muslin bandage is

being applied about it to maintain its integrity. Note the excellent

position of the knee and ankle joints, the plaster support for the

protection of the toes, and the data inscribed on the cast.

the toes was avoided. The knee was immobilized inabout 15° flexion. Failure

to provide this small degree of flexion increased the difficulty of obtaining

fixation of the foot at the proper angle, since complete extension of the knee

increased the tension on the gastrocnemius muscle.
CHAPTER IV

The Management of Compound Battle Fractures

Part I. The Evolution of the Program of

Staged Management

CONCEPTS AND PRACTICES BEFORE WORLD WAR II

Orthopedic practices in general use at the end of World War called for the

management of most compound battle fractures in splints or appliances based

on the general principles of splinting. Skin traction was used for continuous

traction. Only occasional fractures were put up in skeletal traction, and plaster

was not generally used because freedom of joint movement was considered

desirable.

In the management of compound fractures, great emphasis was placed

upon the sterilization of the wound. Infection was combated by local applications of such agents as BIP (bismuth subnitrate, iodoform, and paraffin) or by

the elaborate irrigation ritual of the Carrel-Dakin method. Evaluation of the

results accomplished during the last months of the war, when these methods

had become fairly well stabilized, showed high incidence of infection, which

was likely to run prolonged course; high incidence of malunion and nonunion; and rates for amputations and for fatalities which exceeded reasonable

expectancies.

After the war, the Carrel-Dakin method continued to be used in the management of civilian compound fractures and joint injuries, at first enthusiastically, then with increasing dissatisfaction. It was tedious and troublesome to

apply, and the end results left much to be desired. Gradually, for these reasons,

it fell into disuse. Meantime, method usually credited to H. Winnett Orr

was increasing in popularity. This method had been devised to meet the dual

problems of an infected wound and fractured bone. The wound was left

open, to secure drainage, and the fracture was managed by skeletal fixation in

plaster cast. One objective of the method was the prevention of the trauma

and reinfection which experience had shown was likely to occur with frequent

dressings.

The first wartime test of the closed plaster technique (which, incidentally,

was revival of the “occlusive” method described by Ollier in 1872) came during the Spanish Civil War, when it was employed by Trueta and others with

Trueta, J.: Treatmentof War Wounds and Fractures With Special Reference to the Closed Method as Used in the

War in Spain. New York: Paul B. Hoeber, Inc.
54 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

number of modifications. It was eventually used in some 20,000 cases. In

1,073 open fractures personally treated by Trueta, the reported results were

excellent. There were only deaths, and only of these, both after operations

for gangrene, were directly related to the compound fractures. Results were

classified as poor in 91 other cases, in of which amputation was necessary.

As these results became generally known, the closed plaster method became

increasingly popular, and, when World War II broke out in 1939, it was natural

that it should be employed in the Allied armies, as well as in the German and

the Russian Armies.

The steps of the closed plaster technique vere described by Trueta as

fellows:

2. Once the patient is anesthetized, thoroughly wash the entire extremity and the

wound with water, soap and nail brush, until the whole is completely clean and the wound

itself is bleeding; shave all hair. Paint the surrounding skin with weak alcoholic solution

of iodine, without touching the wound in any circumstances.

3. Excise the skin edges of the wound, remove all contused tissue and widen the wound

as much as may be required. Excise carefully and unhesitatingly all nonviable muscular

and cellular tissues, noting in particular the colour of the injured muscles, their contractility

on stimulation with forceps, and their capacity to bleed.

4. Open up the neighbouring cellular spaces affected by the contusion and, where

necessary, incise the soft tissues, following up the cellular spaces in the depths of the wound,

always keeping in mind the need for adequate drainage. Remove any haematoma present.

5. Remove the majority of bone fragments that are completely denuded of periosteum

or displaced, and all foreign bodies found at the site of fracture. There is no need to be

concerned much about any pieces of bullet that are difficult to locate; but it is most important

to excise carefully all foreign organic matter (pieces of clothing, wood, etc.). The procedures

described above—namely, the removal of all foreign matter, the excision of all the tissues

immediately surrounding the wound, including devitalized soft parts in the vicinity, and the

opening up of cellular spaces—is known technically as debridement.

6. If the thigh, knee joint or leg is fractured, reduce the fracture by traction on an

orthopaedic table or by hand. In arm fractures which require traction or abduction, appb

the appropriate apparatus. Details may be found in the chapters dealing with wound

of the different regions.

7. Once the fracture is reduced firmly dress the wound with sterile gauze and immediately immobilize with plaster, including the two adjoining joints if possible.

8. Give an injection of tetanus antitoxin.

Drainage and Suture

In cases in which deep cavities are present drainage must be arranged by opening up the

aponeurotic planes and the intermuscular spaces; this drainage can generally be maintained

by the insertion of sterile gauze, but in some cases no inconvenience results from the insertion

of rubber tube which may be buried under the plaster and retained until the first change

of the cast. No complication of any kind can be attributed to drainage; on the other hand, retained discharge, the result of bad drainage, may bring about disaster.

The immediate reaction to this method of treatment was sometimes

severe. The temperature might rise to 104° F., and the axillary or inguinal

lymph nodes might become enlarged. These phenomena were not regarded by

Trueta as indications, in themselves, for the premature removal of the cast or

for cutting windows into it. The only indication for removal of the plaster
MANAGEMENT, COMPOUND BATTLE FRACTURES 55

ahead of the time determined upon—from 10 days to month after operation,

depending upon circumstances—was the appearance of such symptoms and

signs as edema of the distal portion of the extremity; inability to move the

toes or fingers; and evidences of progressive infection, including lassitude,

progressive increase in the intensity of the pain, and rising pidse rate. As

rule, the cast was kept in place without change for 10 to 15 days in summer and

for month in winter. The seasonal distinction was explained by the fact that

the strong odor which emanated from the wound in this method of treatment

was not ell tolerated during the summer by the patient’s associates in the ward.

UNITED STATES EXPERIENCES WITH THE CLOSED

PLASTER METHOD

Since United States experiences with the closed plaster method had been

reasonably good in civilian practice and since British and other European

surgeons had apparently had good results with it in the first months of World

ar II, it was natural that United States Army medical officers should be

prepared to use it in the North African invasion. The circumstances early in

the invasion were not conducive to coordinated plan of timed surgery such

as was developed later. Evacuation hospitals were widely separated, and often

the medical officers in them had no knowledge of what hospitals were behind

them. The situation, in short, was an invitation to the one-stage management

of compound fractures which was offered by the closed plaster method.

In the early experience in North Africa, the general plan of management,

although it was not really official, was as follows: After debridement in

forward hospital, the wound was dressed with vaseline gauze; the fracture was

reduced; and plaster cast was applied, in which skeletal transfixion pins were

sometimes incorporated. The patient was then transferred to general hospital where, in the absence of specific indications to the contrary, the cast was

left in place for to weeks. At the end of this time, it was assumed, wound

healing would be progressing satisfactorily by granulation, and the fracture

would also be well on its way toward healing.

In theory, this was not an unsound policy. In practice, it proved unworkable, and the results were poor. Patients were frequently febrile when they

were received in general hospitals; often the temperature was very high. If

the casts had been split or bivalved, as theater regulations required (p. 40),

the plaster was often disintegrating and ineffective. If the casts had not been

split, the circulation was sometimes threatened. Transfixion pins were often

broken, and infection about them was frequent. Even when the fracture had

been adequately reduced in the forward hospital, position was likely to be lost

in transit over long distances and rough roads, and second reduction was

necessary at the general hospital. Finally, when the casts were left in situ the

theoretical length of time, blister formation, excoriations of the skin, and

pressure sores were frequently present when they were removed.
56 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Because of the poor condition in which so many casualties were received

in general hospitals, it was found inadvisable to allow the casts to remain in

place for the specified length of time, and they were usually changed at once.

Inspection was likely to reveal two reasons for the infection: (1) Devitalized

tissue had not been completely excised, and (2) the wound was actually plugged

by the pack of vaseline-impregnated gauze. Displacement of fractures was

frequent, but, if only week or two had elapsed since wounding, the displacement could usually be corrected by manipulation or skeletal traction. If

weeks or more had elapsed, in many cases this was not possible, and faulty

reduction had to be accepted.

Even in the relatively small number of cases in which conditions appeared

to be favorable when the casualties were received at the general hospital,

surface impressions were not always correct. When the cast was finally

removed, at the end of several weeks, unsuspected infectious processes were

often revealed. In many cases, purulent exudate had been dammed back by

the dressings which plugged the wound, and the infection had been buried

beneath the closed plaster. Moreover, reduction of the fracture was often

lost as the cast became loose as result of atrophy of the musculature as well

as decreased swelling.

These observations in the first months of the North African invasion made

it clear that strict application of the closed plaster regimen was not practical

in the circumstances which then prevailed. Initial surgery was often inadequate, perhaps because it was, of necessity, performed bj' surgeons without

previous experience in military surgery.

By the early spring of 1943, the closed plaster method bad been modified

to meet these circumstances. All casts applied after initial surgery in the

forward area were removed at the fixed hospital not later than the 15th day

after wounding. The surgeon who assumed charge of the patient thus had

an opportunity to inspect and appraise the wound when the dressings were

removed and before it was re-dressed. It was also possible to manipulate the

fracture, institute traction, or carry out whatever other measures of fracture

management the particular case required. Finally, the wound was covered

with an occlusive dressing, and, if traction had not been instituted, fresh

plaster cast was applied.

The 15th day after wounding was arbitrarily set as the upper time limit

for these manipulations. It is true that some fractures were reducible after

longer time lapses but most of them were not, and additional postponement of

attempts at correction would have introduced the risk of serious trauma to

the soft parts, which in turn was conducive to infection.

At this period in the war, the attention of surgeons in general hospitals

was chiefly concentrated on the reduction of fractures. It was believed that

an open wound was necessary to permit prolonged drainage and that interference with the wound would reactivate infection. Secondary surgery, when
MANAGEMENT, COMPOUND BATTLE FRACTURES 57

the cast was removed, was therefore 'imited to the unroofing of areas of dead

tissue and the excision of presenting and protruding tags of similar tissue.

The depths of the wound were seldom investigated. Slow healing of the

wound by granulation, with resultant scar formation, was accepted as the best

that could be expected in the circumstances.

As the months passed and experience increased, concepts of wound management and fracture management began to alter. It began to be realized, as

later experience amply proved, that, if devitalized tissue was not completely

excised at the first surgical attack on the injury, infection was likely outcome.

If large hematomas remained in undrained dead space, they were likely to

undergo purulent decomposition. If dead tissue were allowed to remain in the

wound, neither systemic nor local chemotherapy nor combination of these

methods could prevent wound infection. Once wound infection had developed, local necrosis of living tissue would follow, and vicious circle was likely to be

established.

Several clinical observations of considerable importance, as follows, were

made during this period of the war:

1. Although the sulfonamides had no ability to prevent local infection,

invasive infection was extremely infrequent when they were used, and infected

wounds seldom manifested the cardinal signs of inflammation.

2. Systemic chemotherapy, though it could not prevent local infection,

was apparently extremely effective in preventing the type of invasive infection

of streptococcic origin which had been associated with so many compound

fractures in World War I.

3. Unreduced fractures which required repeated manipulations or whose

position in traction required repeated readjustments were peculiarly likely to

become infected.

4. Infection was also likely to occur in injuries in which the fracture was

exposed in the wound and dead space was difficult to obliterate. This was

particularly true of fractures of such bones as the tibia, the ulna, and the

tarsus, all of which lie immediately beneath the skin.

The significance of these various observations was not immediately realized.

The fear of reactivating infection persisted, and wounds containing grossly

devitalizing tissue continued, for the most part, to be managed in the general

hospitals by hands-off policy, in anticipation of the spontaneous sequestration of dead tissues. Delayed surgical excision was thought to be neither

feasible nor safe. For the same reason, inadequate reduction of many fractures, particularly of the tibia, the fibula, and the bones of the forearm, and

fractures about the joints, continued to be accepted because it was feared

that infection would follow operative manipulation and reduction. As the

result of these concepts and practices, the incidence of malunion and nonunion

of compound fractures continued too high through most of 1943, and wound

healing was prolonged and sometimes was not obtained at all.
58 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

DEVELOPMENT OF THE PROGRAM OF

REPARATIVE SURGERY

The closed plaster method of management of compound fractures was for

all practical purposes written off early in 1944 because, even with the modifications which had been introduced, the results were not satisfactory. Analysis

of the results, furthermore, showed that improvement could be accomplished

only by fundamental change in surgical concepts. Superficial alterations of

technique would not accomplish the purpose. In particular, it would be

necessary to discard the concept that surgery in an infected field could not be

performed because of the risk of precipitating limb-endangering osteomyelitis

if not life-endangering generalized infection.

The changed approach to battle-incurred compound fractures and the

revised concept of their management were both embodied in the reparativesurgery program which had been instituted in the Mediterranean Theater of

Operations late in 1943. At this time, the delayed closure of clinically clean

wounds of the soft parts began to be practiced by number of surgeons and

was enthusiastically encouraged by the consultant in surgery for the theater.

Though this story is told in detail in another volume of the clinical series of

this history, it must be briefly summarized here, because it provides the background for the experience in the reparative surgery ol compound fractures.

It was always general principle of military surgery in World War II

that wounds should be left open following debridement. The wartime experience with primary closure of soft-tissue wounds was brief and unhappy.

Wound healing by granulation, however, had not provided the answer to the

problem, and, as just indicated, delayed closure of soft-tissue wounds began

to be practiced late in 1943, at first occasionally, then more frequently, and

with informal official encouragement.

This was not new idea. It had been practiced to some extent in World

War I, with, however, one essential difference. No matter at what time delayed primary closure was to be instituted, cultures were taken from the

wound when it was exposed for dressings, and closure was not scheduled if the

bacterial count was high. In effect, this meant that the wound must be

dressed one or more times to obtainthe material for culture. It meant, further,

that each of these dressings offered fresh opportunities for infection. Finally,

it meant that considerable amount of laboratory work was prerequisite to

the closure of any wound. For two reasons, therefore, the policy of delayed

primary wound closure had only limited application in World War I: (1) If

bacterial counts were high, as they frequently were, the optimal time for wound

closure was missed, and healing by granulation had to be accepted. (2) Multiple

dressings and extensive laboratory studies were so time consuming as to be

completely impractical when the flow of casualties was heavy.

In World War II, delayed primary wound closure was based upon an

entirely different concept. It was preferably accomplished within to days
MANAGEMENT, COMPOUND BATTLE FRACTURES 59

after wounding if the wound looked clinically clean and if surgical limitations

(that is, loss of tissue, dead space, or excessive tension if the wound were to

be sutured) did not contraindicate it. Bacterial counts were not made. The

decision to close the wound or leave it open longer was based entirely on very

careful inspection and clinical appraisal. If tags of devitalized tissue could

be excised and hematomas and dead space could be eliminated, wound closure

was not regarded as contraindicated. If skin deficits prevented closure by

suture, reparative surgery was still performed if closure could be effected by

rotation or advancement of flaps of skin or by the use of split-thickness skin

grafts. In other words, the criteria for closure were not bacteriologic but

clinical. The requirements were (1) clean wound, either present on inspection

in the general hospital or secured by some additional excisional surgery; and

(2) freedom from the surgical limitations just listed.

Even if the casualty was not seen in the general hospital until 10 days or

more after wounding, delayed closure of clean wounds was still practiced.

Granulation had usually begun in such cases, and closure involved, just as in

World War I, actual excision of the wound. Even after this lapse of time,

cultures and bacterial counts were omitted. The decision for or against closure

was based on the clinical impression that invasive wound infection was or was

not present. If it was not present, closure was accomplished after what

amounted to second debridement.

The extensive bacteriologic studies carried out by Lyons and Rustigian,

which are also reported in detail in another volume of this clinical series, completely confirmed the soundness of these practices. These observers were able

to demonstrate that cultures taken from blood clots and from bits of devitalized

tissue removed from an otherwise clean wound which healed after delayed

closure with no evidence at all of infection exhibited bacterial flora entirely

comparable to that found on cultures of similar material secured from wounds

in which infection was established. The mere presence of these bacteria,

therefore, was obviously not the cause of wound infection.

From these observations, the following concepts were derived:

1. Wound suppuration becomes established as the result of the decomposition of devitalized tissue and hematomas in dead space.

2. Pathogenic bacteria are present in all war wounds, but they are unlikely

to survive if the tissue from which they secure their nutriment is eliminated

at debridement.

3. If this pabulum is removed and if living tissue is protected from invasive

infection by an effective antibacterial agent, then the bacterial flora of clinically

clean wounds can be disregarded, infection or sepsis is not complication to

be feared, and whatever reparative surgery may be indicated can be performed

on established surgical principles and will be followed by sound wound healing

in the great majority of cases.

By the time of the fall of Rome, in June 1944, the consultant in surgery

for the Mediterranean theater was able to report that up to that time at least
60 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-332, C-44-367

Figure 22.—Staged surgery of wound of soft tissue of calf. A. Appearance of wound

before initial wound surgery. B. Appearance of wound at completion of initial surgery.

Note exposed fascia and tendon in wound. Note also extent of resection of damaged

muscle tissue. C. Wound healing after closure by suture at reparative surgery days

later. Split-thickness relaxing incisions have been made to avoid excessive tension

on the suture line.

25,000 soft-tissue wounds had been closed by delayed primary suture on the

indication of their gross appearance alone. Bacterial counts were not made

in any of these injuries, partly because identification of species and tests for

pathogenicity would have required weeks of arduous laboratory work and

partly because preliminary qualitative or quantitative bacteriologic analysis of

the flora of the wound by smear and culture would not have provided information of either diagnostic or prognostic value. In at least 95 percent of the

soft-tissue wounds managed by these principles, healing occurred with no loss

of life or limb and without serious complications (figs. 22, 23, and 24). The

most usual explanation in the percent of unsuccessful closures was failure to

remove residual dead tissue in the deep recesses ol the wound before the wound

was sutured.
MANAGEMENT, COMPOUND BATTLE FRACTURES 61

AFIP C-44-331, C-44-368

Figure 23.—Staged surgery of wound of soft tissues of right arm. A. Appearance of

wounds of entry and exit before initial wound surgery in operating tent of evacuation

hospital. B. Appearance of wound of entry (the smaller of the wounds shown in

view A) after excisional surgery. Exploration disclosed that the median and ulnar

nerves and the profunda brachii artery had been severed. Considerable muscle tissue

was devitalized. The artery was ligated, and the damaged muscle tissue excised.

The severed nerves were merely identified. C. Healed incision 3}4 weeks after delayed

closure at reparative surgery. D. Healed wound of exit (shown in view A) after

coverage by split-thickness skin grafts.

APPLICATION OF THE REPARATIVE-SURGERY PROGRAM

TO COMPOUND FRACTURES

The writing off of the closed plaster management of compound fractures,

even with its modifications, occurred, as already noted, early in 1944. By this

time, the effectiveness of the reparative-surgery program for wounds of the

soft parts had become fully established. It was logical to extend this program,

which had proved so eminently successful, to the management of compound

fractures, in which results, to date, had often left great deal to be desired.

The program had already been applied, informally, to small groups of cases

in half dozen hospitals, with generally good results. Its expansion into

396961°—57
62 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP A-44-347

Figure 24.—Reparative surgery of wound of left axilla and shoulder. A. Appearance of

wounds in operating room of base hospital justbefore reparative surgery. Note axillary

artery and severed nerve trunk visible in axillary wound. B. Appearance of wounds

at conclusion of reparative surgery. By extending the axillary wound with an incision

along the posterior margin of the chest wall, it was possible to advance and rotate

flap of skin, after which it was possible to cover the axillary contents and close the

wound without excessive tension on the suture line. C. Healed wounds 15 days after

delayed closure.

theater wide program of management in the late spring of 1944 could not have

occurred under more propitious circumstances, for the following reasons:

1. The educational program in forward hospitals concerning standardized

principles of excisional surgery and transportation splinting had begun to bear

fruit, and debridement, as general rule, was now being performed completely

and correctly.

2. The chain of evacuation from Cassino, by ambulance and train, to
MANAGEMENT, COMPOUND BATTLE FRACTURES 63

general hospitals in Naples and Caserta was relatively short. After 23 May

1944, air evacuation from the Anzio area was also functioning well.

3. The functions of forward and general hospitals in the management of

compound fractures had been completely clarified. The mission of forward

hospitals was the salvage of life and limb by initial wound surgery, together

with the application of transportation splinting, without effort at definitive

reduction. The mission of fixed hospitals in the rear was the prevention of

infection or its treatment, closure of the wound, and reduction of the fracture.

It was recognized, in short, that the management of compound fractures in

overseas theaters was two-stage procedure. The mission of forward hospitals

did not include fracture management, and the splinting applied in them was

designed primarily for transportation and not to maintain precise alinement

of bones.

4. bed status had been established in general hospitals which permitted

patients to be held the length of time necessary for the employment ofreparative

surgery and fracture management.

5. Supplies of blood had become available in sufficient quantities to permit

transfusions in more liberal amounts than had previously been possible or than

had been regarded as necessary.

6. Penicillin had become available in sufficient quantities for general use.

The extension of the reparative-surgery program to the management of

compound fractures was intimately related to the availability of penicillin. The

original plan had been to establish an orthopedic center in the theater to test

the surgical possibilities of this new agent as soon as it could be supplied in

sufficient quantities for this purpose. This plan was later discarded. Instead,

Maj. Oscar P. Hampton, Jr., MC, theater consultant in orthopedic surgery,

and Maj. Champ Lyons, MC, who had done much of the original work with

penicillin in the Zone of Interior, were constituted team to be attached, in

turn, to each of five general hospitals in the Naples area, for periods of to

weeks, to initiate in them program of reparative surgery under penicillin

protection for compound fractures.

This project was set up with no preconceived notions. No effort was made

to prove anything at all about penicillin. It was merely used as probable

safeguard while surgical eradication of an infectious process was undertaken.

The first cases selected for treatment in each hospital were invariably infected

compound fractures. Surgery was aggressive. It included not only the drainage of abscesses but also the excision of devitalized tissue, foreign bodies, and

sequestra; freshening of wound edges; reduction of fractures, with, if necessary,

stabilization by internal fixation; and closure of wounds by suture about days

after this operation. Liberal blood transfusions were an essential part of the

program.

Within few weeks, the soundness of these new policies had become so

apparent that the program was extended to include all fractures and all joint

injuries. Subsequent appraisal of results showed that when the original injury

did not make prolonged drainage inevitable and reduction of fractures impos-
64 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

sible, the reparative-surgery program was found to be capable of accomplishing,

in large measure, its original objectives; namely, (1) elimination of wound

infection; (2) rapid wound healing, with minimal scar formation; (3) optimum

reduction and stabilization of fractures; and (4) maximum functional restoration of the wounded part. These objectives were achieved by three-point

plan of management consisting of (1) adequate blood replacement, to overcome

anemia, permit the prolonged anesthesia so often necessary in compound

fractures, and aid in wound healing and in the defense against infection; (2)

antibiotic therapy, to protect living tissue against invasive infection; (3) precise

surgical therapy, designed to repair defects caused by the missile or resulting

from initial wound surgery and planned, at the same time, to prevent infection

or to control it if it was already present.

Blood replacement and antibiotic therapy, valuable as they were proved

to be, were recognized from the beginning as merely adjunct measures. Good

surgery was the keystone of the reparative-surgery program for compound

fractures. Wound healing by granulation was inevitable and had to be permitted in certain proportion of all compound fractures, but it was no longer

accepted in any instance in which the program of delayed closure of wounds

by suture or skin graft was applicable.

Part IT. The Initial Surgery of Compound Fractures

SURGICAL TIMING

The surgery of wounds involving bones and joints was ideally rendered in

three phases, initial wound surgery in the combat zone and reparative surgery

in the communications zone, with reconstructive surgery, if it was necessary,

function of hospitals in the Zone of Interior. One of the most important

medical developments in World War II was the perfection of surgical timing,

by which hospitalization, evacuation policies, and the scheduled transportation

of patients from one medical installation to another were progressively correlated with the temporal necessities of surgical management. As always in

warfare, tactical circumstances and the maintenance of combat efficiency required the evacuation of the injured soldier who was not to return to duty within

the theater farther and farther away from the battlefront, both to remove him from the combat zone and to leave hospital facilities near the front available

for the freshly wounded, whose need for care was urgent. This military necessity required, in turn, that medical care be rendered in phases, by different

surgeons, at different times and in different places. Professional and logistic considerations were problems which could be solved only in relation to

each other.

The pattern of wartime surgical care is thus radically different from the

pattern of civilian care. This is one of the things that makes their introduc-
MANAGEMENT, COMPOUND BATTLE FRACTURES 65

tiou to military surgery so difficult for medical officers, however competent

they may be, who are fresh from civilian practice. It is matter of the first

importance that they learn and adhere to the prescribed routine, and it is here

that the educational efforts of consultants have particularly wide field of

usefulness.

Because of their character, bone and joint injuries lent themselves particularly well to surgical timing. In them, as in other wounds of the extremities,

surgical care was rendered in phases, in installations equipped and staffed to

supply the special phases of care required at the time after wounding when the casualty reached them. It cannot be too strongly emphasized that it was

the timing of each phase of management, not the location of the installation in

which the surgery was performed, which was of supreme importance.

As the consultant in surgery for the Mediterranean theater, Col. Edward

D. Churchill, MC, repeatedly emphasized, surgical considerations established

the necessity for (1) as short timelag as possible between wounding and initial

wound surgery; (2) an optimum 4- to 7-day delay between excisional initial

surgery and reparative wound revision and closure; and (3) suitable holding

periods in hospitals coincident with those stages of wound management.

The timelag between wounding and the institution of first-aid measures,

although it was often lengthened by the intensity of combat, seldom exceeded

few hours. The timelag between the institution of first-aid measures and

initial wound surgery for bone and joint casualties was influenced by variety

of factors, including the intensity of combat, the numbers of casualties, the

distance of the evacuation hospital from the frontline, the condition of the

roads, the availability of transportation, and the delay required for resuscitation. As rule, it did not exceed 12 to 16 hours.

From the standpoint ofreparative surgery, it was preferable that casualties

reach general hospital in the communications zone by the 4th day after the

first operation and essential that they reach it not later than the 7th to the

10th day. Since the majority of casualties with injuries limited to the bones

and joints became transportable from forward hospitals within to days

after initial wound surgery, this requirement could usually be met without

difficulty. Hospitalization for periods varying from to 12 weeks, depending

upon the nature and location of the fracture, was necessary after reparative

surgery.

The chief thing that an inexperienced medical officer had to learn, whether

or not he had had experience in orthopedic surgery in civilian practice, was

that battle-incurred compound fractures are materially different from those

resulting from traffic and other civilian accidents. For example

1, Battle-incurred fractures in World War II were usually produced by

high-velocity missiles or shell fragments which had, for all practical purposes,

the effect of an internal explosion. The shattering effect of the energy imparted

by the missile produced bone fragments which frequently themselves acted as

Churchill, E. D.: The Surgical Management of the Wounded in the Mediterranean Theater at the Time of the

Fall of Rome. Ann. Surg. 120:269-283, September 1944.
66 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

secondary missiles, being driven into the muscle tissue and adding greatly to

the original soft-tissue damage. These fragments, like the original missiles,

had tearing, disruptive action which led to extensive damage in multiple

directions, often far from the site of injury.

2. Battle-incurred compound fractures were always compounded from

without in. The missiles passed through clothing which was often soaked

with the mud, grime, and filth of the battlefield. They often blasted or carried

fragments of the clothing and other material into the wound with them.

3. The timelag from wounding to operation, which is usually minimal in

civilian injuries, while very occasionally as short as to hours, not infrequently

was as long as 12 to 24 hours. The mere lapse of many of these periods of

time implies that at operation the wounds had passed beyond the stage of

simple contamination and were potentially infected.

Convalescent hospitals in either the combat or communications zone

played little part in the management of casualties with bone and joint injuries.

The mission of these hospitals was to receive lightly wounded men after their

professional care had been completed at evacuation hospitals and to prepare

them for return to combat duty after short period of what amounted to rehabilitation. Very few soldiers with injuries of the bones and joints had injuries whose care could be completed within the holding periods permitted at

evacuation or convalescent hospitals. In the great majority of instances, for

that matter, care could not be completed at general hospitals in the communications zone, and evacuation to the Zone of Interior was necessary.

FIRST AID

The preliminary management of compound fractures is briefly summarized

in this chapter, to make the record complete. The only measures employed

on the battlefield and in the battalion aid stations and collecting and clearing

stations were those necessary to check hemorrhage, prevent further damage to

soft tissues, relieve pain, avert or control shock, and prevent further contamination of the wound while the wounded soldier was being evacuated from the

frontline to hospital staffed and equipped to perform initial wound surgery.

These steps included

1. The application of sterile occlusive dressings. These dressings were

inspected at each of the echelons of the division medical service but were removed and replaced only for cause, which was chiefly the suspicion of fresh

or recurrent hemorrhage.

2. The control of hemorrhage by compression dressings. If they were

not effective and if the bleeding vessel could not be visualized and controlled

by the application of hemostat, tourniquet was used. Casualties with

bone and joint injuries became first-priority cases once tourniquet was

applied.

3. The administration of morphine, in limited doses, if the pain was too

severe to be controlled by simpler measures. The routine administration of
MANAGEMENT, COMPOUND BATTLE FRACTURES 67

morphine in the large doses given early in the war was later replaced by more

discriminating use of morphine, in smaller doses, and of sedatives, according

to the requirements of the individual patient. Actually, man who had suffered compound fracture was frequently promptly relieved of pain by the

correct application of emergency splinting (p. 32),

4. Plasma transfusion. Transfusions of plasma while the casualty was

in one of the stations en route to an evacuation or field hospital had single

objective, to provide lifesaving resuscitation and make him transportable.

Plasma was administered as necessary in the battalion aid station, the collecting

station, or the clearing station. Blood was not available in these medical

echelons of the Mediterranean theater during World War II. If, however, the blood pressure was found to be critically low in the clearing station, experienced medical officers, instead of holding the patient there to administer

plasma, frequently transferred him to the adjacent field hospital, where whole

blood was always available.

5. Emergency splinting, which was an essential step in all bony and massive soft-tissue injuries of the extremities. This subject is discussed in detail

in separate chapter (p. 31).

6. Other measures. These included the administration of booster dose

of tetanus toxoid and the institution of chemotherapy. Until near the end

of the war, chemotherapy included the local use of sulfonamide powder or

crystals.

PREPARATION FOR INITIAL WOUND SURGERY

The routine preoperative management of casualties with bone and joint

injuries in forward hospital consisted of the following steps:

1. rapid examination, after the clothing had been cut away, to determine the location and extent of the injuries and to evaluate the soldier’s general

condition.

2. Inspection of the dressings and of the emergency splinting. It resuscitation occupied any considerable time or if operation was delayed for other

reasons, the inspection was repeated at regular intervals. It was frequently

necessary to reinforce the splinting or to adjust it when the patient was first

examined. If the lower extremity was in half-ring leg splint, the traction

hitch was examined, to be certain that pressure on the dorsum of the foot was

not excessive. Careful attention to splinting frequently eliminated the

necessity for the administration of morphine or other drugs to control pain.

3. Conservation of body warmth, by the use of blankets under the patient

as well as over him. Excessive covering and external heat, which would cause

sweating and loss of body fluids, were avoided.

4. The prompt use of tourniquet if there was evidence of bleeding.

Patients with tourniquets already in situ were, as already noted, first-priority

cases.
68 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

5. Roentgenologic examination, which was an essential part of the preoperative routine in all hone and joint injuries. Roentgenograms, which were

made in the usual anteroposterior and lateral views, were planned to include

not oidy the known area of damaged bone and retained foreign bodies but also

as large portion of the surrounding areas as possible.

6. Induced vomiting or gastric lavage, unless the stomach had already

been completely emptied by vomiting or more than 12 hours had elapsed since

intake of food.

7. Withholding of food and fluids by mouth. If the patient complained

of thirst, he was permitted to rinse Ids mouth or to suck moist sponge.

Resuscitation. —Many casualties were in moderate or severe shock and

required some resuscitation as part of the preoperative preparation. The

measures employed to combat shock included

1. The use of the Trendelenburg position unless complicating chest or

head wounds contraindicated it. The patient was very gradually restored to

level, recumbent position when the systolic blood pressure reached 80 mm. Hg.

2. Oxygen administration by nasal tube if cyanosis was present.

3. Blood and plasma transfusions according to the indications of the

special case. The necessity was determined entirely by clinical findings

(table 2). Detailed laboratory studies were impractical in the preoperative

wards of an evacuation hospital, and medical officers, as their experience

increased, became more and more skilled in the interpretation of clinical

observations in terms of blood replacement.

In practice, the liberal use of whole blood proved the most effective single

measure of resuscitation for casualties in actual or impending shock. Most

men with compound fractures required some replacement of lost blood before

and during operation. Often they required large quantities.

In at least half of all cases, patients with fractures of the femur required

minimum of 1,000 cc. of blood before they could be subjected to initial

wound surgery. Studies in the 16th Evacuation Hospital showed that 28 of

100 casualties with fractures of the femur required between 1,500 and 2,000 cc.

of blood before and during operation and that only required no blood at all. Of

100 patients with compound fractures of the radius, ulna, or both bones of the

forearm, in contrast, only required between 1,500 and 2,000 cc. of blood, and

63 received no blood at all before and during operation. Patients with compound fractures of the humerus and of the tibia, fibula, or both bones of the

leg formed an intermediate group in respect to the need for whole blood. Of

the 400 patients with compound fractures of the bones included in this survey

(table 3), only 110 (27.5 percent) required no blood at all before and during

operation, while 48 (about 12 percent) required between 1,500 and 2,000 cc.

Blood could not be administered by any rule of thumb. The individual

man’s condition determined how much he needed and when he "was fit for

surgery. Enough had to be given to overcome the most severe symptoms and

signs of shock, plus enough to prepare him for the additional strain of anesthesia

and operation and to compensate for the estimated blood loss on the operating
MANAGEMENT, COMPOUND BATTLE FRACTURES 69

Table

2.

—Relationship of

degree

of

shock

and

average blood

loss

in

67

patients

with

all

types

of

wounds

Degree

of

shock

Clinical

observations

Average

blood

loss

(corrected values

in

round numbers,

in

percentage

of

normal)

Blood

pressure(approximate)

Pulse

quality

Skin

temper-ature

Skin

color

Skin

circulation (response to

pressure,

blanching)

Thirst

Mental

state

Blood vol- ume Hemo- globin

Percent

Percent

Normal...

Normal

Normal

Normal

Clear

and

distressed

14

20

Slight

Decreased 20

percent

or

less.

do

Cool

Pale

Definite

slowing

do

do

21

30

Moderate

Decreased 20

to

40

percent.

Definite decrease in

volume.

do

do

doDefinite

Clear

and

some apathy

unless

stimulated.

34

46

SevereDecreased 40

percent

to

nonrecordable.

Weak

to

impercep- tible.

Cold

Ashen

to

cyanotic (mottling).

Very

sluggish

Severe

Apathetic

to

comatose: little

distress

except

thirst.

46

55

Source:

Medical

Department, United

States

Army,

Surgery

in

World

War

II.

The

Physiologic

Effects

Wounds. of

Washington:

U.

S.

Government Printing

Office, 1952,

pp.

28,

56.
70 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

table. It was very easy matter to underestimate the amount of blood lost

at wounding and during transportation, as well as later at operation.

Table 3.—Flood replacement before and during initial surgery in 100 consecutive compound

fractures of each of the long bones

In most of the casualties with bone and joint injuries, systolic blood

pressures could be restored to 100 mm. Tig before operation. If this level

could be attained without too much delay, that was naturally desirable. If it

could not be, experience showed that operation should be undertaken only (1)

after combination of blood replacement and other measures had raised the

blood pressure to 80 mm. Hg, which was safe and satisfactory level for men

of military age; (2) when the trend of the pulse rate was downward and the

trend of the quality upward; and (3) when other symptoms and signs of shock

were decreasing or had disappeared. It was not safe, however, to undertake

operation until sufficient quantity of blood was available to cover possible

losses at operation.

Plasma transfusion was stopgap therapy and was eventually used only for

that purpose; that is, to elevate the blood pressure to level compatible with

life and to maintain it at that level until transfusions of whole blood could be

given and operation undertaken. The chief usefulness of plasma was in the

echelons of the division medical battalion, but it was also used as indicated in

evacuation and field hospitals.

Another important clinical fact which was eventually confirmed during

World War 11 was that the wounded man did best if he was resuscitated as

rapidly as possible and operated on with equal promptness. wounded man

who had been brought out of shock could readily slip back into it. The second

attempt at resuscitation was always more difficult than the first and was sometimes not as effective. This was as true of patients with extensive compound

fractures as of those with injuries of the chest or abdomen. The aim of resuscitative therapy was not to restore the casualty to his normal status nor to

repair the organic damage caused by even brief period of depressed blood

pressure. Both of these objectives, in fact, were unattainable within limited

time and without the corrective effect of operation, which was itself part of

Blood replacement (in ec.) Radius, ulna,

or both Humerus Tibia, fibula,or both Femur Total

fractures Percentage

2,000 10 11 2.

1,500 12 18 37 9.

1,000 17 36 35 50 138 34.

500._ 17 36 38 13 104 26.

None 63 23 15 110 27.

Total cases 100 100 100 100 400 100.

Theseobservations were made at the 16thEvacuation Hospital in the Mediterranean Theater of Operations.
MANAGEMENT, COMPOUND BATTLE FRACTURES 71

the resuscitative procedure. The aim ofresuscitation in an evacuation hospital

was merely to make the patient fit for initial wound surgery, and his best

interests were served if he was operated on as soon as that objective had been

achieved.

Objectives of initial wound surgery.—The objectives of initial wound

surgery (debridement), regardless of the type of injury, were threefold: (1)

To save life, (2) to save limb, and (3) to prevent or eradicate infection. The

attainment of these objectives was accomplished by (1) the arrest of hemorrhage; (2) the removal of foreign bodies and foreign material within the wound;

(3) the excision of tissues which had been destroyed by the missile (missiles)

or devitalized by the impairment or destruction of the blood supply to the

part; (4) the provision of drainage, which was accomplished by nonclosure

of the wound; and (5) transportation splinting. Transportation splinting is

discussed in detail under separate heading (p. 39). When these objectives

had been accomplished, the result was wound easily managed at reparative

surgery.

APPRAISAL OF THE WOUND

After the wounded man with an injury or injuries of an extremity had

been adequately treated for shock in the shock or preoperative tent of the

evacuation hospital, he was transferred to the operating tent, accompanied

hy the roentgenograms which had been taken of the injured area.

Only occasionally was the soldier removed from the litter on which he

had been transported and placed on an operating table. As general rule,

the litter was placed on the table or was supported by its handles on boxes or

sawhorses, and itself served all the purposes of standard operating table.

This plan had number of advantages. It conserved the time and effort of

the operating-room personnel. More important, it spared the patient the

move from the litter to the operating table before operation, and from the table

to the litter at the end of the procedure. This was highly desirable, because

casualties who had previously been in shock were likely to suffer recurrent

shock if they were moved about.

Examination in the admitting tent of an evacuation hospital (p. 67) was

essential to identify the wounds and determine the patient’s status. detailed examination, however, was impossible under the circumstances which

prevailed in that area, and it was therefore deferred until he had reached the

operating room. It was, as matter of fact, to the advantage of patient in

shock not to disturb him for such an examination until he had been properly

prepared for operation. When he was placed on the operating table, under

good light, with the emergency splinting and dressings removed, and with

roentgenograms available for reference, it was possible to make thorough

examination and complete appraisal of the injuries. The routine was as

follows:

1. The site of entry of the missile (missiles) was determined, and the site

of exit "was sought for.
72 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

2. When the sites of entry and exit had been identified, the course of the

missile was determined. If site of exit was not found, the course was postulated from the site of entry to the point at which the retained missile was

demonstrated by roentgenograms. After this information had been secured,

it was possible to plan the incision or incisions which would provide most

convenient and most satisfactory access to the devitalized tissue and retained

foreign material which had to be removed, as well as to whatever nerve or

vascular injuries might be present.

3. Determination of the presence or absence of arterial pulsations distal

to the wound (wounds) of an extremity was an essential part of preoperative

appraisal. If pulsations could not be obtained, the major blood vessels which

might be damaged had to be visualized and treated according to the indications.

4. Function of major nerve trunks also had to be investigated, though

this was not always an easy matter, since damage to bone and muscle might

prevent active movement of the digits of the hand or foot, even when the

motor nerve supply remained intact. On the other hand, careful investigation

of the status of motor function and sensory supply usually permitted the

surgeon to arrive at some definite conclusion concerning the integrity of the

major nerve trunks. By observation of only the motions of the thumb, for

example, it was possible to decide whether or not there had been functional

damage to each of the three major nerve trunks of the upper extremity. If

the distal phalanx of the thumb could be extended or if the entire thumb

could be abducted and extended, it could be assumed that the radial nerve

was intact. Active flexion of the thumb against the side of the hand established the integrity of the ulnar nerve. When there was evidence of loss of

function in the supply of major peripheral nerve, the nerve was usually

exposed during initial surgery to permit an accurate estimate of the degree

of damage.

GENERAL PRINCIPLES AND PRACTICES

Initial wound surgery, whatever modifications might be necessary in

individual wounds, was ideally conducted on the basis of certain principles

and practices, as follows:

1. The length of the timelag from wounding to operation was of no

importance in the decision whether, or when, to perform initial wound surgery.

Fresh wounds were operated upon as promptly as possible. Old wounds (that is, wounds of more than 48 hours’ duration) were managed in the same

manner except that invasive spreading infections, with cardinal signs of

inflammation such as cellulitis and lymphangitis, were best managed by antibiotics, immobilization, and the application of warm wet dressings until an

optimum time for surgery could be selected. There was no hesitation, however, in draining septic hematomas, fascial-plane abscesses, and large masses of dead,

autolyzing tissue when the casualty was first seen.
MANAGEMENT, COMPOUND BATTLE FRACTURES 73

2. precise knowledge of regional anatomy was essential. Indeed, the initial surgery of war wounds of the extremity amounted to postgraduate

course in surgical anatomy. The surgeon had to know the location of the

nerve and blood supply of every muscle and had to respect blood vessels and

nerves in his dissection. This was particularly important when there were

large wounds in the region of heavy muscles, such as the gastrocnemius-soleus

group in the calf and the rectus femoris in the thigh. The technique had to be

both careful and precise, for irreparable damage could be done if major blood

vessels and nerve trunks were damaged in the course of the operation.

3. Roentgenograms were made routinely in two views, so as to cover as

broad field as possible about the wound or wounds. They were available for

use in the operating tent.

4. An adequate light and competent assistant were basic requirements.

5. wide field was prepared, to allow for extension of the original incision

or for counterincision as might be necessary.

6. The operative procedure was carried out in an orderly manner. There

was no place in initial wound surgery for haphazard, bloody, cut-and-slash techniques.

7. Adequate exposure was essential for the complete excision of devitalized

tissue. Bold incision was therefore the first step at operation. As general

rule, the line of incision was placed parallel to the long axis of the limb, though

on the hand, the foot, or the buttock the incision might follow the natural lines

of the skin. The creation of circular skin defects had to be avoided, though

excision of small area (2 to mm.) of devitalized skin on the margins of the

wound might be indicated.

8. Dead and devitalized tissues had to be completely excised. This was

the most important single step in preventing infection. Failure to excise

devitalized muscle seeded with pathogenic bacteria led to the sepsis for which

combat-incurred wounds are notorious. If tissue devitalized by the missile

or produced by the surgeon in the course of operation was left in situ, wound

healing would not occur until it had sloughed away. The fascial layers had to

be incised as freely as the skin, since free access to devitalized muscle is necessary for thorough excisional surgery.

9. Retained foreign bodies, especially if they were of any considerable

size, were best removed at initial surgery. It was important that they be

identified and, if possible, removed, because the path which led to them was the

track along which devitalized muscle would be found. Moreover, foreign

bodies, especially high-explosive shell fragments, were likely to carry into the

wound bits of clothing, shoe leather, or other foreign material, which would be

removed when the fragments themselves were removed. Deep recesses containing foreign bodies might be approached by counterincisions planned

anatomically over fascial planes rather than by cutting through normal muscle

structure.

10. Fine hemostats were used whenever they were available, and only the

smallest possible amount of tissue was ligated. Structures within the wound
74 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

were not traumatized more than was necessary by the use of tissue forceps.

Sponging was done very gently.

11. Ligatures for the control of bleeding vessels were as fine as possible.

They could be either absorbable or nonabsorbable, but the young surgeon

found his operating time shortened when nonabsorbable sutures were used

because they were bulkier and therefore easier to handle.

12. Incisions and counterincisions were left open, and no sutures were

used following the excisional phase. The provision of drainage, which was

inherent in this policy, was cardinal principle of the management of such

injuries. There were only two exceptions to this rule: The synovial membrane was closed in wounds of the joints (p. 216), and flaps of skin were tacked

loosely in wounds of the hand to cover cartilaginous surfaces and tendons which

would otherwise be left exposed.

13. The unsutured wound was carefully dressed with fine-mesh gauze so

that all raw surfaces were covered. The purpose of the dressing was merely

to hold the raw surfaces of the wound apart and permit drainage from its

depths. The portion of the dressing placed in the depths of the wound always

had to be placed loosely. Otherwise, as the wound and the area about it began

to swell, the dressing would become dangerously tight.

TECHNICAL CONSIDERATIONS

The wide variation in the location of battle injuries of the extremities and

in the extent of the damage to the deeper structures required variations in the

surgical procedure which made it impossible to outline the step-by-step technique for initial surgery which could be outlined for an appendectomy, for instance, or the repair of an inguinal hernia. The principles and policies just

listed served as guide to what had to be done. Certain technical considerations, however, were applicable to all types of wounds (fig. 25).

Incision.—The location of the wound usually, though not always, determined the location of the surgical incision. Wherever it was located, care was

taken to make it of adequate length. It was always better to make it too long

rather than too short; the unnecessary length did no harm, since an incision

heals from side to side, not from end to end. It was also desirable that the

surgeon, at the initial operation, plan the skin incision so as to expose the

devitalized deeper structures.

Instead of an incision through the wound, standard longitudinal incision

was frequently used, so placed as to open into muscle planes and offer better

access to devitalized muscle tissue. It was never wise to extend an incision

proximally and distally from the center of wound which ran in the opposite

direction, or from the center of circular wound. These practices created

crucial type of incision, which handicapped the closure of the operative incision

at reparative surgery and might even prevent closure entirely, particularly at

the point at which the wound of entry was crossed by the surgical incision.

If an incision had to be extended proximally and distally from the wound pro-
MANAGEMENT, COMPOUND BATTLE FRACTURES 75

Figure 25.—Technique of initial wound surgery of soft-part wound.

A. Incision of skin, in long axis of extremity and excision of the traumatized skin border. B. Exposure of depths of wound, excision of

devitalized fascia. Damaged muscle in depths of wound is visualized.

C. Saucerized wound. Debridement is almost completed. The last

of the devitalized muscle is being cut away with scissors.
76 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP FA-45-50, FA-45-47

Figure 20.—Staged surgery of wound of thigh. A. Anterior wound of thigh compounding

fracture of femoral shaft. Appearance weeks after reparative surgery. B. Lateral

wound of soft parts weeks after reparative surgery. Note that in these wounds the

proximal and distal incisions extending from the transverse wounds of entry were correctly made at initial wound surgery. Z-plasty incisions, which can be closed without

difficulty, were thus obtained, rather than cruciate incisions, difficult to close, which

would have resulted had the surgical incisions been made across the center of the

transverse wounds. (These wounds were debrided by Maj. Howard B. Shorbe, MC,

2d Auxiliary Surgical Group.)

duced by the missile, it was best to begin each limb at an opposite comer of the

wound, so as to leave, in effect, Z-shaped incision (fig. 26). This kind of

incision was particularly desirable in areas in which the skin was normally

tight, as over the anterior surface of the leg.

Skin devitalized by the entrance of the missile had to be excised, but as

little as possible was removed and no normal skin was sacrificed. The skin

incision was made with knife, and surgical perfectionists demanded that

knife also be used for the excision of the skin edges about the wound. Experience showed, however, that, when this practice was followed, there was usually

tendency to excise more skin than was necessary. If the surgeon’s technique

was such that the excision could be limited to removal of to mm. of skin,

then the scalpel was preferable, since its cutting edge was sharper than the

cutting edges of scissors. On the other hand, the advantages of excision by

scalpel were more theoretic than real, and trimming of the skin edges of

wound with scissors was easier and generally more rapid.

Excisional surgery.—Once the skin incision had been made and the wound

laid fully open, there was no objection to the careful use of pair of sharp

scissors for excision of devitalized fascia and muscle. Strong encircling fascia, such as the fascia lata, was opened widely, and all grossly traumatized areas

were excised.
MANAGEMENT, COMPOUND BATTLE FRACTURES 77

AFIP CA-44-135

Figure 27.—Initial surgery of large, ragged wound of anterior surface of right thigh.

A. Appearance of wound before initial surgery. B. Wound after adequate excision

of devitalized tissue.

The decision as to just what muscle tissue should be excised was decidedly

less simple, because devitalization was not so easily determined. timehonored criterion of death of muscle is its failure to contract when it is pinched

with thumb forceps, and this test was frequently used. Muscle which contracted when pinched was unquestionably viable, but the reverse was not true; failure of contraction did not necessarily mean that the muscle was dead and

should be excised. Muscle which bled freely when it was cut, even if it did

not contract when it was pinched, was probably still viable.

If bleeding did not occur, then the muscle was definitely not viable and

the excision had to be carried back until muscle which bled on section was

reached. On the other hand, even though there was some bleeding when

damaged muscle was cut, it was always best to carry out excisional surgery if

the tissue appeared macerated or the muscle bundles were separated (fig. 27).

In other words, while it was essential that excisional surgery be thorough, it

was the responsibility of the military surgeon to be certain that the incision he

undertook was justified and that he was not extending it beyond indicated

limits.

The wound, as has been repeatedly emphasized, was left open when initial

wound surgery was concluded. saucerized type of wound was generally

desirable, though there were exceptions, particularly when the original injury

was of the through-and-through variety. Large dead spaces, in which serum

and wound exudate could collect, were eliminated by counterincisions and dependent drainage. Rubber-tissue drains were not used after initial wound

surgery except when they were essential to insure dependent drainage of residual

dead space.

Dressing of the wound.—The raw surfaces of the wound were covered

with fine-mesh gauze. After the program of reparative surgery was in effect

396961°—57
78 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

at the fixed hospitals in the theater, dry gauze was regarded as best for this

purpose, since drainage of wound exudate was provided by capillary attraction

when it was used. When the gauze was removed, several days after the first

operation, clean, relatively dry surface was usually found. Petrolatum-impregnated gauze could also be used, but capillary attraction was not provided

through its meshes and when it was removed the surface of the wound was

likely to have slimy and less healthy appearance than when dry gauze was

used.

Whether dry or petrolatum-impregnated gauze was used, the wound was

dressed in the following manner: Single strips of gauze were arranged side by

side around the perimeter with the ends of the strips in the depths of the wound,

until all raw surfaces had been covered (fig. 28). It was not the intention to

Figure 28.—Appearance of wound after strips of dry or petrolatumimpregnated fine-mesh gauze had been loosely introduced into

depths at completion of initial surgery.

pack the wound. The purpose of the dressing was merely to hold the raw

surfaces apart and provide drainage from the depths of the wound. Inexperienced military surgeons, partly because of their inexperience and partly

because of desire to reduce the oozing of blood from the raw surfaces, were

inclined to pack the wound tightly. When this was done, there was no provision for the swelling which normally follows an operative procedure, and the

tightly packed dressings became even more undesirably tight.

After the fine-mesh gauze strips had been placed in the wound, they were

covered with standard gauze dressings.

MANAGEMENT OF BONE FRAGMENTS

It was impossible to avoid moving bony fragments about during the debridement of compound fractures, and it was easy, unless great care was taken,

to tear them away from attached soft tissue. All manipulations of fragments
MANAGEMENT, COMPOUND BATTLE FRACTURES 79

therefore had to be very gentle. Sponging had to be done carefully in the region of the fractures, for jagged fragments could become entangled in the meshes of

the gauze and could be avulsed from their remaining attachments, especially

when the sponge was removed from the wound.

To the end of the war, there was no universal agreement in the Mediterranean theater as to the management of bone fragments. few surgeons

believed that all fragments should be allowed to remain in situ or should be

replaced after they had been removed and cleansed, on the ground that segmental bone defects would thus be avoided and the chances of union increased.

The background of this policy was the concept that these fragments were, in effect, bone grafts, which could be expected to participate in the process of

healing.

The majority of surgeons took the opposite point of view. They willingly

admitted that the removal of bone fragments introduced the risk of segmental

defects and that segmental defects, in turn, militated against the union of fractures. In their opinion, however, these fragments should be removed because, since they were totally devoid of soft-tissue attachments and were therefore

without blood supply, they were, in effect, devitalized tissue, which might serve

as nidus of infection and prevent healing of both the injured bone and the

compounding wound.

The whole disagreement was, to certain extent, academic. Surgeons of

both schools of thought naturally left in situ all fragments with any sort of

soft-tissue attachments, regardless of their size, since it could be assumed that

some degree of vascularization would persist through these connections. Fragments totally devoid of soft-tissue attachments were usually small (threefourths inch in diameter or less), and their removal seldom created defects of

sufficient size to prevent good contact between major bone fragments.

The policy therefore evolved of removing all small fragments of bone

totally devoid of soft tissue and of leaving in situ those with even the smallest

amount of attachment to the soft parts. If large fragment was totally detached and its removal would create segmental bony defect, the chance of

leaving it in place was usually taken, even though it had no soft-tissue attachment. Fragments of bone totally devoid of soft tissue were, as rule, small

fragments of cortical bone, which made up only relatively minorportion of the

bony circumference at the level of the fracture.

The policy of removing totally separated fragments of bone from the

wound had sound basis. It was repeatedly observed in general hospitals in

the earlier months of the war that when compounding wounds, without softtissue deficits, failed to heal within few weeks, exploration of the depths of

the wound was likely to reveal totally loose fragments of bone which were acting

as sequestra. For this reason, delayed healing and nonhealing were particularly

frequent in compound fractures of the tibia, in which fragments of cortex were

often indriven into the medullary canal and remained in that location until

they were removed surgically.
80 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

FRACTURE MANAGEMENT

The management of compound fractures at initial wound surgery was

limited to the correction of gross malposition. Splinting was applied only for

transportation purposes (p. 39). Definitive reduction was postponed until the

reparative stage of surgery, which was carried out in the fixed hospital. There

were the following sound reasons for this policy:

1. Initial wound surgery was usually performed in an operating tent in

forward hospital, often with the wounded man lying on the same litter on which

he had been brought into the hospital (p. 71). Neither environment nor circumstances were conducive to the accurate reduction of fractures.

2. Roentgenologic controls, which are essential for accurate fracture reduction, were not feasible in evacuation hospitals.

3. Even if precise fracture reduction could have been obtained under these

unfavorable circumstances, reduction would likely have been lost during

application of the plaster cast.

4. Even if precise reduction could have been maintained during the application of the cast, displacement of the fragments would have been almost inevitable after the cast had been split or bivalved, as was required in forward areas,

to guard against circulatory impairment during transportation.

5. The early experience in the North African theater had shown that the

use of internal fixation and of skeletal fixation in casts as primary procedures in

forward hospitals was attended with high incidence of infection and extremely unsatisfactory end results.

6. The limited personnel in forward hospitals did not warrant the expenditure of time and effort which would have been required to reduce compound

fractures properly. The delays thus entailed, in fact, might have put other

wounded men awaiting surgery in jeopardy of life as well as of limb.

POSTOPERATIVE REGIMEN

The postoperative regimen after initial wound surgery consisted of standard

measures, with additional blood replacement as necessary. Casualties with compound fractures of the femur and other serious injuries often required additional transfusions. The fingers or toes were inspected at regular, frequent

intervals, to evaluate the circulatory status of the injured part, so that bandages and casts could be loosened if any vascular impairment became evident.

Repeated inspection was also necessary to detect early signs of gas-bacillus

infection, which readily developed in limbs which were the site of compound

fractures associated with vascular damage. Finally, repeated inspections were

necessary to detect early evidence of continuing or recurrent hemorrhage.

EVACUATION

The soldier with compound fracture was held in the evacuation hospital

after initial wound surgery only long enough for him to recover from the
MANAGEMENT, COMPOUND BATTLE FRACTURES 81

immediate effects of operation and for the surgeon who had operated on him to be certain that he could be transported safely to the rear. casualty with

an injury of bone or joint generally became transportable within 24 to 48

hours. His transportability was determined not only by his actual status but

also by certain external considerations, such as the tactical situation, the mode of

transportation available, the distance to be traversed, and the number of casualties to be moved. If there was any doubt at all about the soldier’s status, it

was usually the policy to keep him in the forward hospital day or two longer,

particularly if it seemed that the transportation time might be unduly prolonged by delays at airfields or other holding points or for other reasons.

Part III. The Reparative Surgery of Compound Fractures

Under the concept of reparative surgery as it developed in the Mediterranean theater, surgery of some kind was indicated on every casualty with

compound fracture as soon after his arrival at fixed hospital as he could be

properly prepared for the operation. The procedure, depending upon the

necessities of the special case, was excisional, reparative, or both. This concept

represented an entirely new development of World War II.

Four to seven days after wounding was regarded as the optimum time for

the reparative stage of wound surgery, and particularly for the closure of

compounding wound, though maximum of 10 days was still within permissible limits. Operation within these time limits was perfectly practical objective. It gave time for the transfer of the patient from an evacuation to

fixed hospital; for the proper evaluation of his status after he had arrived;

and for preoperative preparation, including roentgenologic examination and

blood replacement. In series of 188 compound fractures treated during

push period at the 23d General Hospital during the breakout from the Anzio

beachhead, the average time between wounding and reparative surgery was

8.3 days. This was usual, not an exceptional, accomplishment.

From the physiologic standpoint, the time lapse of to days between

initial and reparative surgery allowed for the sequestration of bits of residual

devitalized tissue which had been overlooked or which could not be excised at

initial wound surgery. By the end of this interval, it was possible to make

decision concerning the viability of questionably devitalized tissue which had

been deliberately left in situ at the first operation. It was not too long time

to permit further debridement, if it should be indicated, before infection could

become established. Purulent exudate formed by the decomposition of dead

tissue would not yet have had time to exert locally necrotizing action, and

heavy granulation tissue would not yet have formed and fixed in position the

deep and superficial soft parts. Finally, this interval was within the golden

period for the management of fractures. It was too soon for them to have

become fixed by callus formation, and they were still amenable to closed or

open manipulation.
82 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

PREOPERATIVE PREPARATION

Roentgenologic examination. New roentgenograms were made as soon as

the casualty was admitted to the general hospital. The films made in the

evacuation hospital were supposed to travel with the patient, but this rule

was not always observed. Even when they were available, however, they

were used only for comparison, as they had been made before initial wound

surgery, during and after which conditions were likely to have changed. More

recent roentgenograms permitted an accurate appraisal of the position of bony

fragments, the precise loss of bone, and the location of any retained foreign

bodies.

Blood replacement.—Secondary anemia, often of considerable degree,

was present in large number of the casualties with bone and joint injuries

when they were received at fixed hospitals. This was in spite of the generally

adequate use of blood in the forward hospital. series of 138 fractures of

the long bones treated at the 23d General Hospital well illustrates this point.

Thirty-three patients (24 percent) had hematocrit values under 30. Eighty

others (58 percent) had values between 31 and 40, and only 25 (18 percent)

had values of 40 or higher, the desirable level for the reparative operation.

Only of the 38 patients with fractures of the femur fell into the 40 or higher

group. In another series of 166 fractures of the long bones observed at the

21st General Hospital, the proportions were substantially the same; 37 casualties (22 percent) had hematocrit readings under 30, and only 31 (19 percent)

fell into the group with readings regarded as safe for operation without further

preparation.

Since operation with low hematocrit levels would have introduced completely preventable risk, the correction of secondary anemia was the first step

in preoperative preparation. Transfusions were given, as rule, until the

desired level of 40 or better was reached. The copper sulfate falling-drop

technique proved simple and satisfactory method of determining this value

as well as the total serum-protein value.

Preoperative requirements were roughly calculated as 500 cc. of whole

blood for each to points of deficit on the hematocrit reading or for each

0.9-gm. percent deficit in hemoglobin. Except when hemorrhage created an

emergency, which was not often in fixed hospital, the total volume of blood

administered in 24-hour period did not exceed 1,000 cc.

Additional blood was also given as indicated while the reparative operation was in progress as well as during the postoperative period. The principles

of administration were the same, regardless of the location of the injury. On

the other hand, the necessity for blood replacement was usually far greater in

certain fractures, especially fractures of the femur (p. 68), than in others.

No absolute proof can be adduced to show that such intensive blood

replacement was necessary for good results. There is, however, good deal

of indirect proof. More liberal transfusions became the practice at about the
MANAGEMENT, COMPOUND BATTLE FRACTURES 83

same time that penicillin became available and the program of reparative

surgery in compound fractures came into general use. Results in these injuries

were greatly improved after this threefold plan of management was instituted,

though it is naturally impossible to assign credit for the improvement to any

single phase of the program. The risk of prolonged anesthesia and of long and

taxing operation was naturally far less in patient whose anemia had been

corrected. It was also the general impression that casualties who had received

liberal blood transfusions were much less likely to suffer from chronic wound

infections and much more likely to show prompt healing of wounds than those

in whom this measure had been omitted. The postoperative course was also

always much smoother in patients who had received ample transfusion therapy.

Antibiotic therapy.—Before the spring of 1944, when penicillin became

generally available, it was the policy to continue in the fixed hospital the sulfa

drug which had been given in the forward hospital. The same policy was

followed with penicillin. The surgeons in the general and station hospitals

had had the benefit of the teachings of Maj. Champ Lyons, MC, in the proper

use of penicillin after it had become available for use in battle casualties. As

result, this agent was always used as an adjuvant to surgery in an effort to

provide wider margin of safety for the aggressive surgical measures of reparative surgery.

Penicillin therapy initiated in forward hospital was continued in the

general hospital in all wounds involving the bones and joints. It was also used

after operation until wound healing was well on the way to completion. This

was usually to 10 days after the reparative operation. If drainage from the

wound persisted, penicillin was usually given for longer period.

TECHNICAL CONSIDERATIONS

Reparative surgery could not be undertaken unless holding policies were

such that the casualty could be kept at bed rest in the same hospital until

healing of the wound was complete. When the injury was compound fracture,

this requirement also implied healing of the fracture to stage at which transportation could safely be permitted. The early experience in the theater had

shown that the transfer of the wounded from one hospital to another while

sutures were still in place after delayed wound closure and while the wound

was still unhealed, was always hazardous and could be attended with serious

complications.

All reparative surgery was performed under general anesthesia, in an

operating room set up for any type of surgery which might be indicated. This

meant that instruments and equipment were available for skeletal traction

and internal fixation, as well as for the repair of soft-tissue defects by suture

or by graft.

The plaster cast and dressing applied after initial wound surgery were not

removed until the patient was on the operating table and fully anesthetized.
84 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

This practice was an important feature of the reparative stage of military

wound surgery for several reasons, as follows;

1. fundamental concept of the staged management of combat-incurred

injuries was that every wound required some additional surgery, either further

debridement or closure of the wound by suture or skin graft, after initial

surgery. Reduction of the fracture was also necessary, since fracture management was not function of forward hospitals (p. 80).

2. Since these procedures had to be carried out in the operating room,

under anesthesia, there was no reason to subject the patient to painful dressings

on the ward or to the risk of hemorrhage.

3. The risk of secondary contamination on the ward was avoided by the

practice of removing in the operating room the cast and dressings applied

after initial surgery in forward hospital.

4. This practice conserved the time and effort of medical and ward

personnel.

Because of the varieties of injuries encountered, it was not possible to

recommend step-by-step technique for the reparative surgery of compound

fractures. The operation, however, always followed definite plan.

Appraisal and Revision of the Wound

Wound revision was conceived of as an extremely careful completion of

excisionaJ surgery, to remove tissue that might lead to suppuration. The

entire wound, including the fracture site, was exposed by gentle retraction and

explored to verify the adequacy of initial surgery. Incisions were enlarged,

if necessary, to facilitate exposure. Any remaining foreign material, accessible

foreign bodies, totally detached fragments of bone, or devitalized soft tissue

was removed. Old blood clot was cleaned out. Means of obliterating or draining dead space were considered.

In the clinically clean case, wound revision consisted, at the most, of the

excision of remaining tags of devitalized tissue. In compound fractures,

however, further excisional surgery Avas not infrequently indicated. This

was particularly true of large, deep wounds, such as wounds of the thigh

associated with compound fracture of the femur.

Reduction to minimum of residual devitalized tissue was the keystone

of the staged plan of management of battle-incurred compound fractures.

Failure to explore the depths of the wound and to follow up the exploration

with the necessary excisional surgery was repeatedly shown to account for

many of the failures to obtain wound healing when the program of delayed primary wound closure was being tested in the Mediterranean theater late in

1943 and early in 1944. Adequate excisional surgery usually resulted in the

prompt subsidence of infection (fig. 29). To perform the kind of surgery

necessary, the formerly accepted concept—that operation in an infected field

would not only fail in its objectives but might, be followed by serious consequences—had to be discarded.
MANAGEMENT, COMPOUND BATTLE FRACTURES 85

A. Roentgenograms of left leg made

when patient was received in fixed

hospital days after wounding; initial

wound surgery had been performed 2)2

hours after wounding.

AFIP C-44-243

B. Roentgenograms made days

after the reparative operation. Although further sequestration seemed

probable at this time, it did not

occur; when the cast was changed

weeks later, the wound was clean,

drainage had ceased, and there was

clinical evidence of bony stability.

If this fracture site had been explored

when the patient was received in the

general hospital, and if the totally

detached bone fragments which were

acting as devitalized tissue had then

been removed, osteomyelitis of the

tibia might have been prevented.

AFIP C-44-243

Figure 29.—Control of infection in compound comminuted fracture of upper half of left

tibia and upper third of right femur by correct excisional surgery. In this case, when

the cast on the left leg was changed for the second time in the fixed hospital 18 days

after wounding, purulent, foul-smelling drainage suggested an incipient osteomyelitis.

Twelve days later, the wound was explored, and several dead, totally detached, indriven fragments of bone were removed.
86 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Fracture Management

Thorough visualization of the depths of the wound to determine its clinical

status permitted full view of the fracture site. Reduction could therefore, for

all practical purposes, be conducted, at least in part, as an open operation.

Direct inspection was supplemented by study of the roentgenograms taken

just before operation. It was thus possible to decide, with all the evidence at

hand, the best means of obtaining and maintaining reduction.

The method of fracture management depended upon the circumstances of

the special injury. Whenever possible, the ends of the fragments were adjusted under direct vision, after they had been freed from intervening soft

parts. Twisted and rotated fragments were alined. In most cases, the decision was to accomplish reduction either by manipulation and plaster immobilization or by skeletal traction. Internal fixation was employed only

under special circumstances.

Internal fixation.—Internal fixation, per se, was by no means an objective

of the reparative-surgery program. It was usually neither advisable nor possible because of severe comminution. The program permitted its use, however, with the limitations to be outlined below, when it was indicated to maintain

fracture reduction. Fixation was obtained by plating, multiple screws, or

wire sutures.

Rigid stabilization of the fracture in reduction by plate or by multiple

screws offered certain advantages: (1) Anatomic apposition and alinement

wore secured, in anticipation of faster bony union with no deformity; (2) dead

space was obliterated and the traumatizing manipulations just mentioned

were avoided (fig. 30); (3) handling of the extremity for necessary subsequent

wound care was facilitated (fig. 31); (4) early joint motion and muscle exercise,

in anticipation of more rapid return to function, could be permitted; and

(5) the management of concurrent injuries which precluded traction and required repeated trips to the operating room was facilitated.

The use of internal fixation was, however, limited by three factors other

than comminution. These were (1) the desire to minimize intrawound trauma

caused by the operative procedure, which could produce additional devitalized

tissue; (2) interference with the covering ofall exposed bone cortex with vascular

soft parts (fig. 32); and (3) the desire to avoid the periosteal stripping which

may be necessary to permit the application of bone plate and which carries

the danger of massive sequestration (fig. 33). Periosteal stripping, which

deprives the outer cortex of bone of its nourishment, is an important consideration in surgery in field known to be contaminated and potentially infected,

and tins consideration therefore always had to be recognized in the reparative

surgery of compound fractures. Practically, if the wound was regarded as

clean and if the other factors were favorable, especially the availability of

vascular soft parts for covering bone, as in the arm or thigh, there was less

hesitancy in stripping sufficient periosteum to permit the required surgery.
MANAGEMENT, COMPOUND BATTLE FRACTURES 87

If, on the other hand, the wound was regarded as dirty or doubtful, stripping

was restricted or avoided.

When the factors that might restrict its use were not unfavorable and

the contour of the fracture permitted, rigid internal fixation was frequently

employed in order to gain the advantages of well-reduced and stabilized

fracture. Fixation through the compounding wound was at times practical

but had the disadvantages of retraumatizing tissue. It also had the disadvantage of placing the metal on bone usually devoid of periosteum, as well as

at the bottom of dead space created by excision of devitalized muscle. For

plating, therefore, separate standard approach to the fracture was advisable, to permit covering of the bone and metal by periosteum and vascular soft

parts (fig. 34).

In actual practice, when internal fixation was indicated, multiple-screw

fixation (by or more screws) was frequently used (figs. 35, 36, and 31). Many

fractures by their obliquity lent themselves to this technique. Little or no

additional periosteal stripping was required to permit placement of the screws,

and intrawound trauma was not excessive. If the fracture, because of comminution, did not permit rigid fixation, one or more wire sutures were sometimes used to hold major fragments in approximation. These could usually

be placed without additional periosteal stripping, factor of particular importance in wound with recognized established infection. In comminuted

fractures with segmental bone loss, wire sutures permitted approximation of

the major fragments.

Bony union is prime consideration in any fracture, and contact of the

fragments greatly enhances the chances of union. The shortening of an extremity to overcome segmental loss and obtain contact of fragments by internal

fixation of some kind was therefore often justifiable and indicated procedure

that was permissible under reparative fracture surgery (figs. 37 and 38).

nerve-trunk or muscle-group deficit associated with fracture at times was

the indication for the deliberate removal of attached bone fragments and

shortening of the extremity. In this way, continuity of all the severed major

structures was achieved, with the objective of maximum functional restoration

of the extremity instead of merely good fracture result as demonstrated by

roentgenograms (fig. 39).

There were number of special types of fractures in which internal fixation was frequently employed at the first operation of reparative surgery, to

achieve special objectives. Among them were (1) fractures about joints, such

as fractures of the condyles of the femur or the humerus, to permit anatomic

replacement of articular surfaces; (2) fractures of long bones deep in muscle

tissue, such as fractures of the femoral shaft and upper radius, in which circumstances favored early reattachment of soft parts to the bone; (3) fractures

which experience had shown were difficult to hold in reduction by other

means, such as fractures of the olecranon and fractures associated with

massive loss of soft tissue (fig. 38); and (4) fractures with segmental loss of

bone, to achieve contact of the fragments and prevent nonunion (fig. 32).
88 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Figure 30.—Compound comminuted fractures of left femur

and patella, multiple penetrating wounds of knee, thigh,

and buttock. Inadequate initial surgery; additional excisional surgery days later, with both femoral and patellar

wounds left open. Septic course; failure of reduction by

skeletal traction in 90-90-90 position. Final management

by delayed internal fixation. A. Extremity in skeletal traction month after injury; femoral fragments distracted, gasabscess formation. B. Drainage of fascial-plane abscess by

posterolateral fasciotomy 21 days later. C. Plating of fractured femur at same operation after removal of totally separated bone fragments. D. Partial suture of wound. E.

Instillation of penicillin into knee joint at same operation.

Arthrotomy through transverse wound and connecting lateral

parapatellar incision revealed dead, detached patellar cartilage and autolysis of femoral and tibial cartilage at contact

points and points at which patella had rested upon condyles.

Curettage of raw condylar areas, excision of patella, and

closure of synovial membrane and skin.

AFIP C-44-215
MANAGEMENT, COMPOUND BATTLE FRACTURES 89

Figure 30—Continued. F. Staged closure of compounding wound of

femur over small drain, days after operation shown in views B, C. and D.

G. Appearance of wound 13 days after reparative surgery and days

after staged closure shown in view F. Healing has been obtained, except

for small granulating areas in old compounding wound and at proximal

end of drainage incision. II. Roentgenograms made months after

wounding. It was thought that small area of sequestrum formation

might be present at this time. I. Roentgenograms showing solid bony

union and excellent anatomic alinement of femoral fracture, 13 months

after wounding. The metal was laterremoved because of some absorption

about one of the screws. Granulation tissue present under plante was curetted. J. Healed wounds of knee and thigh, 13 months after

wounding.

This patient, weeks after wounding, presented septic knee joint,

grossly septic wound of thigh, unreduced fracture of femur, and gas

abscess which could have been mistaken for gas gangrene. He could

logically have been considered candidate for amputation. This gloomy

outlook was altered by complete excisional surgery, closure of dead

space, fracture stabilization, adequate drainage, and staged wound closures, together with adequate blood replacement and protection of

living tissue from invasive infection by systemic therapy. End result

was control of septic process in knee and thigh and union of fracture in

anatomic alinement.

AFIP C-44-215, C-44-247; U. S. Army photos
90 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fd-44-17

Figure 31. {See opposite page for legends.)
MANAGEMENT, COMPOUND BATTLE FRACTURES 91

Internal fixation was preferably avoided when the disadvantages exceeded

advantages, as in fractures of the tibia, in which periosteal stripping was

hazardous because overlying skin is not sufficiently vascularized soft part

and in which the presence of metal may interfere with even skin closure.

When the indications and advantages were not clear cut, it was thought

best to perform wound closure and attempt reduction of the fracture by manipulation or traction. If the attempt was unsuccessful, planned open reduction and internal fixation could be carried out later, perhaps after healing of

the compounding wound. The important point was that if poor anatomic

results could be prevented by surgical measures performed on sound principles,

results of this kind were no longer accepted for fear of lighting up infection.

Wound Closure and Drainage

The hazards of an open wound in compound fracture are the sequestration and sloughing of exposed bone cortex, tendon, and fascia; reinfection at

dressings; and slow wound healing by granulation. The advantage of an

open wound is continuing drainage from the depths of the wound until healing

by granulation has sealed off the fracture site. The gaping wound forms

natural channel for drainage. When the wound is not dependent, however,

and infection intervenes, there may be pocketing, puddling, or pooling of

purulent exudate in the fracture site or adjacent fascial planes with continuing

local necrosis of the collagenous tissues.

In reparative surgery of compound fractures, the hazards of an open

wound were recognized, and an attempt was made to overcome them by wound

closure. The need was also recognized for providing means of egress for the

possible breakdown of any residual devitalized tissue not yet separated and of

Figure 31.—Reparative management of massive wound of left thigh with associated compound fracture of femur. A. Massive wound of thigh compounding fracture of femur

shown atreparative surgery, days after wounding, with the extremity in the 90-90-90

position. Note the distal end of the proximal bony fragment projecting in the wound.

B. Anteroposterior and lateral views of fracture before reparative surgery. The

patient was transported in Tobruk splint. C. Exposure of fracture site by gentle

retraction, after which the fracture was stabilized by multiple-screw fixation with

minimal periosteal stripping. D. Partial closure of wound, with drainage established

by dry fine-mesh gauze inserted into residual dead space about fracture site. The

remaining defect probably represents the skin loss at wounding. Ten days later,

coverage was successfully effected with split-thickness skin graft. E. Anteroposterior

and lateral roentgenograms made in Zone of Interior hospital months after reparative

surgery. The fracture is uniting in excellent position and almost in anatomic alinement.

Internal fixation by multiple screws was selected in preference to other methods in this

injury because the huge compounding wound of the thigh would probably have decreased

the effectiveness of skeletal traction. Staged operative procedures were necessary to obtain

complete wound healing. The contour of the fracture permitted satisfactory stabilization

with screws without additional periosteal stripping. (This patient was managed by Maj.

Charles M. Henry, MC, 36th General Hospital.)
92 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-2fi3, C-44-302, (England GH)RC-80, (England GH)RC-84

Figure 32. {See opposite page for legends.)
MANAGEMENT, COMPOUND BATTLE FRACTURES 93

contaminated hematoma in unobliterated dead space. In the light of these

facts, the complete closure of wounds compounding fractures was justified only

when the pabulum for wound infection was nil. deep abscess about fracture site underneath sutured or healed epithelial bridge could produce nothing

hut irreparable damage. An increased margin of safety was obtained, therefore,

by providing drainage, dependent if possible, by utilizing wounds or counterincisions as indicated. Drains were carefully inserted, so as not to cause tissue

necrosis, and were removed between the 3d and 10th day, depending upon the

indications, before rigid sinus formation had occurred.

The problem of closure of the compounding wound was approached with

the major objective of covering exposed bone cortex, tendon, and fascia with

healthy soft parts, and with the minor objective of reducing skin defects to

size compatible with adequate drainage. Closure was accomplished, whenever

possible, by simple, loosely tied, interrupted sutures. Sliding or rotation of

flaps often permitted closure of the wound (fig. 36). It was recognized that

soft parts must adhere to the bony cortex to permit revascularization, whereby

the dying bone could be absorbed and replaced by new living bone (fig. 40).

Otherwise, sequestration was inevitable. Wound closure, therefore, was

Figure 32.—Management of compound comminuted fracture of middle third of right tibia

and fibula, with multiple penetrating wounds of left leg, by delayed internal fixation.

A. Wounded left leg prepared for reparative surgery in fixed hospital days after

wounding and initial wound surgery. Note the multiple wounds. B. Stabilization of

fracture of tibia through incision connecting anterior wounds. After an unsuccessful

attempt to fix the fracture by multiple screws, the periosteum was stripped over long

middle fragment, and stabilization was accomplished by the anteromedial application

of long plate to strut the comminuted fragments. C. Closure of surgical wound.

Note that two posteromedial wounds have been connected to form relaxing incision,

to permit closure of the surgical wound and also to provide for drainage. D. Roentgenograms made in fixed hospital before and after reparative surgery. Note hairline reduction of tibia in postoperative films. E. Roentgenograms made in Zone of Interior

hospital months after wounding. Stabilization of the fracture had been accomplished,

but the plate, with some cortical bone, was still exposed, although there was no evidence

of infection. week later the plate, screws, and four sequestra ere removed; firm

union of the fracture was found at operation. F. Roentgenograms made 11 months

after wounding, showdng solid union of fracture.

In retrospect, this fracture of the tibia might have been adequately stabilized by plating

the fibula or might have been managed by skeletal traction in cast. Either of these methods would have avoided periosteal stripping and the application of metal at point at

which it was likely to interfere with the healing of soft parts over bone. The anteromedial

surface of the tibia is not good location for plating if there is any question of wound healing, though in this case the location of the wounds determined the location of the incision

and of the site on which the metal had to be placed.

396961°—57
94 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

A. Drawing of compounding wound at

this time. B. Closure of wound with

drainage of residual dead space by dry

fine-mesh gauze.

AFIP Fd-44-18

C. Appearance of wound days later.

Healing is now practically complete.

AFIP Fd-44-18

E. Reduction of fracture by two-wire

skeletal traction. Wire lifting distal femoral fragment is visualized, but wire

inserted in tibial tubercle for longitudinal

traction is not seen. The fracture united

in good apposition, length, and alinement.

(This patient was managed by Lt. Col.

Roderick E. Begg, MC, and Capt. John

E. Manning, MC, 46th General Hospital.)

AFIP Fd-44-18

D. Firmly healed wound month after

reparative surgery.

Figure 33.—Staged management of compound comminuted fracture of left femur, reparative

phase. In this case, because of the tactical situation, initial surgery for very large

posterior wound compounding the fracture had to be delayed until 60 hours after

wounding. In spite of the long timelag, excisional surgery at the initial operation was

thorough, and the wound was quite clean when it was observed in the operating room

at the general hospital days later.
MANAGEMENT, COMPOUND BATTLE FRACTURES 95

AFIP C-44-210

Figure 34. —Management of compound comminuted fracture of middle third of left femur

by delayed internal fixation. A. Anteroposterior and lateral roentgenograms of left

femur before reparative surgery. B. Anteromedial wound exposed in operating room.

The extremity is in the 90-90-90 operating position. C. Stabilization of fracture in

reduction through posterolateral incision by bone plate. An additional screw was

inserted through the compounding medial wound. D. Closure of surgical incision

with drainage. E. Closure of compounding medial wound with drainage.

After operation, the extremity was placed in skeletal traction in Thomas splint with

Pierson attachment. Active and passive knee motion and quadriceps exercises were instituted promptly. When the patient reached the Zone of Interior weeks after wounding,

the wounds were well healed, the fracture had united in anatomic alinement, and full

range of knee motion was possible. He was returned to duty in motor pool in general

hospital 12 months after wounding.

The approach to the fractured femur via standard anatomic plane permitted the bone

which was exposed by surgery to be covered by healthy soft parts and also permitted dependent drainage. The fracture was reduced anatomically and was stabilized, so that the

extremity could be handled as necessary for care of the soft-tissue wounds. Management

of the fracture by skeletal traction would probably have provided adequate reduction, but

joint exercises would have been delayed and hospitalization would have been prolonged

overseas.
96 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-287

Figure 35.—Staged surgery of bilateral compound battle fractures of shaft of femur, reparative phase. This soldier received 1,500 cc. of whole blood in forward hospital before

and during initial wound surgery, 1,500 cc. in the general hospital before the reparative

operation, 500 cc. during the operation, and 500 cc. after operation. In spite of these

massive transfusions, the highest hematocrit reading after blood replacement was 41.

A. Anteroposterior views of each femur in the general hospital, with double hip spica

used for transportation splinting still in situ. B. Lateral views.
MANAGEMENT, COMPOUND BATTLE FRACTURES 97

AFIP C-44-287

Figure 35—Continued. C. Medial stellate compounding wound of left thigh after suture.

D. Lateral compounding wound of left thigh after suture. Drainage was maintained

for several days through the posterolateral fascial plane.
98 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP 044-287

Figure 35—Continued. E. Anteroposterior and lateral views of left femur showing inade- quate reduction with tibial pin for traction in Army half-ring leg splint. F. Same as

view E, after addition of femoral wire for lift of distal fragment (two-wire traction).

The distal fragment is now in excellent apposition and alinement.
MANAGEMENT, COMPOUND BATTLE FRACTURES 99

AFIP C-44-315, C-44-287

Figure 35—Continued. G. Two-wire skeletal traction applied to left lower extremity.

Note sound healing of compounding wound weeks after reparative surgery. H. Active motion of left knee (65° to 70°) months after wounding. At this time, the fracture of the femoral shaft is firmly united, and all compounding wounds are well healed.
100 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-287

Figure 35—Continued. I. Rather severe compounding wound of fracture of right femur.

Patient is on operating table, ready for reparative surgery. Note loss of muscle tissue

and skin. Note also tourniquetabout limb, to reduce further blood loss. J. Exposure

of fracture of right femur through incision extending distally from wound. The fracture was easily reduced and firmly fixed internallv with multiple screws. K. Partial

wound closure, loose packing of remaining defect with dry fine-mesh gauze. Note

establishment of dependent drainage through posterolateral fascial plane. Wound

healing by granulation had to be accepted in this instance because of the size of the

soft-tissue defect.
MANAGEMENT, COMPOUND BATTLE FRACTURES 101

AFIP CA-44-474, C-44-287

Figure 35—Continued. L. Postoperative anteroposterior and lateral roentgenograms

showing excellent reduction of fracture of right femoral shaft. The internal fixation

was protected by balanced-suspension skeletal traction. M. Appearance of right

thigh weeks after reparative operation. All wounds are healed, but the granulating

area is not yet scarified. There is no sinus to bone.
102 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-287

Figure 35—Continued. N. Range of active motion in right knee months after reparative

surgery. The fracture is soundly united, and all wounds are well healed. O. Anterior

view of thighs and upper legs, showing healed wounds, months after reparative surgery.

(This patient was managed by Capt. John J. Modlin, MC, 21st General Hospital.)
MANAGEMENT, COMPOUND BATTLE FRACTURES 103

designed to obviate the hazards of exposed bone cortex, the salvage of which

was probably the most important attainment of reparative surgery of compound fractures (figs. 41, 36, 37, and 40).

In actual practice, some compounding wounds were closed with drains of

rubber tissue or dry, fine-mesh gauze, which emerged through the most dependent portion of the wound or through counterincision (figs. 35, 37, and 38).

In others, surgical limitations, such as dead space which could not be obliterated or loss of soft tissue, precluded closure of the wound by suture. In these

instances, partial closure, so as to protect denuded bone cortex, was often

possible (fig. 42). In still other instances, usually following extensive wound

revision for dirty wounds, the entire wound was left unsutured in order to

provide the advantages of drainage through an open wound (figs. 30 and 34).

In such cases, closure of the wound was usually carried out few days later, if the wound was clinically clean.

If closure could not be undertaken because of loss of tissue, the wound

was loosely packed with dry, fine-mesh gauze in the expectation that healing

would occur from the depths by granulation (figs. 42, 31, and 35).

POSTOPERATIVE MANAGEMENT

Immobilization of the compound fracture was instituted immediately

after reparative surgery. Special techniques are discussed under the heading

of management of regional fractures (p. 115).

Compounding wounds closed by suture were dressed within to days

after operation, to make certain that wound healing was progressing as had

been anticipated. When the extremity had been put up in plaster, the wound

was reached through window cut into the cast; care had to be taken, when

the window was replaced, to avoid so-called window edema, which could be

prevented by using the same amount of padding as had been used originally.

Ideally, inspections and dressings were carried out under strict aseptic

technique, including the use of masks to cover the nose and mouth, to reduce

the chances of droplet infection. Practically, this ideal was seldom achieved.

RESULTS

The delayed primary closure of combat-incurred wounds was carried out

infrequently and in only limited number of cases in World War (p. 58).

Under the principles of reparative surgery, the program of staged wound

closure was established in World War II as logical and surgically sound

policy in wounds of the soft parts and in compound fractures.

It is true that wounds limited to the soft parts are naturally inclined to

heal, but they healed faster and with less scarring under the program of reparative surgery. With this method, multiple dressings of open wounds, which

were often extremely painful, were eliminated. The chances of secondary

infection of granulating wounds were reduced. Scar formation was minimized.
104 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-44-520

Figure 36. (See opposite page for legends.)
MANAGEMENT, COMPOUND BATTLE FRACTURES 105

Figure 36.—Compound fractures of left tibia and fibula managed by internal fixation of

tibia by multiple screws. A. Anteroposterior and lateral views of fractures before and

after fixation of tibia, which has been stabilized in reduction by multiple screws through

anteromedial wound. Note that the contour of the fracture permits stabilization by

this method. In addition, the screws could be placed without significant periosteal

stripping, and soft parts were available to cover all exposed bone and metal. The

fractures were compounded by anteromedial and posterolateral wounds. B. Healed

anteromedial wound. Closure without tension was effected by posteromedial relaxing

incision. The supplementary incision might have been split grafted at the same operation, though this was not done. Drainage was established through the smaller posterolateral wound. Healing by granulation occurred in this wound and in the relaxing

incision. C. Anteroposterior and lateral views of fractures months after internal

fixation of tibia, showing healing of fracture in anatomic alinement. Note that only

of the screws have been effective in stabilization. D. Solidly healed anteromedial

wounds months after reparative surgery. Note the shorter, more anterior scar on the

leg, resulting from the incision made in Zone of Interior hospital to remove the screws, because of some tenderness over the head of one of them, before the patient was returned

to duty. (This patient was managed by Maj. Joe M. Parker, MC, 21st General Hospital.)
106 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-44-519

Figure 37.-—Severely comminuted compound fracture in middle third of right humerus

associated with extensive loss of muscle and skin over anterior surface of arm and clinical signs of radial-nerve paralysis. Staged management. This patient was admitted

to general hospital days after initial surgery, during the formative phase of the

reparative-surgery program. The arm was placed in balanced skeletal traction, and the

large wound was dressed in anticipation of healing by granulation. Eight days later,

the wound was draining profusely, and adequate reduction of the fracture had not been

achieved. The wound was then revised under anesthesia, and all residual devitalized

muscle tissue was excised. The radial nerve, damage to which had been suspected,

was found intact. Several totally separated fragments of bone were removed, and the

segmental defect thus created was overcome by approximating major fragments with

wire suture through the cortex of each fragment. Available muscle tissue and fascia

were sutured to cover exposed bone, and shoulder spica cast was applied. Three weeks

later, the granulating defect on the arm was successfully covered with split-thickness

graft. A. Anteroposterior and lateral views showing inadequate reduction of fracture

in skeletal traction. B. Apposition of major fragments achieved by wire-suture fixation after removal of totally loose comminuted fragments. C. Healed soft-tissue wound

after application of split-thickness graft through window in cast. Access could not be

obtained to the wound over the anterior chest wall near the axillary fold, and it was still

unhealed when the shoulder spica was removed 10 weeks after reparative surgery.

Additional surgery was required in the Zone of Interior because of scar-tissue contracture of the anterior axillary fold. D. Anteroposterior and lateral roentgenograms made

in Zone of Interior showing solid healing of compound fracture of humerus.
MANAGEMENT, COMPOUND BATTLE FRACTURES 107

The incidence of permanent disability was decreased, and the period of temporary disability was shortened.

The program of reparative surgery also proved sound surgical method

in the management of clinically dirty wounds and wounds in which infection

had become established. These wounds had always furnished serious difficulties in military surgery. The problem was largely solved by the application

of the principles of reparative surgery. By this routine, dirty wounds and

infected wounds were promptly converted into clean wounds, and staged

reparative procedures could then be instituted.

The reparative-surgery program proved as applicable to combat-incurred

compound fractures as to soft-tissue wounds. When it was applied, wound

infection was reduced. If infection did develop, secondary wound revision

was instituted. The aggressive policy (1) of excising the pabulum upon which

pathogenic bacteria could feed and (2) of instituting drainage was in sharp

contrast to the former plan of waiting for the sequestration of devitalized

tissue, including devitalized bone, plan which was always attended by the

further necrosis of living tissue.

The World War II experience supplies complete refutation for the former

concept that surgery carried out in an infected field is inevitably followed by

generalized infection. So far as is known, no deaths, amputations, or serious

systemic sequelae could be attributed to the program of reparative surgery.

Reduction of fractures was greatly improved after the introduction of

reparative surgery, for the reason that inadequate and unsatisfactory reduction

was no longer accepted if it could be corrected by either surgical or nonsurgical

measures. Segmental bone defects, in which nonunion is almost the rule if

they remain uncorrected, were also seldom accepted. Internal fixation was

chosen on definite indications to maintain anatomic position and permit early

joint motion and exercise. In many instances, functional results were thus

greatly improved.

The complete healing obtained in most cases following suture of the wound

converted the compound fracture into simple or closed fracture. Even if

healing was not complete, the fracture site was often rapidly closed off, so that

the same effect was achieved. Small skin defects either were left to heal by

granulation or were covered by skin grafts. As rule, when wound healing

was not as good as had been hoped for, the unsatisfactory result could be

attributed not to any defect in the surgical program but to errors in judgment

as to what was surgically feasible or to errors in surgical technique.

In some cases encountered in the Mediterranean theater, the nature of

the injury was such that prolonged drainage from the depths of the wound

was inevitable, no matter what method of management was used. These

injuries were characterized by numerous partially detached bone fragments

and great deal of associated dead space. The clinical course was usually

the same. Drainage persisted until the denuded bone had been revitalized or

had sequestrated and could be removed surgically. Sinus formation was

frequent and persistent when sequestration occurred. When the sinus led to
108 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP FcW4-19

Figure 38.—Severe compound comminuted fracture of middle third of shaft of right humerus with loss of more than cm. of bone. Management by approximation of major

fragments with single wire suture and wound closure. and B. Anteroposterior and lateral

roentgenograms made on patient’s admission to evacuation hospital before initial wound

surgery. At this operation, the brachial artery and the median and ulnar nerves were

found intact, but the radial nerve was severed.
MANAGEMENT, COMPOUND BATTLE FRACTURES 109

AFIP Fd-44-19

Figure 38—Continued. C. Lateral compounding wound seen in operating room in general

hospital days later. D. Closure of wound by suture, without excessive tension. E. Large

and small medial wounds of same extremity ready forreparative surgery. F. Same wounds

at conclusion of reparative surgery. The smaller wound has been sutured; the larger has

been covered with split-thickness skin graft.

396961 57
110 ORTHOPEDIC SURGERY US MEDITERRANEAN THEATER

AFIP Fd-44-19, 54-3045-1

Figure 38—Continued. G. Anteroposterior and lateral views showing the minimal contact

of major fragments obtained by wire suture. H. Same as view G, months after reparative

surgery, showing nonunion of fracture. tantalum cuff encloses the repaired radial nerve.

The soft-tissue wounds in this case healed promptly, and the prompt healing greatly facilitated nerve repair. The fracture was finally united after bone grafting several months later.

The failure of the attempt to obtain union by use of wire suture at reparative surgery does

not in any way lessen the correctness of the effort. (This patient was managed by Maj.

Charles M. Henry, MC, 36th General Hospital.)
MANAGEMENT, COMPOUND BATTLE FRACTURES 111

AFIP CB-44-56, (England GH) KC-83

Figure 39.—Staged management of associated humeral-radial fracture and nerve injury.

Inspection of the radial nerve at reparative surgery 10 days after wounding showed

destruction of inches of nerve tissue. The fractured humerus was shortened by

excision of portions of the comminuted fragments; then the major fragments were

plated. The nerve ends were united with one suture and wrapped in fibrin film. Prompt

healing after closure of wound by suture; definitive nerve suture 16 days later; excellent

end result. A. Steps of reparative operation 10 days after wounding. B. Steps of

definitive nerve repair 16 days later. C. Anteroposterior and lateral roentgenograms

showing united fracture in perfect alinement 6}4 months later. At this time, there was

evidence of returning function in the radial nerve supply. Orthopedic surgery was

performed by Maj. Joe M. Parker, MC, and neurosurgery by Lt. Col. Henry G.

Schwartz, MC, 21st General Hospital.
112 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-216, C-44-286

Figure 40.—Reparative management of mildly comminuted fracture of right tibia resulting

from penetration of limb by high-explosive shell fragment. A. Anteroposterior and

lateral roentgenograms at general hospital 10 days after wounding. The compounding

wound had been left open after debridement in forward hospital. B. Closure of compounding wound at reparative surgery. long posteromedial relaxing incision permitted the use of sliding flap and thus permitted closure without tension. The defect

created by the relaxing incision has been covered with split-thickness graft. C. Healed wounds weeks after reparative surgery. Note that the take on the skin graft

is about 95 percent. Sound wound healing followed soon afterward. This casualty

could be rehabilitated for duty in the theater of operations, which was rather unusual

result in compound fractures of the bones of the leg and one which would have been

impossible except under the regimen of reparative surgery. (This patient was managed

by Capt. George H. Marcy, MC, 23d General Hospital.)

sequestra that could not be prevented surgically, the outcome had to be accepted as the inevitable result of injury. In these cases, failure of wound

healing was attributable to the presence of retained dead tissue and not to

bacterial infection per se.
MANAGEMENT, COMPOUND BATTLE FRACTURES 113

AFIP C-44-273

Figure 41.—Management of compound comminuted fracture of shaft of femur by balancedsuspension skeletal traction; sequestration of denuded bone not covered by soft parts.

The anterolateral wound compounding the femoral fracture was extensive, and the

considerable muscle loss left the femoral fragments exposed for several inches. Reduction of the fracture was carried out in general hospital shortly after the patient was

received, but reparative surgery was omitted. A. Anteroposterior and lateral roentgenograms showing fracture of femoral shaft in traction just before reduction in general hospital. B. Anteroposterior and lateral roentgenograms showing healed fracture with

massive sequestrum formation, 68 days after wounding. C. Wound of thigh 78 days

after wounding. Note continued drainage and lack of healing.

The sequestra were eventually removed, and dependent drainage was established, under

penicillin protection, but skin grafting was necessary before wound healing was eventually

achieved. In this case, early reparative surgery, with closure of the wound over the exposed

bone, might have prevented sequestration of the femoral fragments. Wound healing and

fracture healing were finally achieved, after delayed reparative surgery. (The case was

managed at the 21st General Hospital in January 1944, before the program of reparative

surgery of compound fractures had become theaterwide.)

The program of reparative surgery proved again that in the management

of combat-incurred compound fractures there is no substitute for surgery.

Blood and penicillin were essential adjuvants, but the whole program was based

upon the concept that the bacterial flora in an open war wound is of minor
114 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-225

Figure 42.—Management of compound fracture of upper third of right tibia by staged

surgery and modified closed plaster technique. A. Anteroposterior and lateral roentgenograms showing defect in upper third of tibia following initial surgery. B. Large

compounding wound of soft tissues, with several stellate extensions, shown in operating

room in general hospital just before reparative surgery. C. Suture of extensions of

wound, so as to cover all exposed cortical bone. The remaining defect was left open,

and the modified closed plasterregimen was instituted. When the sutures were removed,

12 days after the reparative operation, through large window in the cast, the stellate

incisions were found well healed.

The remaining defect was loosely packed with fine-mesh gauze, and the window as

replaced in the cast and secured with several turns of plaster bandage. The next dressing

was set for the period at which the cast would be changed, to eeks after the first

dressing, probably after the soldier had been transferred to the Zone of Interior. The

modified closed plaster method was used in this case because loss of tissue made complete

closure of the soft-tissue wound impossible. In addition, closure would have been doomed

to failure because of the underlying dead space caused by the defect in the cancellous bone.

It was essential, in this injury, that the exposed cortical bone be covered, and this was

achieved by partial closure.

importance compared to the pathologic process itself. By the end of World

ar II, this concept of the management of combat-incurred wounds had been

generally accepted, and the spotlight of attention had been focused where it

belonged; that is, upon their surgical management.
115

CHAPTER

Regional Compound Fractures

Part I. Compound Fractures of the Humerus, Radius, and Ulna

GENERAL CONSIDERATIONS

Compound fractures of the bones of the upper extremity were frequent,

as is shown by the experience of two general hospitals which functioned in the

Mediterranean theater. These bones were injured in 992 (34.1 percent) of

the 2,911 compound fractures treated at the 45th General Hospital during

1944, and in 685 (37.1 percent) of the 1,844 compound fractures treated at the

21st General Hospital over the same period. When the 332 fractures of bones

of the hand are excluded, composite figures for the two hospitals show that the

bones of the arm and forearm were involved in 1,098 (23.1 percent) of all the compound fractures treated in them during 1944. Of these injuries, 322 were

compound fractures of the humerus, and 338 were compound fractures of the

radius, ulna, or both bones.

Compound fractures of the long bones of the upper extremity offered

peculiarly attractive field for the application of the principles and procedures

of reparative surgery. They are therefore discussed in considerable detail.

The management of injuries of the hand is not considered in this volume.

These injuries are discussed in detail in the volume on hand surgery.

PROBLEMS OF MANAGEAIENT

Certain special problems of management presented themselves in compound fractures of the upper extremity:

1. The major objective of the management of all wounds of the arm and

forearm, including all compound fractures, was maximum restoration of the

function of the hand. This function varies from the finer precision movements

to grasping with strength. It was therefore essential, in addition to repair of

the bony framework and skin covering, that the integrity of muscle, tendon,

and nerve be restored, as nearly as possible, to its original state or that it be

otherwise compensated for, and that early motion, particularly of the fingers,

Data for this section were collected by Maj. Joe M. Parker, MC, and Capt. Francis R. Crouch, MC, 21st General

Hospital; Capt. John W. Rovane, MC, 300th General Hospital: Maj. William R. Ferguson, MC, Capt. Robert B. Gottschalk, MC, and Capt. James H. Flynn, MC, 33d General Hospital: and Lt. Col. George A. Duncan, MC, 45th General

Hospital.
116 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

be instituted, to minimize fixation of joints, muscles, and tendons. The

overwhelming importance offunction of the hand always had to borne in mind, therefore, when the management of compound fractures and other injuries of

the arm and forearm was determined upon.

2. severed nerve in the arm or forearm or severed tendon or tendons

in the forearm was sometimes of greater importance than the associated compound fracture or fractures. In the staging of reparative-surgery procedures,

however, the repair of nerves and tendons was postponed until the wound

had healed and there had been optimal restoration of the bony framework

(fig. 39). Nerves and tendons could then safely be repaired through healed

wound. These operations were functions of hospitals in the United States. The

necessities of concurrent injuries therefore sometimes determined the method

of fracture management and sometimes dictated the plastic procedures which

might be necessary to accomplish wound healing in injuries of the upper

extremity.

3. Bone loss with resulting partial or segmental defects was not infrequent, particularly in the humerus, and called for special methods of fracture

management (figs. 43 and 44; also figs. 37 and 38).

4. Immobilization of the upper extremity is difficult, circumstance which

made maintenance of reduction of certain fractures, particularly those of the

humerus and of both bones of the forearm, correspondingly difficult.

5. In spite of the serious problems of management presented by compound

battle-incurred fractures of the upper extremity, the favorable factors on the

whole outweighed the unfavorable. The richly vascularized muscular sleeve

about the whole circumference of the arm and upper forearm predisposed to

rapid healing of both wounds and fractures and to minimal infection. Similarly,

except in the lower forearm, there is paucity of dense fascia and tendons and

therefore an absence of tissues with poor blood supply and correspondingly

limited resistance to infection. The well-developed muscular sleeve just

described facilitated the coverage and revascularization of bones denuded at

wounding and further denuded at surger} Dead space was readily obliterated, and adequate drainage could be secured with equal ease. Maintenance

of full bone length in this region was relatively unimportant from the standpoint of future function. Finally, bone and nerve surgery could be performed

at the same operation or in stages, according to the necessities of the special case.

GENERAL PRINCIPLES OF MANAGEMENT

Unless serious associated injuries required longer stays in evacuation hospitals, soldiers with wounds of the upper extremity usually reached general hospitals within to days after initial wound surgery. Since blood loss was

considerably less severe than in compound fractures of the femur and of the

bones of the leg, little time had to be spent in elaborate preoperative preparation. Transfusions in the amount of 500 to 1,000 cc. usuallv restored the
REGIONAL COMPOUND FRACTURES 117

hematocrit reading to the 40 regarded as optimal before reparative surgery.

Most casualties therefore reached the operating room by the 7th day after

wounding and seldom later than the 10th day. This meant that practically all surgery could be done within the optimum period. In series of 147 compound fractures of the humerus, for instance, to be reported later in this chapter

(p. 130), reparative surgery was done on an average of 6.5 days after wounding.

study of peripheral-nerve funct ion was part of the preoperative survey in wounds of the arm and forearm, but final appraisal was made in the operating

room, after the cast had been removed and before anesthesia was begun. The

status of nerve function could thus be determined with absolute certainty when the extremities were unhampered by supporting casts or dressings.

Wound management.—Wound management in compound fractures of the

upper extremity followed the general principles of reparative surgery. The

wound was widely exposed, so that inspection to the depths was possible and

the fracture could be fully visualized. Any residual devitalized tissue was

excised. Small, totally separated fragments of bone were removed. The

decision as to fracture management was made, and internal fixation, if it was

the method selected, was carried out.

Whenever possible, the wound was closed by accurate approximation of

the soft parts, to achieve obliteration of dead space, coverage of denuded bone,

or protection of nerves and blood vessels from possible damage by bone fragments. Buried cotton sutures were employed in one hospital during the last

months of the war. Drainage was employed routinely in the first days of the

reparative-surgery program. Later, it was provided only on specific indications, which existed in perhaps 70 percent of all cases.

When incomplete initial surgery had resulted in clinically dirty wound,

so that extensive additional excisional surgery was required, closure was usually

postponed for several days, to be certain that the wound was clean. Whenever

possible in these circumstances, the bone was covered by muscle, in an effort to

effect as rapid revascularization of the bone as possible.

Splinting.—The general principles of splinting were applied in immobilization of the extremity after reparative surgery. All plaster casts, including

hanging casts, were trimmed at the proximal palmar crease unless specific

indications existed for immobilization of the fingers. Precise splinting, which

permitted active motion of the fingers, was provided in associated radialnerve injuries, so as to avoid continuing stretch of the paralyzed muscles and

yet permit full range of active motion (fig. 45). It was not considered necessary to employ special splinting for median- or ulnar-nerve palsies.

After the early healing phase in compounding wounds of the forearm and

immediately after reparative surgery in wounds above the elbow, full and

active finger motion was encouraged as part of routine postoperative management. If nerve, muscle, or tendon injuries prevented full and active motion

of all the joints of the fingers, the fingers were moved passively many times

daily, in order to prevent fixation.
118 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP (Cushing GH) P-1505-A-E, 74S

Figure 43. (See opposite page for legends.)
REGIONAL COMPOUND FRACTURES 119

AFIP (Cushing GH) P-1505-A-E, 743

Figure 43. —Management by delayed internal fixation of compound comminuted fracture

of shaft of right humerus, with segmental loss of bone and laceration of median and

ulnar nerves. Ligation of the brachial artery and vein was necessary at initial wound surgery, at which the severed median nerve was approximated and the ends

of the severed ulnar nerve were tagged with wire sutures. A. Anteroposterior roentgenogram showing compound comminuted fracture of right humerus, before reparative

surgery. Note bone loss and resulting defect. Totally loose bone fragments were

removed at the reparative operation. B. Lateral roentgenogram of fracture. C.

Anteroposterior roentgenogram of fracture after internal fixation with wire sutures,

23 days after wounding. At this operation, the end of each fragment was squared to

provide maximum surface for the bony contact achieved by the fixation procedure.

The resultant shortening was about inches. The wound was left open for the next

days, then was partially closed by suture and skin flap was rotated so as to cover

all denuded bone. D. Lateral roentgenogram showing fracture after internal fixation.

This view, like the anteroposterior view C, shows the fragments in good contact with each

other. E. Anteroposterior roentgenogram made in Zone of Interior hospital months

after wounding. The fracture united promptly, without sequestration or removal of

metal, and wound healing was also satisfactory. F. Lateral roentgenogram made in

Zone of Interior hospital.

In this case, all residual devitalized tissue was excised at wound revision. Twelve days

later, apposition of the fragments of bone was obtained by surgery on the bone. Eight

days later, wound closure was accomplished, the open wound having provided drainage in

the interval between the operations. The aggressive surgical approach prevented almost

certain nonunion of the fracture, while the procedures undertaken for wound healing made it

possible to undertake nerve surgery soon after the patient reached the Zone of Interior.

(This case was managed by Maj. Herbert W. Harris, MC, at the 17th General Hospital.)
120 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP (Cushing GH) P-1504

Figure 44.—Management by delayed internal fixation of compound comminuted fracture

of right humerus with segmental loss of bone and laceration of radial nerve. A. Anteroposterior roentgenogram of fracture of humerus after approximation of fragments bj

two wire sutures at reparative surgery. Note that contact between the fragments is

only minimal. B. Lateral roentgenogram of fracture shown in view A. C. Lateral

roentgenogram made in Zone of Interior hospital 8% months after wounding, showing

nonunion of fracture of humerus. The wounds healed well, but bone grafting was

necessary to secure union of the fracture. Definitive suture of the radial nerve was

carried out at the same operation.

Although the approximation of fragments in this case did not lead to union, the procedure

employed provided chance for union to occur and facilitated later reconstructive surgery.

Without internal fixation, nonunion was inevitable because of the segmental bone loss at

wounding. (The case was managed at the 21st General Hospital by Maj. Joe M. Parker,

MC, and Lt. Col. Henry G. Schwartz, MC.)
REGIONAL COMPOUND FRACTURES 121

AFIP C-44-363, Fd-44-14

Figure 45.—Splinting for paralysis of radial nerve. A. Hanging cast utilized for reduction

of fracture of humerus. Note fingers relaxed, in functional position. B. Complete

flexion of fingers and thumb by power of median- and ulnar-nerve supply. and D.

Closeups showing elastic supports to prevent continuing stretch of paralyzed muscles.

Note discarded plasma tubing, used in preference to the elastic cord which was supplied

for traction. Tubing is more effective because it stretches more readily. piece of

string tied to the plasma tubing passes between the third and fourth fingers and is

attached to portion of tongue depressor. The cuff around the thumb is made of

adhesive tape.

COMPOUND FRACTURES OF THE HUMERUS

The material on compound fractures of the humerus is based on surveys

from three hospitals, as follows:

271 compound fractures of the humerus treated at the 21st General

Hospital in Italy and later in the European Theater of Operations during 1944

and 1945.

221 compound fractures of the humerus analyzed from the 1944-45 disposition-board proceedings at the 300th General Hospital in the Mediterranean

theater.

147 compound fractures of the humerus treated at the 33d General Hospital

in 1944 and 1945, during the last months of the war.
122 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Compound fractures of the humerus are most conveniently discussed

according to the location of the fracture. In the 337 cases from the 300th

and 33d General Hospitals in which these data were stated, the injuries involved

the shoulder joint and the proximal end of the humerus in 18 percent, the shaft

from the surgical neck to the supracondylar level in 65 percent, and the distal

end and elbow joint in 17 percent.

Fractures of the Proximal End of the Humerus

Several particularly important observations, with correspondingly important therapeutic implications, were made in compound fractures of the

proximal end of the humerus with involvement of the shoulder joint. These

observations included the following:

Dislocations of the head of the humerus were very frequently associated

with compound fractures of the head and neck (fig. 46). They were overlooked

at the initial operation in large proportion of the cases encountered early in

the war. In one group of 24 consecutive injuries of the proximal head of the

humerus with involvement of the shoulder joint, there were associated dislocations. When the frequency of the association was realized, it became common practice to obtain stereoscopic roentgenograms of all fractures about the

shoulder joint before reparative surgery. The dislocation was usually anterior,

and, if the head of the humerus was split longitudinally, the fracture surface

was found resting on the anterior lip of the glenoid. Closed reduction was not

possible in this type of case. Instead, it was necessary to restore the normal

regional relationships by open operation on the fracture dislocation.

Concurrent injury to the major nerve trunks was not frequent, but the

wounds were frequently so located that damage to the axillary nerve seemed

highly probable. Nothing could be done about such an injury, as this nerve

is too small to be attacked directly and repair was therefore out of the question.

It was the general practice, in order to preserve any undamaged nerve supply

for the deltoid, to employ an anterior approach to the fracture, with reflection

of the deltoid, and often with utilization of portion of the compounding

wound.

If the head of the humerus was not too badly comminuted, the usual

procedure was to maintain reduction by or screws or by wire sutures. When

the comminution was so extensive that reduction was impossible, the dislocated head was excised, and the upper end of the shaft of the humerus was placed

against the glenoid. If enough of the head remained intact to permit partial

restoration of the cartilaginous relationship of the shoulder, with decrease in the articular surface of the head, observations at operation showed that

theremnant of the surface of the head glided well through fairrange of motion.

The end results of this technique are not known.

When both the head of the humerus and the glenoid process were so

completely shattered that it was impossible to reorganize any articular mechanism in the shoulder joint at reparative surgery, the wound was left open because
REGIONAL COMPOUND FRACTURES 123

the extensive damage to the articular cartilage probably made prolonged drainage inevitable. The best plan of management was to immobilize the

shoulder in plaster in the position of function, in the expectation that spontaneous fusion would occur.

Fractures of the Shaft of the Humerus

Compound fractures of the shaft of the humerus included wide variety

of injuries. The compounding wounds varied considerably in size, depending

upon the type and velocity of the missile and the extent of the initial debridement. Bone injuries ranged from incomplete cortical fractures to avulsions of several inches of the shaft. As rule, the extent of bony damage paralleled

the extent of soft-tissue damage.

Wounds in this area were likely to be clinically clean. It was usually

possible, without undue difficulty or further trauma, (1) to explore them

adequately and to remove devitalized tags of tissue, totally loose fragments of

bone, and other foreign material; and (2) to appraise the extent of bone damage

and determine possible nerve damage.

After the type of fracture management had been decided upon and internal

fixation, if it was indicated at this time, had been carried out, the wounds were

closed by the layer-suture technique. Wound closure was carried out as part

of reparative surgery in about 70 percent of all fractures of the shaft of the

humerus. certain number of the remaining cases were left unsutured because

the wounds were of small size. The others were closed or grafted at staged

procedure. As already noted, it was unusual to find any evidence of infection

in wounds of this area of the humerus or any considerable amount of retained

foreign material or necrotic tissue. When these circumstances were encountered,

the usual secondary excisional surgery was performed, and closure was delayed

for to days after operation.

Methods of fracture management in compound injuries of the shaft of the

humerus depended upon whether or not bone loss had occurred.

Fractures without bone loss.—In fractures without bone loss, the hanging

cast was frequently used whenever the patient could be ambulatory (fig. 47).

It as replaced by the shoulder spica (fig. 48) in cases of massive soft-tissue

injury or in cases in which distraction of the humeral fragments had occurred

or seemed likely to occur. In addition to its advantages from the therapeutic

standpoint, the hanging cast converted bed patient into an ambulatory

patient, permitting him to go to mess and to the latrine and generally to take

care of himself. These were considerations of no little importance in busy

general hospital with limited manpower. Patients w’ere comfortable in the

cast and quickly learned how to lie down and rise from the bed without assistance

and without discomfort. During periods of temporary recumbency soon after

wounding, reduction was maintained by traction, which as provided by

weight extending from plaster loop at the elbow over pulley at the foot of

the bed. Later, the elbow was merely supported by pillow.
124 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP 88226, CA-44-346, 88230, 88228, 88229, 92364, 92365

Figure 46. See opposite page for legends.)
REGIONAL COMPOUND FRACTURES 125

If the fracture was in the lower portion of the shaft, alinement was best

maintained by placing the forearm in complete pronation, as precaution

against outward bowing at the fracture site. The cast was made lighter than in civilian practice and was never weighted, since badly comminuted battleincurred fractures with associated soft-tissue damage were easily distracted.

In the early days of the North African campaign, the shoulder spica was

frequently used for fractures of the shaft of the humerus, and some surgeons

continued to use it in all cases of this kind. Those who tested the hanging cast,

however, usually came to prefer it. The spica was difficult to apply satisfactorily with the patient recumbent, and, even when it was applied snugly

with the patient erect, it was not at all unusual, 10 to 14 days later, to find that

it had become loose and that the fragments were angulated. In busy overseas theater, cast which had to be replaced at frequent intervals was open

to serious objection. United States experiences in civilian practice would

have suggested wider wartime use of the shoulder spica. It was widely used

in the Spanish Civil War, as well as by British surgeons in the North African

theater.

It was the general opinion in the Mediterranean theater that the hanging

cast, in addition to being more comfortable for the patient than the shoulder

spica, gave better results from the standpoint of bony alinement and mainFigurk 46.—Comminuted fracture dislocation of right shoulder, comminuted fracture of

shaft of humerus, comminuted fractures of both bones of forearm, associated injuries

of median and radial nerves. A. Anteroposterior roentgenogram in general hospital

showing fracture dislocation of shoulder and comminuted fracture of shaft of humerus.

B. Compounding wounds of shoulder and middle third of forearm just before reparative

surgery. Note exposed tendons in wound of forearm. C. Anteroposterior roentgenogram of shoulder and upper arm after reconstruction of head of humerus and fixation

by multiple screws. Extremity is in skeletal traction for comminuted fracture of shaft

of humerus. D. Compounding wounds after closure at reparative surgery. Note

proximal and distal extension of wound of shoulder region to permit adequate exposure.

E. Skeletal traction applied for comminuted fracture of humerus, with wire through

olecranon, and for comminuted fractures of bones of forearm, with wire through distal

ends of both bones. F. Anteroposterior view of bones of forearm in skeletal traction.

Note suture of stainless-steel wire inserted at reparative surgery to hold major fragments

of radius in apposition. G. Anteroposterior roentgenogram showing united fracture of

humerus in Zone of Interior 3J4 months after reparative surgery. Note that absorption

of bone in the head of the humerus has left the proximal ends of the screws projecting

into the soft tissues. H. Same as view G, after removal of screws. Further union of

the fracture of the shaft occurred later. I. Range of overhead reach months after

reparative surgery. J. Range of internal motion at same time. When this photograph

was made, radial-nerve function had returned, but median-nerve paralysis was still

present. Later, spontaneous recovery occurred. The extremely satisfactory result

achieved in these serious injuries was made possible only by an aggressive surgical

approach and the employment of varied armamentarium of procedures at reparative

surgery. (This patient was managed by Maj. Joe M. Parker, MC, at the 21st General

Hospital.)

396961°—57 10
126 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fd-45-22

Figure 47.—Hanging cast used for fracture of humerus. A. Cast with patient erectNote plaster loops for sling and for traction in recumbency. Wrist is free, but hand

is supported by plaster extension. B. Patient recumbent. Traction from loop is

utilized in this position. Only or pounds are necessary. Note folded towel supporting arm.

tenance of the position of the fragment. Instances were recorded in which

reduction was accomplished satisfactorily by the hanging cast after skeletal

traction had failed. Many patients were evacuated before any opinion about

union could be expressed, but results were generally good in the cases held

long enough for observation.

The hanging cast was often used for transportation to the Zone of Interior.

Patients with injuries of the humerus, with or without involvement of the

shoulder joint, were seldom in condition to travel before the third or fourth

week after wounding. By this time, the bony fragments were usually beginning

to unite, and transportation in this type of cast was regarded as entirely proper.

Fractures with bone loss.—There were two important considerations

in fractures of the shaft of the humerus with bone loss. The first was the

amount of bone lost, and the degree of shortening which would result if the

bone ends were approximated without replacement of the segmental deficit.

The second was the probability of sound primary healing of sutured soft parts,

to facilitate bone grafting at an early date. These considerations were necessarily weighed against each other in deciding whether to accomplish repair

by internal fixation, to overcome the segmental defect, or by other measures

in cases of bone loss.

If shortening did not exceed to cm., good contact of the bone ends

could usually be attained by means of or wire sutures (fig. 37). Sutures

were used in preference to plates because they could be inserted with little or

no periosteal stripping. When they were supplemented by firm external

splinting, the fracture was well immobilized (figs. 38, 43, and 44). With this

technique, reparative surgery of the soft tissues was accomplished without
REGIONAL COMPOUND FRACTURES 127

Figure 48.—Well-applied shoulder spica

cast for fracture involving shoulder joint.

If shoulder fusion is anticipated, the degree

of abduction is debatable.

AFIP Fd-4.5-20

difficulty. In the occasional case in which contact of the fragments had been

particularly satisfactory, hanging cast was employed. Most often, however,

shoulder spica was used.

If bone loss was so extensive that shortening in excess of cm. would be

required to obtain contact of fragments, it was considered preferable to accomplish healing of the compounding wound and return the patient to the

Zone of Interior, with the idea that bony continuity would be restored at

later reconstructive operation. This may or may not have been better plan

than internal fixation of the fracture with wire sutures to obtain contact of

the fragments.

Internal fixation was employed in only small proportion of the fractures

of the shaft of the humerus encountered in the Mediterranean theater (p. 199).

When it was used, plating was usually avoided, for the obvious reason that

stripping of the periosteum would have introduced fresh trauma and would

have enhanced the possibility of sequestration.

In the 271 compound fractures of the humerus analyzed at the 21st

General Hospital, internal fixation was used 22 times but was accomplished

by plating only twice; wire sutures were used 15 times and multiple screws

times. In the 147 cases treated at the 33d General Hospital, internal fixation

was also used 22 times and was accomplished by plating times; wire sutures

were used times, and sutures and screws were used in combination times.

Associated nerve injuries.—In all compound fractures of the shaft of

the humerus, the possibility of an associated nerve injury existed and had to

be taken into account in the preoperative evaluation of the patient. Radialnerve injuries were by far the most frequent, as the following figures show:

In the 271 fractures of the humerus treated at the 21st General Hospital,

there were 108 nerve injuries, including 70 injuries of the radial nerve, 30 of

the ulnar nerve, and of the median nerve. Injuries of the radial nerve were

present in half of all fractures of the middle third of the shaft.
128 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

In the 147 fractures treated at the 33d General Hospital, there were

66 nerve injuries, including 36 injuries of the radial nerve, 20 of the ulnar nerve, and 10 of the median nerve.

Radial-nerve injuries were thus present in 25.4 percent of these two series

(106 of 418 cases), ulnar-nerve injuries were present in 11.9 percent (50 cases),

and median-nerve injuries were present in 4.3 percent (18 cases).

Because nerve injuries are treated in detail in the neurosurgical volume

of the clinical history of World War II, only brief mention need be made of

them here. The important considerations in nerve injuries were that (1) the

possibility of the injury be borne in mind i?i the preoperative survey, as has

already been emphasized, and (2) that, when clinical paralysis was present,

the necessity for exposure of the nerve at operation be considered. The preoperative estimate, as practical matter, was made on the basis of demonstrable

motor and sensory deficits.

Combined nerve and bone surgery proved so successful when it was tried

tentatively that during the last months of the war it became common practice at reparative surgery to expose the involved trunks in all instances of

peripheral-nerve palsy, to permit precise determination of the damage, unless

1. sufficiently detailed note on the record showed that the nerve had

been visualized intact at initial surgery.

2. The location of the wound and of the fracture made it anatomically

unlikely that the nerve had been injured. In such cases, diagnosis of nerve

injury was sometimes made, but returning function usually became evident in

to weeks. This happened in seven cases, for instance, at the 21st General

Hospital.

The status of the nerve was usually determined by inspection after it had

been exposed, though in some cases an injection of physiologic salt solution

was employed as an aid in determination of intraneural continuity. If the

nerve was found severed or so severely traumatized that, although it was

intact, physiologic interruption had evidently occurred, the extent of the

damage was evaluated, and the possibility of approximating the nerve ends

after resection of ttie damaged portion was determined. The technique of

fracture management was often influenced by this decision.

If the divided nerve ends could apparently be brought together without

tension, internal fixation, even if plating was necessary, was sometimes employed, so that staged nerve repair could be carried out as promptly as possible.

Of the 22 internal-fixation operations performed at the 21st General Hospital,

an associated nerve injury and the desirability of early repair were the indications in 15 (fig. 39).

If comminution precluded fixation of the fractured bone, cm. or more

of the length of the arm was often deliberately sacrificed by removal of loose

fragments, in order to accomplish stable internal fixation and permit nerve

repair to be undertaken within the optimal period of weeks after wounding.

If nerve deficit existed, section of the fractured shaft of the humerus,
REGIONAL COMPOUND FRACTURES 129

sometimes up to cm., was excised, so that the ends of the damaged nerve

could be brought together.

Definitive nerve suture was never performed at the first operation of reparative surgery. Nerve surgery at this operation never went beyond the

loose approximation of the ends of the nerve by single suture, and even this

procedure was by no means the rule. Definitive repair as undertaken at

later date, through healed wound. What could be accomplished at the staged

nerve operation, however, often depended upon what had been done about

the fracture at reparative surgery.

In view of the very poor results which were being reported after nerve

grafting in the Zone of Interior and the relatively or actually good results being

achieved by the combined procedure described, this new and radical approach

to fractures of the shaft of the humerus associated with nerve injuries was

regarded as fully justified. Obviously, the close cooperation of orthopedic

surgeons and neurosurgeons was essential for the best results.

The majority of the combined procedures in this series were undertaken

in injuries of the radial nerve. Relatively few were undertaken for injuries of

the median and ulnar nerves, which, though probably of greater importance

functionally, were less frequent.

Fractures of the Distal Portion of the Humerus

In fractures of the distal portion of the humerus involving the elbow joint,

the extent of the injury again determined the technique to be employed.

Fractures of the condyles, if they were not too greatly comminuted, were

reduced as anatomically as possible and were often fixed internally, to facilitate

early motion. This was consideration of the utmost importance in the restoration of function.

T-fractures. with separation of the condyles, were often held in reduction

by two screws or by combination of wire sutures and screws. This area of

the humerus, fortunately, usually tolerates without difficulty the manipulation

and stripping of the periosteum necessary for accurate reduction of the fragments. It was occasionally necessary to shift Haps of skin in order to close the

tissues over exposed bones or joints. One case was observed in which thick

flap of skin was utilized to seal the elbow joint, which was preserved with

only this covering.

Markedly comminuted fractures about the elbow, with destruction of the

condyles of the humerus and the upper ends of the radius and ulna, permitted

little choice in fracture management. The technique employed depended upon

the condition of the compounding wound. Clean wounds of the elbows with

marked comminution ere treated by delayed closure. At one hospital, if

infection was present, resection of the elbow joint was sometimes performed.

The wound was closed with drainage or was left open and closed at later

operation. The flail elbows which resulted from these operations did not seem

to be satisfactory while the natients remained under observation and were
130 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

probably no more satisfactory later. The value of this procedure, therefore,

was debatable except as means of controlling severe infection and avoiding

amputation.

Fractures of the lower end of the humerus were associated with more ulnarand with fewerradial-nerve lesions than fractures of the shaft. Wounds characterized by avulsion of the medial epicondyle were so frequently accompanied

by ulnar-nerve paralysis that accurate appraisal of possible nerve damage was

routine step in their management.

Results of Reparative Surgery

As in all compound fractures, the compilation of end results was impossible

overseas in fractures of the humerus. The great majority of patients were

transferred to the Zone of Interior before complete wound healing or complete

union of the fracture had occurred. There was, however, general agreement

in the theater that, in terms of wound healing and in the maintenance of satisfactory reduction of fractures until union was in progress, the reparative surgery of compound fractures of the humerus had produced excellent results.

In many cases, wound healing was complete within weeks of wounding, and

in many others it was complete at this time except for small areas of granulation. It appeared that, if the plastic and other procedures necessary to achieve

skin coverage had been correctly performed, only sequestrating bone retarded

wound healing.

An analysis of the 147 cases treated at the 33d General Hospital provides

support for these generalizations. They were classified as follows;

27 cases with massive soft-tissue destruction and, in most instances, severe

bone comminution (group A).

69 cases with moderate soft-tissue damage and severe comminution of

bone (group B).

51 cases with minimal soft-tissue damage and minimal comminution of

bone (group C).

Treatment was regarded as successful in these cases if the wound was

completely healed or if only small areas of healthy granulation tissue were

present, so that the fracture site was well sealed off Fracture management was

regarded as successful if adequate apposition and alinement of fragments were

maintained until union had occurred or until the patient was transferred to

the Zone of Interior. Management was regarded as unsuccessful (1) if the

fracture site was not sealed off and there was sinus or opening wound leading

to it and (2) if satisfactory reduction of the fracture was not maintained under

the circumstances just described. Classification of results as unsuccessful because of persisting sinus to bone set rather rigid qualifications for wound

healing, particularly in comminuted fractures, in which many bone fragments

are partially denuded at wounding and therefore are potential sequestra. The

total of 151 cases were treated at the 33d General Hospital, but cases were omitted from the analysis, in which

amputation was necessary because of circulatory gangrene, and others in which no followup could be secured.
REGIONAL COMPOUND FRACTURES 131

data available in the series of compound fractures of the humerus analyzed

from the 33d General Hospital (tables 4, 5, and 6) deserve certain brief comments.

The results were tabulated from the standpoint of wound revision as the

first step of reparative surgery because they improved as time passed and

revision of the wound became more complete. Early in the experience, the

depths of the wound, including the fracture site, were not routinely exposed.

Table 4.—Residts in relation to procedure and wound healing in 147 compound fractures of the humerus treated at the 33d General Hospital 1944~4&

Table 5.—Results in relation to technique and status of fracture in 147 compound fractures of

the humerus treated at the 33d General Hospital 1944~45

Procedure

Successful Unsuccessful

Group Group Group Total Group Group Group Total

Wound re'vision:

Complete

Incomplete

22 51

10

29

18

102

28

otal 22 61 47 130 13

Technique of closure:

Suture 18 59 47 124 11

Partial suture

Total 22 62 50 134 13

See text, p. 130, for code.

The details ofwound revision were unknown in cases.

Technique

Successful Unsuccessful

Group Group Group Total Group Group Group Total

12

24

23

11

11

27

41

62

12

21

Other plaster immobilization

Internal fixation and plaster

Total 26 62 51 139

See text, p. 130, for code.

While it is known that union was delayed in this case, reduction was adequate.
132 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Table .—Results in relation to wound healing and status offracture in 147compound fractures of the humerus treated at the 33d General Hospital 1944~45

Totally detached bone fragments and dead tissue were therefore left in situ

in many cases. At this time, revision was limited to the trimming of tags of

devitalized tissue along the wound edge. Later, the importance of insuring

that the wound was free of all devitalized tissue before repair was undertaken

became generally recognized. It then became routine to expose the depths of the wound by gentle retraction, evacuate old blood clot, and excise necrotic

tissue and bone fragments totally devoid of soft-tissue attachment. Considerably better results were produced under this new policy (table 4).

In of 13 wounds in which healing was classified as unsatisfactory,

typical osteomyelitis was present, of the type frequently seen in battle-incurred

fractures and always characterized by heavy drainage and rather extensive sequestration. Union is known to have occurred in some of these cases in

spite of these unfavorable circumstances.

Some information is available from other hospitals to supplement the

material presented in these tables from the 33d General Hospital. It is known, for instance, that in 112 of the 128 compound fractures treated while the 21st

General Hospital was functioning in the hospital center at Naples, the wounds

were completely healed or almost completely healed when the patients were

evacuated to the Zone of Interior.

In 116 cases managed at the 300th General Hospital, later information

showed that, when the patients were considered ready for evacuation to the

United States 90 to 120 days after wounding, complete healing had occurred

in 94 cases, and in 11 others, while there were some areas of granulation, there

was no opening to the fracture site. In nine cases, there were sinuses to the

bone, and there were two instances of osteomyelitis, in both of which the fracture site was infected and sequestration was occurring.

Since the combined bone-nerve reparative regimen placed emphasis on

early wound healing, so that nerve suture might be performed through clean

surgical approach within to weeks after healing, information concerning

Results Group Group Group Total

Successful wound healing and fracture management.

Successful wound healing, unsuccessful fracture

management

22 57 50 129

10

Unsuccessful wound healing, successful fracture

management

Unsuccessful wound healing and fracture management

Total 27 69 51 147

See text, p. 130, for code.
REGIONAL COMPOUND FRACTURES 133

this point is of interest. In the 116 cases for which information is available in the series from the 300th General Hospital, 30 of the wounds (26 percent)

were healed within weeks, and 41 others (35 percent) within total of weeks.

Sixty-one percent of the wounds were thus healed within the optimal time for

nerve suture. Eight other wounds were healed within weeks, but no information is available for the remaining cases.

COMPOUND FRACTURES OF THE RADIUS AND ULNA

The statistical material on compound fractures of the bones of the forearm

is based on the following surveys:

243 compound fractures—112 of the radius, 97 of the ulna, and 34 of both

bones observed at the 21st General Hospital in Italy and later in Europe during

late 1944 and 1945.

272 compound fractures—113 of the radius, 107 of the ulna, and 52 of

both bones, analyzed from the 1944-45 disposition-board proceedings at the

300th General Hospital in the Mediterranean theater.

319 compound fractures—136 of the radius, 124 of the ulna, and 59 of

both bones, treated at the 45th General Hospital. Both the 1944 and 1945 admissions are included in this series.

This makes total of 834 compound fractures of the bones of the forearm—-

361 of the radius, 328 of the ulna, and 145 of both bones. Not all data are

available in all series.

Wound management in compound fractures of the bones of the forearm

followed the principles generally employed in reparative surgery. The technique varied, for anatomic reasons, according to the portion of the forearm in

which the fracture was located. Although the structures of the upper half of

the forearm are more tendinous than those of the upper arm, no special difficulties were usually encountered in that area. As the wrist is approached,

muscle is replaced by fascia and tendon, both of which are structures with

little power to resist infection, because of their poor blood supply. For these

reasons, wounds in this area were sometimes necrotic and sloughing when the

patients reached the general hospital. Closure could not be considered in

such cases until after further exicisional surgery, and closure frequently

required split-thickness skin grafts or sliding or advancement of skin flaps.

Fracture management.—Fractures of single bone usually presented no

problem in fracture management, for, just as in fractures of single bone of the

leg, the intact bone served as splint for the fractured bone, and displacement

was seldom significant. Procedures to achieve reduction were necessary only

in fractures about the joints and in an occasional instance of narrowing of the

interosseous space. In the 209 compound fractures of the radius or of the ulna

observed at the 21st General Hospital, cast immobilization, with no effort at

further reduction, was all that was necessary in 190. This was typical experience.
134 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Fractures involving the olecranon process required anatomic reduction

and fixation to restore joint congruity. Wire-suture fixation was often useful.

Fractures of the head of the radius were best managed by excision of the

comminuted fragments. This procedure removed potential nidus of infection

and eliminated handicap to future function of the elbow.

Fractures of both bones of the forearm in the upper third often presented

problems in the maintenance of reduction (fig. 49). When soft tissue was

available for early wound healing, it was often good plan to place long plate

on the ulna, to serve as strut for the comminuted fragments, as well as to

maintain length and alinement in the injured bones. This was not always

possible, however. The subcutaneous position of the ulna often created difficulties in wound healing when only skin was available for coverage of the bone and

metal. In spite of these problems, repair of soft parts of the upper forearm

was usually successful if excisional surgery was complete and soft-tissue loss

was not excessive.

If the contour of the fracture permitted rigid stabilization of both bones

and if soft parts for adequate coverage were available, stabilization by multiple

screws or plates was often useful. This procedure accomplished anatomic

reduction, avoided encroachment of the bones on the interosseous space, and

permitted earlier pronation and supination.

In comminuted fractures of both bones without bone loss, skeletal traction

with wire through the distal ends was occasionally used to accomplish adequate

reduction.

In comminuted fractures of both bones with bone loss, internal fixation,

usually by wire sutures, was used to approximate the fragments. Comminuted

fragments of one bone were occasionally removed to permit approximation of

the fractured ends of the other. As rule, however, this was not advisable

because of the successes attained in bridging defects with bone grafts at reconstructive surgery.

In the distal portion of the forearm, because of the relatively superficial

position of the bones, internal fixation by plating was performed only on special

indications (fig. 50). It was essential that sufficient soft tissue be available for

closure.

Combined bone-nerve injuries.—Peripheral-nerve injury was almost as

common in wounds of the forearm as in wounds of the arm. In the 243 fractures

observed at the 21st General Hospital, the radial nerve was injured 28 times, the

ulnar 32 times, and the median 25 times, total incidence of more than third.

Nerve lesions in the forearm were more often incomplete than in similar lesions

in the upper arm.

All 28 of the radial injuries just mentioned occurred in the upper forearm,

in which combined nerve and bone operations are likely to be technically

difficult if not entirely impractical. In these cases, approximation of the nerve

ends was frequently of less importance because the principal deficit could be

overcome later by some reconstructive procedure at the wrist, usually tendon

transplant or fusion operation. Repair of the median and ulnar nerves was,
REGIONAL COMPOUND FRACTURES 135

U. S. Army photos

Figure 49.—Unsuccessful management of compound comminuted fracture of upper third

of right radius (head) and ulna (just distal to coronoid process). Anteroposterior and

lateral roentgenograms of fractures after incomplete manipulative reduction at reparative

surgery in general hospital. Note angulation of ulna and loose fragments of radius.

The fracture united in this position, and months after wounding rotation was almost

nil and elbow motion was limited to 10° to 15°.

In this case, the wound healed satisfactorily, but osteotomy was eventually necessary to

correct the malunion of the ulnar fracture. If the loose fragments of the upper radius had

been removed and the ulna plated in good alinement at reparative surgery, prompt healing

could have been anticipated, for skin and soft parts were available for satisfactory wound

closure. This procedure would have permitted reasonably early elbow motion and would

probably have produced an improvement in the end result.

however, matter of paramount importance, and in this series from the 21st

General Hospital the bony structure was deliberately shortened five times, and

the fractures were plated to facilitate later nerve suture. None of the bone

defects thus created exceeded cm.

Nerve and tendon operations in the lower forearm were always performed

in the Zone of Interior.

Results.—Although no statistical data were available on the results accomplished in reparative surgery of compound fractures of the forearm, it was

generally acknowledged that neither the healing of compounding wounds nor

the reduction of fractures was as satisfactory as corresponding results in compound fractures of the humerus. For this, there were number of explanations,

including the exposed position of fracture sites in the ulna, the abundance of

poorly vascularized fascial and tendinous structures in the distal portion of the

forearm, and the paucity of well-vascularized soft tissue in this area.
136 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP (O’Reilly GH) 4071-4074

Figure 50.—Management of compound comminuted fracture of distal third of left radius

and ulna by delayed internal fixation. Reparative surgery, 11 days after wounding,

consisted only of manipulative reduction of the fractures and partial wound closure.

The wound healed only in part, and necrotic bone presented through an opening in it.

A. Anteroposterior and lateral roentgenograms of fractures of radius and ulna month

after unsuccessful manipulative reduction. Note poor alinement of fractures and destruction of bone. B. Anteroposterior roentgenogram showing same fractures 3]i months

after wounding and weeks after they had been plated in reduction. Apposition and

alinement are now good. The shortening from necrosis and bone loss was about

inches. C. Lateral roentgenogram taken at same time as view B. D. Anteroposterior

and lateral roentgenograms months after fractures had been plated. Removal of

sequestra and metal was necessary to accomplish wound healing.

In this case, failure to achieve adequate reduction and wound healing after the first

operation of reparative surgery indicated the necessity for additional surgery long before it

was performed. In spite of the delay, however, and the infection, correct reparative surgery

was eventually responsible for an excellent result. (This case was managed at the 300th

General Hospital by Maj. Spencer A. Collom, Jr., MC.)
REGIONAL COMPOUND FRACTURES 137

Although results in compound fractures of the forearm were not as good as

those obtained in similar injuries of the upper arm, later results were known to

be far superior to those obtained before the program of reparative surgery

was introduced in the Mediterranean theater. It is known, for instance, that

84 of the 319 soldiers treated at the 45th General Hospital (approximately 26

percent) were returned to duty within the 90- to 120-day holding period in this

theater. These are excellent results, and there is no reason to believe that they

were not generally duplicated.

CONCLUSIONS

As this limited analysis has shown, the objectives of reparative surgery in compound fractures of the humerus and the bones of the forearm (minimal

infection, optimal fracture reduction, early wound healing, maximal functional

recovery) were apparently achieved in large proportion of these injuries. In

many of the casualties, the additional reconstructive surgery which would have

been necessary under the old plan of management was not necessary under the

new plan. In other cases, the reconstructive phase of surgery was expedited,

and the necessity for multiple operations was decreased. The mission of overseas surgery was thus largely accomplished in battle-incurred compound fractures of the upper extremity managed in the Mediterranean Theater of Operations.

Part II. Compound Fractures of the Femur

GENERAL CONSIDERATIONS

According to the machine records of the Mediterranean Theater of Operations as they were available for examination in July and August 1945, fractures

of the femur made up 12.7 percent of the principal diagnoses of battle fractures

at the time of dispositions by the various general hospitals in the theater. This

is in general agreement with the experience of the 45th General Hospital in the

year 1944, which can be assumed to be representative. In that year, fractures

of the femur accounted for 11.3 percent of all compound fractures managed on

the orthopedic section of this hospital. When only compound fractures of the

extremities were considered, the incidence increased to 12.6 percent. When

fractures of the bones of the hand and the foot were excluded, the incidence of

compound fractures of the femur rose to 19.2 percent.

In World War II, just as in World War I, battle-incurred compound

fracture of the femur was properly regarded as one of the most serious skeletal

injuries which soldier could sustain. In World War I, there were 971 deaths

Thestatistical data in this section were collected by Capt. John J. Modlin, MC, Maj. Joe M. Parker, MC, and Capt.

Russell J. Crider, MC, 21st General Hospital; Col. Francis J. Cox, MC, 24th General Hospital; Maj. William R. Ferguson,

MC, 33d General Hospital: Maj. Irvin Cahen, MC, 64th General Hospital; Maj. Spencer A. Collom, Jr., MC, and Maj.

William M. Ewing, MC, 300th General Hospital; Maj. Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, MC,

23d General Hospital; and Lt. Col. George A. Duncan, MC, 45th General Hospital.
138 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

(25.2 percent) in the 3,850 recorded femoral fractures. These fractures constituted 23.6 percent of all recorded battle fractures (16,339). In study made

in Fifth U. S. Army mobile hospitals in 1945, 114 of the 1,450 deaths (including

deaths on arrival) (7.9 percent) were attributed to compound fractures of the

lower extremity. It seems fair to assume that the great majority of these injuries were fractures of the femur. The World War II figures do not include

traumatic amputations of the thigh, which may have been included in the

figures for World War I.

Compound fractures of the femur furnished major problems in both forward

and fixed hospitals. Considerable time and effort were required for their management; in view of their frequency, this was very practical consideration in

overseas hospitals. In forward hospitals, even when experienced surgeonswere

in charge, hours was regarded as acceptable operating time for initial surgery,

counting from the time the wounded man was placed on the operating table until

the transportation spica was applied.

Large amounts of blood had usually been lost in compound fractures of the

femur, and shock was correspondingly severe. Massive transfusions were necessary for resuscitation in evacuation hospitals, as well as for protection during

initial wound surgery. In 100 consecutive compound fractures of the femur

managed at the 16th Evacuation Hospital, 28 patients required from 1,500 to

2,000 cc. of whole blood before and during the operative procedure (p. 68).

Large quantities of blood were also required in preparation of these patients

for reparative surgery at general hospitals. In 50 casualties received at the 23d

General Hospital from evacuation hospitals on the Anzio beachhead, the

hematocritreading was under 30 in 38 cases. In another group of 242 casualties

received at the 21st General Hospital, the great majority had to be given 2,000

cc. or more of blood before the hematocrit reached 40, the desirable preoperative

minimum. Fifty-three casualties treated at the 300th General Hospital required an average amount of 1,900 cc. of blood during the preoperative and postoperative periods.

Even in civilian practice, simple fractures of the femur may be difficult to

manage. Battle fractures were often severely comminuted and were complicated by one or more large compounding wounds. If infection had become

established, additional problems were introduced. Erosion of femoral artery

was always possibility in such cases, and amputation occasionally had to be

considered for lifesaving reasons. Battle fractures, therefore, presented exceedingly difficult problems of management. Even seasoned ward surgeons were

overtaxed and exhausted by the long hours of work required later in the care of

these patients on the wards. Carelessness in any regard could result in loss of

reduction or in retardation or failure of wound healing.

The wards devoted to fractures of the femur, with their forests of Balkan

frames and their mazes of splints, ropes, pulleys, and weights, were, however, among the most interesting in the hospital. Fractures of the femur were of

Walker, John B.: End Results, Fractures of Long Bones. In The Medical Department of the United States Army

in the World War. Washington; GovernmentPrinting Office, 1927, vol. XI, pt. 1, pp. 491-547.
REGIONAL COMPOUND FRACTURES 139

special interest for another reason: this was the one type of fracture held long

enough in theater of operations to permit evaluation of the union of the fracture and healing of the compounding wound.

SURVEY OF RESULTS, SPRING, 1944

Balanced-suspension skeletal traction was from the beginning the standard

method of management offemoral fractures in the general and station hospitals

of the Mediterranean theater. In few instances, only plaster hip spica was

used, but this was unusual.

The results obtained by these techniques during 1943 and the first months of

1944, although relatively satisfactory, were regarded as less than optimum in

many instances. Adequate reduction was usually secured with skeletal traction, but it was frequently not ideal, and the alinement obtained in fractures of

both the upper and lower third of the femur often left much to be desired. While

healing of the compounding wounds by granulation eventually occurred in the

majority of cases, the process was undesirably slow and often was attended with

heavy scar formation. The incidence of deep-seated abscesses in the posterior

fascial planes was not unduly high, though it increased early in 1944, during the

attacks on Cassino and at the Anzio beachhead. It was generally observed that

infection was most frequent when the fracture had not been reduced or well

immobilized or had been distracted and when repeated manipulations had been

undertaken to correct these errors. It was often difficult to maintainreduction

while the necessary dressing of large compounding wounds was carried out. The location, magnitude, and condition of these wounds complicated the management of the fracture and played part in the establishment of infection.

During April and May 1944, survey of fractures of the femur was conducted in six general hospitals and in station hospital which was then serving

as general hospital in the Naples area, in order to appraise the results of the

methods of management employed before the regimen of reparative surgery had

been instituted. All of the soldiers studied had been wounded at least 50 clays

earlier, during the mountain and beachhead fighting in Italy in January, February, and March. They had been cared for underrelatively adverse conditions,

in overcrowded field and evacuation hospitals which were exposed to enemy

artillery fire, including that of the “Anzio Annie” railroad gun. Many had been

evacuated over water. They had thenbeen treated in crowded general hospitals,

some of which were staffed by surgeons relatively inexperienced in military surgery. During this period, the incidence of clostridial myositis reached its

height in the Mediterranean theater, and the hazard of this complication was

added to the other problems of fractures ol the femur.

total of 235 patients with fractures of the femur was included in the

survey. Three (1.3 percent) died after admission to general hospitals, and

amputation was required in two other cases (0.85 percent).

In the remaining 230 cases, adequate reduction had usually been achieved,

though the position was not optimal in certain subtrochanteric fractures,
140 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

fractures of the distal third, and fractures characterized by loss of bone substance. In some cases, the use of the flexed knee position and of tight popliteal

slings for fractures of the lower third of the femur had given rise to such complications as skin irritations; thrombophlebitis; and inability to extend the

knee after the fracture had united, because of prolonged stretch of the quadriceps muscle. On the whole, the methods employed had not been conducive

to early, maximum return of motion in the knee joint. This was partly because of prolonged knee flexion, partly because of heavy scarring in the thigh,

and partly because quadriceps and knee exercises had been inadequate.

Forty-two cases (17.9 percent of the total 235 cases) were either infected

at the time of the survey or had been considered infected between the 30th

and 50th days after wounding. This number included three cases complicated

by clostridial myositis, which in each instance had appeared soon after the

patients reached the general hospital. Criteria of infection were purulent

exudate draining copiously from the fracture site; purulent collections in fascial planes; or daily temperature elevations, usually to 101°F. or over, with malaise,

anemia, and other evidences of toxemia. At the time of the survey, sinuses to

the fracture site were present in 23 cases.

In each of the 42 infected cases, the infectious process had been managed

by apparently adequate drainage. The fact that sinuses to the fracture site

were present in only 23 cases 50 days or more after wounding was taken to

mean that in the 19other cases infection had been controlled and that the fracture

site had been sealed off by the healing process. Unfortunately, no data were

collected on the number of completely healed wounds, chiefly because the

objective of the survey was an investigation (1) of the incidence of infection

involving fracture sites and (2) of the sequelae of infection.

The survey of these 235 compound fractures of the femur led to the

following conclusions: 1. In the light of the severity of these battle-incurred injuries, it was

scarcely to be expected that the proportion of either deaths or amputations

could be materially reduced below the present levels.

2. The incidence of infection was relatively low, as was the incidence of

sinuses to the bones, but further improvement in both respects seemed possible.

3. Better reduction in so-called problem fractures seemed possible of

achievement, as well as faster healing of compounding wounds, with minimal

scar formation.

4. Improvement in the range of knee motion and in quadriceps-muscle

tone seemed possible if more active attention were devoted to both points.

SOURCE MATERIAL

The observations in the remainder of this chapter were either made personally or were derived from reports submitted by the chiefs of orthopedic

sections of various general hospitals in Italy, as follows:

164 compound fractures of the femur treated at the 24th and 64th General
REGIONAL COMPOUND FRACTURES 141

Hospitals, plus 535 additional cases studied from the proceedings of disposition

boards on file in the Office of the Surgeon. This is total of 699 cases (series A).

482 compound fractures of the femur treated at the 21st, 33d, and 300th

General Hospitals (series B).

Not all data were available in all cases.

High-explosive shells and mine fragments accounted for the injury in 464

of the 699 cases in series A. Small-arms lire accounted for 222 cases (32 percent), and accidental causes for the remainder. The proportion of injuries

attributable to small-arms fire in this combined series is somewhat higher than

the proportion estimated for battle wounds in general.

The location of the femoral fracture in the 1,181 cases making up series and was the proximal third in 331 cases (28 percent), the middle third in

466 cases (39 percent), and the distal third in 384 cases (33 percent). There

was thus no great variation in the involvement of the various levels of the bone.

Since it is likely that fractures at the junction of the middle third with the

upper or the lower segment were classified as fractures of the middle third, the

chances are that each third of the bone was affected in almost equal degree.

In the 535 compound fractures of the femoral shaft making up the disposition boards’ material in series A, all but of which were combat incurred,

there were 41 injuries (7.7 percent) to the sciatic nerve or to the peroneal or

the tibia! nerve below the bifurcation of the sciatic nerve. This was almost

precisely the same as the 7.1-percent incidence in 133 compound fractures of

the shaft included in series B, from the 33d General Hospital. In both series,

some of the nerve injuries were incomplete.

THE PROGRAM OF REPARATIVE SURGERY

In spite of the usual severity of their wounds and the frequent necessity

for somewhat prolonged stay in forward hospitals after initial wound surgery,

soldiers with fractures of the femur generally reached fixed hospitals in the

rear within or days after wounding. Those with associated injuries of the

abdomen, chest, or head usually did not become transportable as soon. The

great majority of these patients, in spite of the intensive preoperative preparation necessary, could usually he submitted to reparative surgery before the 10th

day after wounding (the so-called golden period). In one group of 168 cases,

for instance, 57 patients (34 percent) underwent reparative surgery on or before the 7th day after wounding, and only 11.6 percent were not operated on

until after the 10th day.

Anatomic conditions and the conditions of the battle-incurred fracture

and the compounding wound were both favorable and unfavorable for the

application of the program of reparative surgery to the management of compound fractures of the femur. Favorable factors were as follows:

1. The regional anatomy was generally favorable, there being large

amount of highly vascularized soft tissue in this region and only small amount

of easily exposed fascial and tendinous tissue. Fascia lata could therefore be

396961°—57 11
142 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

partly excised without seriously affecting function. The heavy soft tissue of

the thigh aided in the obliteration of the dead space by pressure dressings.

Dependent drainage could be surgically established through posterior fascial

planes if posterior wound was not available.

2. Loss of bone creating complete segmental defect was uncommon in

compound fractures of the femur. When there was partial bone loss, fragments of bone and periosteum left in situ appeared to have excellent powers of

regeneration.

3. If internal fixation was indicated, it was facilitated by the size of the

femur, while the depth of the location of the bone made it certain that denuded

bone and metal would be well covered by soft parts.

4. Plastic procedures designed to accomplish wound healing were facilitated

by the abundant, loose skin of the thigh.

Against these favorable factors were the following unfavorable circumstances

1. Missiles frequently followed paths through the thigh that, because of

difficulties of operative position and approach, made them relatively inaccessible. Anatomic considerations made deep exposure of the thigh difficult. As

result, even after what seemed adequate initial surgery, some devitalized

tissue almost invariably remained in the wound.

2. The extensive intermuscular fascial planes of the posterior thigh permitted proximal gravitation of purulent exudate.

3. Although immobilization was essential in the management of the

femoral fracture, it prejudiced the ultimate range of knee motion. Knee

function is an important criterion in the evaluation of end results, and from this

standpoint the results achieved in femoral fractures were sometimes less than

optimal.

TECHNICAL CONSIDERATIONS

The surgery of battle-incurred compound fractures of the femur followed

closely the general pattern for the reparative surgery of compound fractures

(p. 83). With the soldier anesthetized, the transportation splinting provided

by the forward hospital after initial surgery (usually 1% hip spica but occasionally Tobruk splint) was removed in the operating room. Kirschner

wire was inserted in the lower femur or proximal tibia, its location being determined by the level of the fracture and the site of the wounds. The extremity

was then placed in the 90-90-90 position (fig. 51). This operative position,

developed by Maj. Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey,

MC, at the 23d General Hospital, was invaluable for reparative surgery of

battle fractures of the femur. It permitted free circumferential access to the

thigh and also provided adjustable balanced skeletal traction as an aid to

operative reduction of the fracture.

The depths of the wound and the fracture sites were exposed by gentle

retraction. Old blood clot, residual devitalized tissue, and totally free bone

fragments were removed.
REGIONAL COMPOUND FRACTURES 143

AFIP CC-44-50

Figure 51.—Suspension traction in 90-90-90 position for operation on compound fracture of femur. Kirschner wire shown in upper tibia may also

be placed in lower femur. If skeletal traction is not feasible the same

position may be maintained by the use of slings under the leg. The

90-90-90 position is an excellent operative position for reparative surgery

in injuries of the thigh and femur, since it provides full circumferential

access to the part.

study of the fracture contour by direct vision, together with study of

the roentgenograms, determined whether some form of internal fixation should

be employed or whether skeletal traction alone should be depended upon to

achieve reduction of the fracture.

Internal Fixation

The contour of only minority of the fractures of the femur permitted the effective use of internal fixation. In the majority of cases, therefore, balancedsuspension skeletal traction was the method employed for fracture reduction

(figs. 33 and 35). When internal fixation was applicable, it was performed

through the compounding wound only if adequate access to the fracture site

was permitted (figs. 31 and 35). The standard anterolateral approach as

sometimes used but, more frequently, the posterolateral fascial plane was

selected (figs. 52 and 34). This plane was considered advantageous because

it gave excellent exposure of the shaft of the femur and it could be used for

dependent drainage. Moreover, the trauma of the operative procedure was

posterior to the bone, and the products of the resulting devitalized tissue were

therefore easily drained away.
144 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fd-446, Fd-44-65

Figure 52.—Management of compound oblique fracture of upper third of right femur by

delayed internal fixation, with staged closure of wounds. This patient received initial

surgery 7% hours after wounding, but reparative surgery in the general hospital was

delayed until 19 days after wounding because he was afebrile and because of the heavy

load of casualties, many of whom required both initial and reparative surgery. A. Appearance of old compounding wound at reparative surgery 19 days after wounding.

B. Appearance of limb at completion of reparative surgery. The old compounding

wound has been excised. Internal fixation by multiple screws was carried out through

the posterolateral surgical incision. Both wounds were left open. C. Roentgenograms

before and after internal fixation. The preoperative roentgenograms were made soon

after initial surgery, 19 days before the second operation, and do not demonstrate the

shortening (1*4 inches) which was evident at reparative surgery and which was the

indication for internal fixation. D. Partial closure of wounds days after reparative

surgery. Each wound has been drained separately; these are not through-and-through

drains. E. Appearance of wounds weeks after wounding and weeks after partial

staged closure. Although both are almost completely healed at this time, drainage

later recurred from the compounding (lateral) wound.
REGIONAL COMPOUND FRACTURES 145

AFIP 3773, 3772, 3809, 3810, 3808, 3807

Figure 52—Continued. F. Anteroposterior roentgenogram showing united fracture

months after wounding. Note absorption about two lower screws. G. Lateral roentgenogram taken at same time as view F. Note sequestrum. H. Anteroposterior

roentgenogram after removal of metal and sequestra months after wounding. I.

Lateral roentgenogram taken at same time as view H. In this view, the defect from

sequestration on the posterior surface of the femur is clearly shown. J. Solidly healed

wounds weeks after removal of metal and sequestrum. K. Range of knee motion

months after wounding. The reparative surgery performed on this patient, although

unavoidably delayed, followed eminently sound principles. If traction alone had been

employed, shortening would almost certainly have resulted. The trauma of internal

fixation and the creation of additional devitalized tissue at the first operation of reparative surgery were sound indications for provision of drainage through the two open

wounds and for their staged closure. The prompt healing which followed removal of

the metal and sequestra was typical of many cases of this kind. (The case was managed

by Lt. Col. Roderick E. Begg, MC, and Capt. John E. Manning, MC, at the 46th

General Hospital.)
146 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The objections to the periosteal stripping necessary in internal fixation were

well recognized. On the other hand, the highly vascularized muscular bundles

surrounding the femur favored the early reattachment of soft parts to the

denuded bone, and there was little hesitancy in performing the stripping

required when internal fixation appeared to be useful. Multiple screws were

employed in the relatively few fractures with an obliquity permitting stable

fixation (figs. 31 and 35). In larger group, plating, often augmented by

additional screws, provided stable fixation (fig. 39). stabilized internal

fixation was considered advantageous for number of reasons: (1) Optimal

reduction of the fracture was assured; (2) subsequent wound care was facilitated; (3) earlier, intensive exercises for the knee joint were possible; and (4)

the patient could be transported to the Zone of Interior at an early date,

without fear of loss of apposition or of alinement of the fracture. Condylar

fractures of the femur were preferably fixed internally to restore joint congruity and to maintain reduction during early joint exercises (fig. 53). The

advantages offered by stabilizing internal fixation thus appeared to outweigh the disadvantages of additional trauma within the wound and the necessary denudation of bone.

In severely comminuted fractures, the judicious use of wire sutures allowed

major fragments to be held in apposition. This type offixation was particularly

applicable in fractures with partial loss of substance. It was also valuable in

some cases of established infection, in which it was recognized that periosteal

stripping should be restricted. The following experiences proved these points;

Capt. John J. Modlin, MC, at the 21st General Hospital, used wire-suture

fixation in 33 of series of 138 fractures of the femoral shaft. In this particular

experience, the indications were broadened because of heavy flow of casualties

that made it impossible to render all of the necessary attention to details required for the management of fractures of the femur in balanced skeletal traction. The wire sutures insured apposition of the fragments, and, even

though the balanced-suspension skeletal traction could not be adequately

adjusted during the first few days after operation to obtain good alinement, it

was possible to correct the alinement later. Had apposition of the fragments

not been maintained by the wire suture, it is doubtful that late reduction

would have been possible.

Maj. Irvin Cahen, MC, 64th GeneralHospital, reported that internal fixation

was used as part of the first reparative operation in 14 of series of 79 battle fractures of the femur. The fixation was obtained by plating in cases, by

multiple screws in 4, and by wire sutures in 2.

In followup study on delayed internal fixation of battle fractures in the

Zone of Interior made by the theater consultant in orthopedic surgery (p. 189),

it was found that the procedure had been performed at the first operation of

reparative surgery in 93 (64 percent) of 146 fractures of the femur managed by this method. The fixation in this group was by plating in 41 cases (44

percent), by multiple screws in 39 (42 percent), and by wire sutures in 13 (14
REGIONAL COMPOUND FRACTURES 147

U. S. Army photos

Figure 53.—Internal fixation of displaced fracture of medial femoral condyle. and B.

Anteroposterior and lateral views of region of knee made in evacuation hospital. Note

separation and rotation of medial femoral condyle. and D. Similar views, months

later, showing fracture united in excellent position after internal fixation on 10th day

after wounding. Note perfect preservation of contour of articular surface of lower end

of femur. Fractures which disturb the relationship of articular surfaces of major

joints, as in this injury, require that the fragments be maintained in precise reduction,

and internal fixation, performed through the compounding wound at the first operation

of reparative surgery, has definite field of usefulness. (This patient was managed by

Lt. Col. George A. Duncan, MC, and Maj. Benjamin W. Rawles, Jr., MC, at the 45th

General Hospital.)
148 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

percent). The remaining fixations were performed after adequate reduction

had not been achieved by skeletal traction.

Wound Management

After the method for maintaining fracture reduction had been determined

and internal fixation, if it had been chosen, had been effected, drainage of

residual dead space and wound closure were undertaken. Suture of the

compounding and operative wounds was performed to the extent that was

surgically feasible and was compatible with adequate drainage (figs. 31, 33, 34,

and 35). These wounds were not sutured with the major objective of protection of exposed bone. The objectives of wound closure in compound fractures

of the femur were early wound healing and minimal scar formation, both of

which have beneficial effect on future function.

Drainage.—It was considered important that some opening, preferably

dependent, remain in the wound in most cases to provide route of egress

for the products of possible decomposition of residual devitalized tissue or

blood clot. The necrotizing effect of purulent exudate deep in the thigh could

thus be avoided. Only very occasionally was drainage omitted.

If posterior wounds were present, they were used for drainage. Otherwise,

the posterolateral fascial plane between the biceps femoris and the vastus

lateralis was freely incised (figs. 52, 30, 34, and 35). This plane served well

for drainage of compound fractures between the level of the base of the trochanter and the level just distal to the junction of the middle and lower thirds

of the femur. In high fractures involving the trochanteric region, it was necessary to sever portion of the gluteus maximus if dependent drainage was

to be obtained and the hazard of pocket of purulent exudate beneath this

muscle was to be avoided.

Dependent drainage in the distal third of the thigh was difficult unless

posterior wound was present. Maj. Herbert W. Harris, MC, at the 17th

General Hospital, reported some success with posterolateral incision supplemented by medial incision anterior to the hamstring muscles. Col. Francis

J. Cox, MC, at the 24th General Hospital, considered drainage absolutely

essential and established it in all cases. In his technique, the linea aspera was

incised, so that there was free communication between medial thigh space

and the posterolateral fascial plane. Maj. Newton C. Mead, MC, at the 12th

General Hospital, preferred direct posterior drainage through channel passing

between the hamstring groups to drainage through the posterolateral fascial

plane. Fingertip dissection was used from the fracture site to the posterior

skin, which was then incised. Damage to the sciatic nerve was thus avoided.

In Mead’s experience, this method was effective and was not attended by

complications.

posterolateral fasciotomy used for internal fixation was frequently

left unsutured for few days, in order to provide the free drainage permitted

by an open wound.
REGIONAL COMPOUND FRACTURES 149

While adequate drainage was considered indicated and important in all

these injuries, it was of paramount importance in the presence of dirty wounds

and established infection. If considerable dead tissue had been found (and

excised) wound closure was postponed. In these cases, suture was often

performed several days later, when the wounds were clinically clean.

Postoperative Management

The great majority of the patients with fractured femurs were placed

in balanced-suspension skeletal traction immediately upon their return to the

ward. This was true even of those whose fractures were stabilized in reduction

by internal fixation, in order to facilitate the wound care and to permit an

intensive program of knee-joint exercises. The Kirschner wire used in maintaining the operative position in the operating room usually sufficed for traction

on the ward. If different location appeared desirable, new wire was inserted

immediately. The theoretical objections to the location of the wire in either

the lower femur or the tibia were disregarded, and the site was chosen that

appeared to be the most effective for reduction of the fracture. In general,

the lower femur was the location for the wire in fractures of the upper half

of the bone and the tibia for fractures of the lower half.

An important early development in the reparative surgery of compound

fractures of the femur was the introduction of two-wire or double skeletal

traction for fractures of the distal third of the femur (fig. 54). The tibial

wire for longitudinal traction was supplemented by femoral wire for vertical

traction, which served to lift the ever-troublesome distal fragment into alinement. This simple method, developed by Captain Modlin and Major Cahen,

at separate hospitals, went far to solve the problem presented by lower-third

femoral fractures.

Table shows the location of the wires for traction in 613 compound

fractures of the femur. These data do not include cases in which skeletal

traction was used after internal fixation.

Table 7.—Location of Kirschner wire for skeletal traction in 613 compound fractures of femur

Source Proximal

(femur)

Distal

(tibia)

Femur

and

tibia

Total

21st General Hospital 62 88 45 195

64th General Hospital 16 16 12 44

Proceedings, disposition boards 134 205 35 374

Total 212 309 92 613

Percentage 34. 50. 15. 100.

Two-wire technique.

From files, Office of the Surgeon, Mediterranean Theater of Operations.
150 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CB-44-55

Figure 54.—Diagrammatic showing of two-wire skeletal traction

for battle fracture of femur. A. Deformity on admission to fixed

hospital. B. Incomplete reduction in skeletal traction with wire

in tibial tubercle. C. Adequate reduction after additional wire

has been inserted in lower femoral fragment and vertical lift

has been secured.

Technique of balanced-suspension skeletal traction.-—Four methods of

balanced-suspension skeletal traction for fractures of the femur were used in

the Mediterranean theater. Each offered certain advantages and disadvantages. It was considered desirable that flexion of the knee be held to 15°

or 20° in order to avoid continuing stretch on the quadriceps muscle, prevent

fixation of the ligaments of the knee joint while the joint was in flexion, and

facilitate quadriceps-setting exercises. The degree of flexion of the knee was

therefore an important consideration in the selection of the method of balancedsuspension skeletal traction.

The four techniques of balanced-suspension skeletal traction included

1. The Army half-ring splint with Pierson attachment (fig. 55). This

method was applicable to fractures of the shaft requiring the pressure of sling

posteriorly as an aid in the maintenance of reduction. It was the preferable

method of splinting for two-wire traction for fractures of the lower third of

the femur. An outstanding advantage was that it permitted active and passive knee motion with little or no strain at the fracture site. The principal
REGIONAL COMPOUND FRACTURES 151

AFIP CC-44-48

Figure 55.—Balanced-suspension skeletal traction by means of half-ring

leg splint and Pierson attachment. Note balance as patient raises himself

for bedpan. Knee flexion shown is more than advisable.

disadvantages of the method were pressure of the ring on wounds high in the

thigh and the inaccessibility of posterior wounds for necessary dressings. The

pressure of the ring posteriorly could be avoided by placing it anteriorly.

Major Mead made effective use of this modification of the method in fractures

of the upper third of the femur with posterior wounds. Pressure of the ring

on the anterior superior spine of the ilium was prevented by increasing the

weight lifting the upper end of the splint. Access to posterior wounds was

easier but still awkward.

2. The Navy (Joldersma) method (fig. 56). This method was excellent

for fractures of the upper third of the femur and could be used for the majority

in the upper half. After the development of two-wire traction, it was used

for some fractures of the lower third. The application of the original setup

was cumbersome, but the modifications by Captain Modlin (fig. 57) and Major

Albert O. Linch, MC (fig. 58), were excellent simplifications. The principal

advantages offered by the Navy method of splinting were ready access to all

surfaces of the thigh for subsequent wound care, the ease of nursing care, and

the comfort experienced by the patient.

The great disadvantage of the Navy method was that it did not permit

knee-joint exercises. Therefore, after sufficient healing of the wound and formation of so-called chewing-gum callus formation at the fracture site, this

method was preferably replaced by the Army half-ring splint with Pierson

attachment.
152 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Figure 56. —Navy traction for fracture of femur. A. The canvas sling around the posterior

thigh is standard part of the equipment supplied with Balkan frame. weight of

only or pounds is sufficient to support the thigh. The excellent balance between the

traction and the leg suspension maintains alinement, and elevation of the foot of the

bed providescountertraction against the weight of the body. B. Details of leg suspension

in Navy traction shown in view A. Canton flannel is applied over sheet wadding, each turn

overlapping all but about one-quarter inch of the preceding turn. Internal or external

rotation of the lower femoral fragment is obtained, in Navy parlance, by moving the

pins “inboard” or “outboard.” The string, which is of smooth material, glides easily

through the safety pins and rings on the crossboard. Note the excellent functional

position of the foot.

3. The 90-90-90 method (fig. 59). This method, developed by Maj.

Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, MC, at the 23d General Hospital, and mentioned as an excellent operative position (p. 142), was

sometimes used for fractures of the upper third of the femur. Its principal

advantage was that, like the Navy method, it provided access to wounds high

in the posterior thigh. Its outstanding disadvantage was the prolonged flexion

of the knee to 90°. There was also danger of distraction. As technique of

balanced-suspension skeletal traction for compound fractures of the femur, the

90-90-90 method had only limited application. When it was used, it was

preferably replaced by conventional method after or weeks. As rule,

an orthopedic section did not use both the Navy method and 90-90-90 (vertical) traction, since the Navy setup appeared to offer all the advantages of

the 90-90-90 method without its disadvantages.

4. Russell traction. This method, which was used very occasionally for

fractures of the upper third of the femur, offered no advantages over those

already described.

Captain Modlin and Capt. Russell J. Crider, MC, at the 21st General

Hospital, in series of 185 compound fractures of the femur, employed the

Army half-ring splint with Pierson attachment in 107 cases (58 percent) and

the Navy method in the remaining 78 cases (42 percent). Major Cahen, in
REGIONAL COMPOUND FRACTURES 153

Figure 57.—Modlin modification of Navy

traction for fracture of femur. Both the

application and the removal of the whole

setup are facilitated by the use of the

canvas sling, and the patient is also kept

more comfortable. Note the plasma tubing, extending from the clevis to the foot

support, which maintains the foot at

right angle but still permits active

motion in the ankle.

AFIP C-44-363

smaller group of 45 fractures, used the former method in 26 cases, the latter

in 17, and Russell traction in cases.

Quadriceps exercises and knee motion.—The early, definitive reduction of fractures of the femur after balanced traction was instituted was considered

important in the prevention of deformity and sepsis. Repeated manipulations

of the fractures and major adjustments of the traction setup were traumatizing

to tissue and prejudicial to healing of the wounds. Quadriceps exercises and

program for knee motion were desirable as soon as the wounds had healed

sufficiently and fracture reduction would not be disturbed. In internally

stabilized fractures, these objectives could be accomplished about 10 or 12

days after the operation. In fractures managed entirely by skeletal traction,

exercises and movement were usually postponed until about or weeks after

repair of the wound.

Ideal program.—An ideal program for the management of femoral fractures in skeletal traction, developed by Captain Modlin at the 21st General

Hospital in Naples, was as follows:

The anesthesia provided for the surgery of the fracture and wound was

continued on the ward while the balanced-suspension skeletal traction was set

up. The fracture was manipulated into apposition and alinement, and the

traction apparatus was adjusted to maintain the correct position. Roentgenograms were made immediately. If they showed that adequate reduction had

not been achieved, the fracture was remanipulated, and the apparatus was adjusted again. Adequate reduction was usually achieved by these procedures,

but additional roentgenograms were made the following day, and, if needed,

further adjustments of the traction apparatus were made. This routine was

followed daily, if necessary, until satisfactory reduction had been achieved.

Thereafter, each traction setup was inspected carefully several times each

week, and checkup roentgenograms were made every to 10 days.

The patients were all placed on high-protein, high-caloric diet. The

hemoglobin, plasma-protein, and hematocrit values were checked at intervals
154 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fd-44-12

Figure 58.—Linch modification of Navy traction for

fracture of femur. The cumbersome board and string of

the original technique are replaced by multiple pulleys.

light metal splint can be substituted for the leather

support.

of or days, and blood-replacement therapy was employed to correct

deficits.

supervised program of quadriceps and knee bending exercises was begun

at the earliest practical time. This was usually about weeks after wounding.

The physical therapists attached to the hospital visited the femur ward times

weekly to supervise the program, but exercise periods were conducted daily

under the observation of the ward nurses. Competitive exercises among the

soldiers with femoral fractures were helpful in stimulating interest.

This regimen was observed to pay dividends in excellent fracture reductions, minimal infection, and good knee motion.

Duration of traction.—Skeletal traction for fractures of the femur was

preferably maintained until after clinical stability had become evident and

there was roentgenologic evidence of bony union of the fracture or, in the

exceptional case, until hope of union in the theater had been abandoned. The

usual time in traction for compound fractures of the upper and middle thirds

of the femur was about 10 or 11 weeks, although when casualties were heavy

the time in traction sometimes had to be shortened. Fractures in the lower

third of the femur appeared to unite rapidly and usually required only to

weeks in traction. The longer period was considered absolutely necessary in

fractures above this level, to avoid late angulation. The late weeks of traction

were utilized to improve the range of knee motion.

When sufficient union of the fracture had occurred to permit the discontinuance of the traction, plaster hip spica extending only to the iliac

crests was applied as transportation splinting for the transfer to the Zone of
REGIONAL COMPOUND FRACTURES 155

U. S. Army photos

Figure 59.—Skeletal traction by 90-90-90 suspension method for fracture of left femur.

A. Traction applied. B. Same as view A. Note ease of access to high posterior

wound of thigh. This position, because of its possible adverse effect on the knee,

should not be maintained for more than or weeks.

Interior. followup study in the Zone of Interior in 1945 (p. 189) revealed

instances of fractures of the femur which had been removed from traction

before firm union and which had bowed during transportation in the cast.

Several of these fractures had become fixed in angulation during that period.

These observations were added evidence that hip spica will not prevent

angulation of fracture of the femur and that period of 10 to 12 weeks in

traction is required for the majority of these injuries if the optimal result is

to be achieved.

Captain Modlin and Captain Crider at the 21st General Hospital reported

that in 177 compound fractures of the femur observed at that hospital the

average duration of skeletal traction was 12 weeks. Maj. William R. Ferguson,

MC, at the 33d General Hospital, reported an average traction time of 90 days

in 140 fractures. In the 535 fractures of the femur studied from the proceedings of disposition boards on file in the Office of the Surgeon, Mediterranean

Theater of Operations, the average time in traction was only 8.6 weeks. It is

known, however, that traction was prematurely discontinued in many of these

cases because of the stress of heavy casualty loads.

Other methods of fracture management.—A small but definite number of

fractures of the femoral shaft were not adequately reduced in skeletal traction. In these cases, if it appeared that satisfactory apposition and alinement could be achieved by an open reduction and internal fixation, the necessary surgery was carried out. Faulty reduction of the fractures was not

accepted if it could be prevented by open reduction and internal fixation.

Either the old compounding wound was reopened or separate operative

incision was made. The internal fixation and the subsequent management

of the soft-part wound conformed to the basic principles already described.

Ideally, of course, the compounding wounds were healed by the time

that operative intervention for the unreduced fracture had been selected, so
156 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

that the operative procedure was carried out not on fracture that was still

compound but, in restricted sense, on simple fracture. The hazard of

infection was therefore minimal. The unreduced fracture was, however,

likely to be associated with an unhealed, draining compounding wound or

wounds, and not infrequently definite wound infection was present. As

result, the majority of late internal fixations of fractures of the femur were

performed in the presence of unhealed wounds. In the 146 internally fixed compound fractures of the femur surveyed in the Zone of Interior (p. 194),

53 (36.3 percent) were performed at secondary operation of reparative

surgery. The compounding wounds were recorded as healed at the time of

the fixation in only cases (3.4 percent). They were unhealed in the remaining

48 cases.

Two other methods of managing these major skeletal injuries were used

infrequently. One was immobilization in plaster cast, the other, external

fixation.

Plaster hip spicas (usually the 1% spica, though in one hospital complete

double spica was used) were employed in few selected cases in which apposition and alinement were excellent on admission. Bone loss, in which distraction of fragments was feared if traction were employed, formed another

indication for the application of plaster hip spica. Several surgeons in the

theater preferred the hip spica for fractures associated with well-drained

established infection. Occasionally, heavy casualties and demand for hospital beds influenced the adoption of the plaster spica as the method of fracture management because it permitted early transfer to the Zone of Interior.

In spite of the usefulness of the plaster hip spica in occasional special

cases, observations over the theater led to the conclusion that balancedsuspension skeletal traction, with or without internal fixation, was the preferable method of management in the overwhelming majority of compound

fractures of the femur.

External skeletal fixation was not popular method. In the series

analyzed, it was employed only 19 times (table 8).

Distribution of Methods of Fracture Management

Table shows the methods of fracture management used in the several

series forming the basis of this study. Although skeletal traction was employed after the great majority of internal fixations, the data for this technique

include only cases in which skeletal traction was used without internal fixation.

Table shows the type of metallic internal fixation employed in 284 cases

in these series. The 21st General Hospital series is unusual in that 40 of 74

internal fixations of fractures of the femur (54 percent) were performed with

wire sutures. This relatively high incidence has already been explained (p.

146). The 24th General Hospital also employed wire-suture fixation in high

percentage of cases.
REGIONAL COMPOUND FRACTURES 157

Table 8.—Selection of methods offracture management in 1,063 compoundfractures of femoral shaft

Table 9. Techniques of internal fixation in 28 fractures of femoral shaft

APPRAISAL OF RESULTS

Casualties with fractures of the femur remained in general hospitals

sufficiently long time to allow an appraisal of wound healing (table 10) and,

usually, of union of the fracture. Even patients treated by stabilizing internal fixation of the fractures remained for several weeks, and traction for those

treated by other methods was continued for to 12 weeks. fairly long

term appraisal of results was possible. Important data on the results achieved

from the viewpoint of an overseas theater concerned the deaths, amputations,

healed wounds, wounds healed except for small granulated areas without sinus

formation to bone, sinuses to bone, infected fractures, and the quality of

fracture reductions.

3969G1 —57 12

Source Skeletal

traction

Internal

fixation

Plaster

cast only

Russell

traction

External

skeletal

fixation

Total

21st General Hospital 152 74 226

24th General Hospital 48 27 80

33d General Hospital 112 22 143

64th General Hospital 43 34 79

Proceedings, disposition boards 325 149 52 535

Total 680 306 56 19 1. 063

Percentage, 64 28. 5. 1. 100

From flies, Office of the Surgeon, Mediterranean Theater of Operations.

Source Plates Multiple

screws

Wire

sutures Total

21st General Hospital 12 22 40 74

24th General Hospital 13 27

64th General Hospital 15 13 34

Proceedings, disposition boards 87 42 20 149

Total 120 85 79 284

Percentage.. .. 42. 29. 27. 100

From files, Office of the Surgeon, Mediterranean Theater of Operations.
158 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Table 10.—Appraisal of wound healing in 825 compound fractures of femoral shaft at time

of disposition

In September 1944, survey was made in seven general hospitals in Naples

and Home to gather data on the results achieved in compound fractures of the

femur after the institution of the so-called reparative triad; that is, penicillin,

blood replacement, and precise surgery. The evaluation was made on each

patient by the chief of the orthopedic section of the hospital, after overseas

management had been completed and transfer to the Zone of Interior was

imminent.

Data secured in the 277 cases of compound fractures of the femoral shaft

reported in this survey follow: Number Percent

Deaths 0.

Amputations (exclusive of those caused by damage

of major vessels at wounding)

Infection at some period more than 30 days after

wounding (as evidenced by fever and purulent

drainage from fracture site) 35 12.

Sinus formation to fracture site at time of disposition 29 10.

comparison of these data with those gathered on similar group before

the advent of penicillin, full blood replacement in the fixed hospital, and

reparative surgery (p. 139) revealed no appreciable change in the incidence of

deaths and amputations. The incidence of persistent sinus formation was

about the same in each group. There was, however, smaller proportion of

infected fractures at some period 30 days after wounding (12.6 percent against

17.9 percent).

Status of wounds

Source

Healed

Healed

except for

small

granulating areas

Sinus formation to

bone

Infected

fracture

sites

Total

21st General Hospital (experience in Italy

only) 29 23 22 79

33d General Hospital 70 37 22 133

64th General Hospital 52 14 12 78

Proceedings, disposition boards 249 219 50 17 535

otal 400 293 106 26 825

Percentage 48. 35. 12. 3. 100

From flies, Office of the Surgeon, Mediterranean Theater of Operations.
REGIONAL COMPOUND FRACTURES 159

Persistent sinuses were undoubtedly indicative of sequestrum formation

and were not necessarily criterion of failure of management. In severely comminuted fractures, with many partially denuded fragments, some sequestration was often inevitable. During the survey in the Zone of Interior in early

1945 (p. 191), it was repeatedly observed that sound wound healing followed removal of sequestra, provided that reasonably healthy soft tissues were

available. Therefore, while sequestration was undesirable, its development

did not necessarily prejudice the end result.

An accurate appraisal of the quality of reduction of the fractures of the

femoral shaft in the series studied was not possible. It is known that ade- quate reduction was achieved in the great majority of all cases. Improvements in techniques of skeletal traction and the use of an aggressive surgical approach, combined with internal fixation if it was thought advantageous,

prevented malposition and malalinement. The concept of the management of

these injuries was that (1) the fractures should be reduced and maintained in reduction by whatever means were required; (2) that this objective could

be reached without endangering life or limb; and (3) that wound healing

would seldom be retarded but, if it were, that the end result, as measured by

the function of the extremity, would still be greatly improved. Inadequate

fracture reduction was therefore seldom accepted, and the statement that

fractures of the femur were usually adequately reduced is regarded as justified.

Data concerning the healing of the wounds in these series have been

compiled in table 10. Healing in wounds with small granulating areas was

considered satisfactory; there was no opening to the fracture site in these

cases, and healing processes had converted the compound fracture into

simple fracture. It is known that many wounds in which granulating areas

were recorded on disposition in the theater were healed when the transportation plaster hip spicas were removed in named general hospitals in the Zone of Interior. Infected wounds presented profuse, purulent drainage from the

fracture site. These fractures were usually those associated with severe damage and loss of soft tissue. The heavy drainage probably indicated relatively

heavy sequestration. Nonunion of the fracture was not necessarily present.

CONCLUSIONS

The regimen of reparative surgery as applied to battle-incurred fractures

of the femur in the Mediterranean theater and as evaluated overseas produced

minimal sepsis, improved reduction of fractures, earlier wound healing with

minimal scarring, and improved quadriceps power and range of knee motion

without increased morbidity or mortality. Morbidity, in fact, appeared to

have decreased. The final appraisal of the end results could be made only

in the Zone of Interior, after the function of the extremity had been resumed.

It is believed, however, that the regimen paid rich dividends in the prevention

of deformity and the functional restoration of these severely wounded

extremities.
160 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Part III. Compound Fractures of the Tibia and Fibula

Although results in certain compound fractures were reasonably satisfactory when the program of reparative surgery was introduced in the Mediterranean theater in the spring of 1944, fractures of the tibia and fibula were

not included in the group. The management of the fractures of one bone

(the tibia or the fibula) seldom offered difficulties. The management of

fractures of both the tibia and the fibula constituted major problem, which

cried aloud for solution, and it is fortunate that both bones were injured in

not more than quarter of all wounds of the leg.

The results being obtained in the theater in the spring of 1944 in fractures

of the tibia and fibula did not meet the standards considered desirable and

possible in the overseas management of these injuries. For this failure, there

were number of reasons:

1. When manipulation and traction, correctly applied, had failed to

achieve adequate reduction, the failure was frequently accepted as the best

that could be achieved under the circumstances because operative interference

was considered too hazardous. The fear of infection was easy to understand,

for there had been fairly high incidence of locally necrotizing wound infection

in wounds involving these fracture sites.

2. Wound discharges often pooled in dead spaces about unreduced fractures

of the tibia.

3. Even when healing by granulation proceeded at rate accepted as

normal, it was slow process and was always attended with scar formation, often of massive degree.

4. When tibial cortex was left exposed, in the expectation that it would

be covered by granulations, sequestration almost invariably resulted.

THE REPARATIVE-SURGERY PROGRAM

Compound fractures of the tibia and fibula therefore seemed, at least at

first glance, to offer peculiarly fertile field for the application of the new program of reparative surgery. Its components—surgical closure of compounding wounds; adequate reduction of fractures, by surgical measures if necessary;

and dependent drainage of residual dead space—were all designed’to overcome

the chief failures of the earlier, nonoperative plan of management, with healing

by granulation. The situation, however, was not as hopeful as it seemed. All the factors which were so favorable to the program in fractures of the femur

were unfavorable in fractures of the tibia and fibula because —-

1. Injuries of these bones were frequently associated with significant

degree of bone loss. This fact accounted for delays in union and for many

The statistical material in this section was provided by Maj. William R. Ferguson, MC, and Capt. Robert B. Oottschalk, MC, 33d General Hospital; Lt. Col. George A. Duncan, MC, Maj. R. D. Butterworth, MC, Maj. Benjamin

W. Rawles, Jr., MC, and Capt. Beverly B. Clary, MC, 45th General Hospital: Maj. Joe M. Parker, MC, and Capt. Francis R. Crouch, MC, 21st General Hospital; and Maj. Otto E. Autofrance, MC, 6th General Hospital.
REGIONAL COMPOUND FRACTURES 161

instances of nonunion and was serious consideration in an extremity in

which full weight bearing and almost full length are essential for normal gait.

2. Many difficulties lay in the way of obtaining and maintaining reduction and fracture union in an extremity in which excellent alinement is almost

essential for normal gait. In civilian practice, delayed union or nonunion is

not infrequent in fractures of the bones of the leg.

3. The large anteromedial surface of the tibia lies just under the subcutaneous tissue. As result, the cortex was often exposed at wounding. Since

there are no highly vascularized tissues in this area—even the covering skin is

thin and light—closure of compounding wounds located over the anteromedial

surface of the tibia was always difficult. In addition, there was frequently

significant loss of tissue at wounding, so that closure without tension was

often impossible.

4. Posterior dependent drainage of residual dead space was always difficult

to obtain in this area unless there was large compounding posterior wound.

5. The type of combined bone and nerve surgery which gave such excellent results in compound fractures associated with nerve injuries in the

upper extremity was not practical in the leg. Fortunately, the incidence of

these combined injuries, while somewhat greater than in compound fractures

of the femur, was considerably less than in compound fractures of the shaft

of the humerus.

These unfavorable factors, while they did not prevent the full utilization of the program of reparative surgery in compound fractures of the bones of the

leg, obviously handicapped it before it was instituted.

ANALYSIS OF CASES, 1944-45

The observations in this chapter, in addition to the personal observations, are based on the following collected data:

347 fractures of the tibia, fibula, or both bones treated from June 1944

through May 1945 at the 33d General Hospital.

638 fractures of the tibia, fibula, or both bones treated at the 45th General

Hospital during 1944.

279 fractures of the tibia or the tibia and fibula treated at the 21st General

Hospital during the last months of its operation.

219 fractures of the tibia, fibula, or both bones treated at the 6th General

Hospital from July through December 1944.

654 fractures of the tibia, fibula, or both bones studied from the proceedings of disposition boards in the Office of the Surgeon, Mediterranean Theater

of Operations, and filed after May 1944.

Practically all of these 2,137 fractures were managed after the reparativesurgery program became effective throughout the theater in the spring of 1944.

As usual, not all desired data were available in all series.

All the hospitals from which material was procured functioned in the Mediterranean theater. The material from the 21st General Hospital, which served

as one of the supporting hospitals in the invasion of southern France, also
162 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

covers the period after December 1944, at which time it came under the Chief

Surgeon, European Theater of Operations.

Fractures of the bones of the leg were the most frequent fractures encountered in the Mediterranean theater. The 638 cases handled at the 45th General

Hospital during 1944 may be taken as representative. These cases represented

21 percent of all compound fractures and 24 percent of all compound fractures

of the extremities admitted during this period. When fractures of the bones

of the hand and foot are excluded from the calculations, the proportion rises to

37 percent. Fractures of the bones of the leg also represented 4.6 percent of

all battle injuries treated at the 6th General Hospital from July through

December 1944.

The most detailed information on the causes of compound fractures of

the tibia and fibula was available from the 654 cases studied in dispositionboard proceedings. Details were available for 506 battle injuries and for 116

injuries classified as nonbattle, as follows:

High-explosive shell fragments from artillery, mortars, mines, or grenades

accounted for 345 of the 506 battle injuries (68.2 percent). Small-arms fire

accounted for the remaining 161 cases.

The 116 nonbattle injuries constituted 18.6 percent of the total series (622

cases) in which this information was available. The largest group of fractures,

71 (61.2 percent), were caused by vehicular accidents. Falls accounted for 17

cases (14.7 percent), injuries from falling objects for 13 (11.2 percent), and airplane crashes during training for 11 (9.5 percent). Explosions accounted for

cases and railroad accident for the remaining case.

Information as to the site of the fracture was available in 1,855 of the

2,137 cases analyzed in this chapter. The tibia alone was fractured in 819

instances (44.1 percent), the fibula alone in 523 (28.2 percent), and both bones

in 513 (27.7 percent).

Information as to the presence or absence of associated nerve injuries was

complete in 481 of the 498 cases from the 21st and 6th General Hospitals. In

this group, there were 13 injuries of the tibia! nerve and 47 of the peroneal

nerve, combined total of 60 injuries (12.5 percent). This percentage is to be

compared with 7.7 percent in combined injuries in compound fractures of the femur (p. 141) and 41.6 percent in compound fractures of the humerus (p. 128).

WOUND MANAGEMENT

Detailed data are not available on the preoperative management of patients with compound fractures of the bones of the leg in the general hospitals

of the Mediterranean theater. It is known, however, that they were usually

received in these fixed hospitals by the fifth or sixth day after wounding unless

concurrent injuries required longer stay in forward hospitals. They had

usually received one or more transfusions of whole blood in forward areas, but

additional transfusions were usually required, in the amount of 1,000 to 2,000
REGIONAL COMPOUND FRACTURES 163

cc., before hematocrit readings reached the minimum level (40) regarded as

safe for surgery.

In the absence of specially unfavorable circumstances, the reparative

operation could usually be undertaken well before the 10th day after wounding.

In 100 consecutive cases treated at the 33d General Hospital, the average was

days. In 297 cases studied in disposition-board proceedings, the average

was 8.5 days.

Management of the wound in compound fractures of the tibia and fibula

presented certain special problems. The first had to do with bone fragments.

Completely detached fragments of cortical bone were frequently found free in

the large marrow cavity of the tibia. Because they were potential sequestra,

theirremoval was imperative. Sharp, projecting ledges of bone were removed

by rongeur.

The second problem had to do with wound closure. Loss of tissue was

frequent. Even when the skin edges could be brought together without

tension, healing was often prejudiced by dead space, which was usually present

and which often could not be obliterated or effectively drained. In the early

days of the reparative-surgery program, wound closure was often made more

difficult by the use, in forward hospitals, of longitudinal incisions, with long

transverse axis, through the center of the combat wound. The crucial type

of defect which resulted was almost impossible to close satisfactorily. Eventually, surgeons in forward hospitals recognized this difficulty and thereafter

converted such wounds into modified by the use of proximal and distal

incisions made from opposite corners. Closure was greatly simplified when

such an incision was used at initial wound surgery.

It required discriminating judgment in many cases to decide to close the

wound, perhaps with the aid of relaxing incisions or the advancement of flaps

(figs. 36 and 40), or to leave it partially or completely open, in the expectation

that the defect would heal by granulation (fig. 42). The importance of covering all denuded cortical bone, and preferably the entire fracture site, with

soft parts was well recognized and was major objective of wound closure in

compound fractures, but deliberate acceptance of the closed plaster technique,

with healing by granulation, was sometimes the wiser choice when there was

extensive loss of soft tissue or when dead space was present that could not be

obliterated.

Even if closure was considered safe, drainage was always necessary in

wounds of the leg because some residual dead space was invariably present

and deep abscess formation was always possibility if drains were not used.

It was found best to provide drainage by soft rubber tissue or fine-mesh gauze

and to allow the drain to emerge from the residual dead space through the

sutured wounds. Attempts at dependent drainage through the posterior compartment of the leg were seldom successful, and the trauma of the incision or

erosion from the drainage material introduced the risk of damage to regional

vessels and nerves. When the compounding fractures were anterior, as they
164 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

usually were, the solution of the problem was to keep the patient in the prone

position for week or 10 days after wound closure. This position effectively

prevented puddling of blood and wound exudate in the bony defect.

When the decision was made to leave the wound partially or completely

open, the defect was loosely filled with dry, fine-mesh gauze, and the patient

was nursed in the prone position for week or 10 days.

Still another contingency that had to be considered in injuries of the leg

was how to manage wound that had required extensive revision at the first

operation of reparative surgery. In such cases, the best plan was to leave the

wound open for to days after operation, to take advantage of the good drainage provided by the wide-open incision. In some hospitals, this plan was routine in fractures of the tibia and fibula managed by internal fixation. When

delayed closure was undertaken at the appropriate time, which might be 14

days or more after wounding, it was usually possible to close the skin edges

without tension by the use of relaxing incisions or by shifting of flaps of skin.

The newly created skin defects were usually covered with split-thickness skin

grafts at the same operation.

FRACTURE MANAGEMENT

Fractures of the Tibia or the Fibula

As has already been stated, fractures of either the tibia or the fibula

seldom introduced problems of management, particularly when the injury was

in the fibula. Even when it was in the tibia, plaster immobilization usually

met the needs of the situation. The majority of United States orthopedic

surgeons entered upon military duty with the expectation of managing all

fractures of the tibia and fibula, whether alone or in combination, chiefly by

plaster. Reports from the Spanish Civil War and reports of British surgeons

of their experiences earlier in the war supported this point of view.

All plaster casts on the leg were so applied as to hold the knee and ankle

joints in physiologic position. The arches of the foot were well molded. Unless

muscle or nerve injury required support of the toes, the plaster was trimmed

back to the metatarsal heads, so that full flexion of the toes would be possible.

wire or plaster loop incorporated in the cast protected the foot from the pressure of bed clothing and other trauma.

Fractures of the fibula.—The management of fractures of the fibula was

simple unless the external malleolus was destroyed. In many such cases, only

molding in plaster was possible. Bone loss in the shaft was seldom of significance. Immobilization in plaster was provided for several weeks but was not

necessarily maintained until bony union was complete. The early removal of

the cast permitted muscle and joint exercises during the final stages of fracture

healing and played an important part in reducing the period of disability.

Compound fractures of the fibula were among the few compound battle

fractures that allowed the return of soldiers to full duty status in theater of
REGIONAL COMPOUND FRACTURES 165

operations. In 155 fractures of the fibula treated at the 45th General Hospital,

about 40 percent of the soldiers were returned to their original duty status.

Fractures of the tibia.—Fractures of the tibia in the middle or the upper

third were usually managed by plaster immobilization, to maintain alinement.

The intact fibula acted as strut to secure the normal length.

Fractures of the lower third of the tibia offered more difficulties. The

two-pin plaster technique of external skeletal fixation was occasionally employed

to insure full length and to avoid varus deformity of the foot. This complication usually occurred only in fractures in this location.

Internal fixation was employed in few fractures of the upper third of the

tibia with spread of the condyles or with forward displacement of fragment to

which the patellar tendon was attached. It was also used in few fractures of

the tibia at other levels. This technique was used in 1.5 percent of 158 fractures

of the tibia treated at the 33d General Hospital, in 4.3 percent of 277 cases

treated at the 45th General Hospital, and in 4.7 percent of 277 cases studied

from disposition-board proceedings.

When bone loss had created segmental defect in the tibia, the decision

had to be made whether (1) to osteotomize and shorten the intact fibula in

order to secure contact of the tibial fragments or (2) to leave the fibula intact in the expectation that the bony defect in the tibia could be repaired by grafting

at reconstructive surgery (fig. 60). In number of cases, the fibula was shortened. number of other cases were observed in which it was thought that it

would have been well to use this technique, since the shortening of the extremity

would not have exceeded an inch. Another advantage of this technique was

that deliberate shortening of the extremity sometimes permitted better approximation of the soft tissues. On the other hand, reports from Zone of Interior

hospitals indicated that high proportion of bone-grafting operations for segmental defects of the tibia were successful. In cases in which shortening would

have exceeded an inch, it was therefore the general policy to permit the fibula

to remain intact in expectation of later bone grafting.

Fractures of the Tibia and Fibula

Manipulative reduction with plaster immobilization was sufficient for the

management of many fractures of both bones of the leg. If the fractures were

severely comminuted, this often meant the acceptance of about centimeter

of shortening. The method presented one definite pitfall—late angulation

within the cast, which could occur after edema had disappeared, atrophy of

muscle and fatty tissue had ensued, and the cast had ceased to be snug fit.

Fractures of both the tibia and fibula with segmental defects resulting

from loss of bone at wounding or surgery provided major problem. Unless

shortening would be excessive, it was usually desirable to achieve contact of

the bony fragments. When, however, the defect exceeded an inch or at the

most an inch and half, it was usually preferable to allow it to persist, in an

effort to maintain tibial length. Damage to soft parts, which was usually
166 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

U. S. Army photo

Figure 60.—Anteroposterior and lateral roentgenograms

showing fracture of right tibia with segmental loss of

to Vi inches of bone. The fibula was intact. Union

of the tibia was finally obtained after years of hospitalization spent in staged plastic procedures on the

soft tissues, including split-thickness skin grafting followed by pedicle grafting, and two bone-grafting

procedures.

severe, further complicated the issue. The difficulties of wound management,

the persisting dead space created by the bony defect, the prejudicial effect of

the dead space on wound healing, and the limitation of function to be expected

in an extremity that had been so severely damaged, all had to be weighed in

the decision whether to shorten the extremity, maintain length mechanically,

or, in the occasional case, amputate the limb. When, as just noted, information reached the theater that bridging bone grafts were proving very successful

in the Zone ofInterior, the scales were usually weighted in favor of preservation

of length in the borderline cases in which amputation did not appear to be

indicated, and the technique most applicable to the particular case was selected.

Techniques of fracture management.—In addition to plaster alone, four

other methods of fracture management were employed in the Mediterranean

theater in compound fractures of the tibia and fibula (tables 11 and 12):

1. Skeletal traction in cast was employed effectively in number of

hospitals. The usual plaster immobilization was supplemented by traction

obtained by means of wire or pin inserted in the os calcis and incorporated
REGIONAL COMPOUND FRACTURES 167

into the cast (figs. 61 and 62). When traction was maintained for about

weeks, the risk of late angulation, which has just been mentioned, was greatly

reduced. Stability frequently developed during this period, and apposition

Table 11.—Fracture management in 622 compound fractures of tibia and tibia and fibula

Table 12.—Fracture management in relation to level of tibial injury in 621 compound fractures of tibia and tibia and fibula

Fractures

Technique

Tibia cases Tibia and

fibula cases

Total cases

Cast 277 167 444

Cast traction 45 47

Two-pin fixation in cast 11 12

Internal fixation tibia 13 80 93

Plating (6)

(5)

(2)

(59)

(20)

(1)

(65)

(25)

(3)

Screws

Wire

Plating fibula

External fixation 11 13

Amputation

Total 295 327 622

Data were secured from proceedings of disposition boardson filein the Office of the Surgeon,Mediterranean Theater

of Operations. The technique was not stated in 32 other cases studied.

Figures in parentheses are subtotals.

Level of tibial fracture

Technique Proximal third Mid

third Distalthird

Total

Cast 143 146 154 443

Cast traction 11 27 47

Two-pin fixation in cast 12

Internal fixation tibia 11 48 34 93

Plating (4) (36) (25) (65)

Screws __ (7) (ID (7) (25)

Wire (1) (2) (3)

Plating fibula

External fixation. _____ 11 13

Amputation

Total 171 222 228 621

Data were secured fromproceedings of disposition boards on file in the Office of the Surgeon, Mediterranean Theater

of Operations. The level of the tibial fracture was not stated in 33 other cases studied.

Figures in parentheses are subtotals.
168 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP 54-3045

Figure 61.—Skeletal traction in cast for fractures of both bones of leg. A. Application of

cast. Constant traction is exerted on musculature of leg through Kirschner wire by

means of muslin bandage orrope tied to bow on wire and passed around hips of assistant,

who leans backward. The fracture has been reduced by manipulation. The plaster

cast is well padded from the fracture site upward. Ideally, reduction is obtained by

manipulation and traction at the time the cast is applied and is maintained by traction.

Note functional position of foot. B. Traction with patient recumbent. Cast has

been wedged for alinement. C. Traction with patient on right side.
REGIONAL COMPOUND FRACTURES 169

U. S. Amy photos

Figure 62.—Roentgenologic results of skeletal traction in cast. and B. Anteroposterior

and lateral views of fractures of both bones of right leg at junction of upper and middle

thirds before and after skeletal traction in cast. Note length and alinement obtained

by this method, which also aids in obtaining apposition, though manipulative reduction

is also important in all but grossly comminuted fractures. and D. Same views of

fractures of both bones of right leg at junction of middle and lower thirds.
170 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

was well maintained. Traction supplement of the plaster technique should

probably have been employed more frequently than it was. In number of

instances observed in the Zone of Interior in the spring of 1945, late angulation

had occurred in both bones of the leg when only plaster immobilization was

used. Roentgenograms made shortly before evacuation had showed the

fractures to be well reduced, and the angulation had apparently occurred in

the to weeks occupied by transfer over water and to the Zone of Interior hospital after landing. In some instances, the angulation had become fixed,

and manual correction was not possible.

2. Two-pin stabilization in plaster involved merely the addition of pins

to the plaster technique. This method was enthusiastically employed at one

hospital in the theater but had very limited use in other hospitals. It was

chiefly employed in fractures with segmental defects in which it was desired

that almost full length be maintained. The majority of surgeons preferred not

to employ this technique in the absence of very specific indications. They did

not regard it as effective in maintaining reduction, and they realized the hazards

of persistent distraction, breakage of pins, and infection, which were associated

with it.

3. External skeletal fixation, of which the two-pin plaster technique is

really modification, was steadily gaining in favor in the closing days of the

war as an acceptable method of managing severely comminuted fractures of the

tibia and fibula, including those with bone loss (p. 207). In several hospitals,

the half pins were inserted in the major fragments as the first step of fracture

management at the reparative operation. Then, while the fracture site was

exposed, reduction was accomplished under direct vision, and the stabilizing

bars were locked to maintain it. Finally, long leg plaster cast, in which the

apparatus was incorporated, was applied. The cast held the foot in correct

position and increased the stability of the reduction.

4. It had been hoped, when the program of reparative surgery was introduced in the Mediterranean theater in the spring of 1944, that the problems

of management of fractures of both bones of the leg would be solved in large

measure by the use of internal fixation. This hope was only partly realized

(figs. 63, 64, 65, 32, and 36). In the majority of injuries, comminution was too

severe to make the technique feasible, while periosteal stripping in region of

poorly vascularized soft tissue continued to be hazardous, in spite of penicillin

protection and refinements of surgical technique. Fractures in which coverage

of denuded bone was difficult were usually unsuitable for management by this

technique. In spite of these objections, the judicious application of plates,

screws, or wire sutures in selected cases, particularly those in which it was

possible to cover exposed bone and metal by healthy soft parts, resulted in

improved and often stabilized reductions.

Wires sutures permitted major fragments to be held in approximation and

insured some degree of apposition. Fixation by this method and by screws

was considered less hazardous than plating, but plating was not infrequently

utilized, in spite of the added risk, to obtain the benefit of better stabilization.
REGIONAL COMPOUND FRACTURES 171

AFIP C-44-290

Figure 63. —Management of compound comminuted fractures of lower third of right tibia

and fibula by delayed internal fixation of tibia. Ligation of the posterior tibial artery

was necessary at initial surgery. A. Appearance of wound after reparative surgery

days after wounding. The wound has been only partly closed, to provide for drainage

after internal fixation of the tibia by plating, on the indication of bone loss at the site

of the fracture in the fibula. B. Preoperative and postoperative roentgenograms showing loss of bone at fracture site before reparative surgery and position of fractures after

plating of tibia. C. Range of ankle motion 13 months after wounding. Anteroposterior and rotated anteroposterior roentgenograms showed fractures solidly united and

in good alinement 12 months after wounding. Removal of metal and several small

sequestra was necessary for satisfactory wound healing.

The elective choice of internal fixation by plating was justified in this case because of

(1) the difficulties ordinarily experienced in fractures of the lower third of the tibia and (2)

the availability of soft parts to cover the denuded bone. The end result was excellent.

(The case was managed at the 21st General Hospital by Maj. Newton C. Mead, MC, and

Capt. Francis R. Crouch, MC.)

Toward the end of the war, it began to be recognized that it was better plan

to stage the procedures: Wound healing was accomplished as promptly as

possible, and then, if adequate reduction had not been attained, plating was

carried out through surgical incision. certain number of fractures, however,

continued to present such combined problems of fracture reduction and wound
172 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Lovell GH 27243

Figure 64.—Management of compound comminuted fractures of middle third of left tibia

and fibula by delayed internal fixation. A. Roentgenograms made at evacuation

hospital shortly after wounding. B. Roentgenograms made at general hospital after

stabilization of fracture of tibia by long plate and an additional transfixion screw.

These roentgenograms reveal second fracture, located more distally, not seen on the

original films (view A). few days later, this fracture was fixed in reduction by two

screws. The wound, which had been closed at both the original and the second operation,

did not heal. C. Roentgenograms made in Zone of Interior hospital, 3}i months

after wounding. Note nonunion of fractures and massive sequestration. At this time,

the wound was gaping down to the plate. D. Roentgenograms made weeks later,

after removal of sequestra and metal. Wound healing was obtained after this operation.

Note loss of bone by sequestration.

This case clearly illustrates the hazards of plating of the tibia. The advantages offered

by this technique when it is used before wound healing has occurred do not justify the risks

entailed. In this case, wound healing did not occur and there was massive sequestration

of the bone which had been denuded at operation.
REGIONAL COMPOUND FRACTURES 173

management that early plating through the compounding wound seemed

justified, in spite of the risk involved.

Internal fixation of the fibula (figs. 66 and 67) was employed in several hospitals when transverse or oblique fracture of that bone was associated

with comminuted fracture of the tibia. Plating, in effect, converted the

combined fractures into fracture of only the tibia; the stabilized fibula acted

as strut, maintaining tibial length and holding the tibial fragments in adequate

reduction. Both metal and bone were easily covered by soft tissue, and wound

healing was seldom problem. Plating was usually accomplished through

separate surgical incision. After operation, the limb was put up in long leg

plaster cast.

This technique was used in of 179 fractures of both bones of the leg

treated at the 45th General Hospital. In cases, the indication was large

segmental defect of the tibia, for which it was expected that bridging bone

graft would later be employed. In the other cases, adequate reduction of

the tibia was not possible by other methods. The fixation in of the cases

was accomplished through the compounding wound.

The surgeons at this particular hospital believed that the simplicity and

minimal hazard of this technique, combined with the feasibility of early transportability to the Zone of Interior with no fear of loss of reduction, made

plating of the fibula the method of choice for combined fractures of the tibia

and fibula whenever the contour of the fibular fracture permitted its use.

Other surgeons, with somewhat less enthusiasm, accepted the concept that

this technique had limited application in the management of fractures of

both bones of the leg.

EVALUATION OF RESULTS

Evaluation of the results of reparative surgery of compound fractures of

the bones of the leg was necessarily limited to observation of the status of

healing of the wounds and of reduction of fractures at the time of disposition.

soldier with compound fracture of the fibula could be returned to duty in

fair proportion of cases. soldier with compound fracture of the tibia was

unlikely to be of further military usefulness and was usually candidate for

early transfer to the Zone of Interior. Transfer was effected as soon as reparative management of the wound had been completed and it was reasonably

certain that reduction would not be lost in transit. It was sometimes effected

earlier than was desirable because heavy influxes of casualties demanded bed

space in the theater.

The consensus throughout the theater was that on the whole, because of

the handicaps attendant upon the management of these fractures (p. 160), the

results were inferior to those accomplished in compound fractures of the femur

and of the bones of the upper extremity. It was generally agreed, however,

that they were far superior to the results which had been accomplished before

396961°—57 13
174 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Schick GH 8793

Figure 65. (See opposite page for legends.)
REGIONAL COMPOUND FRACTURES 175

the introduction of the reparative-surgery program. Necrotizing wound

infection had become infrequent. Fracture reduction was improved. Com- plete wound healing was obtained in large number of cases. In other cases, in which healing was incomplete, the size of the defects left to heal by granulation had been greatly reduced.

high incidence of sequestration was considered almost inevitable in comminuted fractures of the tibia. When it occurred, sinuses formed and

wound healing was not accomplished. Removal of the sequestra was recognized as function of reconstructive surgery in the Zone of Interior. It was

performed only on special indications, and in correspondingly few cases, in

the Mediterranean theater. It was generally believed that, in most of these

cases, satisfactory healing of the wounds would occur after removal of dead

bone, provided that sufficient healthy soft tissue was available in the area.

In the 279 fractures of the tibia or the tibia and fibula which were treated

at the 21st General Hospital, the tibia was fractured in 191 cases and the tibia and fibula in 88. The proximal third of the bone was involved in 81 cases and

the distal third in 55; the knee joint was involved in 53 of the former group and

the ankle joint in 12 of the latter. One hundred and ninety of the wounds

were clinically clean on admission. In the remaining 69 cases in which this

information was available, the wound contained necrotic tissue, and there was

heavy exudate.

Details of wound management were available in 270 cases in this series.

Complete suture without drainage was carried out in 81 cases, partial suture or

suture with drainage in 143 cases, and suture with skin graft in cases. Thirty

wounds were left open. Amputation was necessary in cases, in instance

Figure 65.—Management of compound comminuted fractures of right tibia and fibula by

internal fixation of tibia; bilateral compound comminuted fractures of right os calcis

and talus. A. Anteroposterior roentgenogram made in general hospital several days

after wounding, showing fractures of tibia and fibula. B. Lateral roentgenogram, same.

C. Anteroposterior roentgenogram showing fractures of bones of leg after internal

fixation of tibia by plating through the compounding wound, which was closed. D. Lateral roentgenogram, same. E. Anteroposterior roentgenogram after removal of

metal and sequestra in Zone of Interior hospital. Wound healing did not occur until

after this procedure. The fracture is united, but heavy sequestration has reduced

the strength of the bone. F. Lateral roentgenogram made at same time as view E.

G. Roentgenogram showing severe distortion of bones of heel shortly after wounding.

This roentgenogram is to be compared with view F, in which the destruction in these

bones months after wounding is well demonstrated.

As this case is viewed in retrospect, the severe trauma to the right foot and leg might

well have been considered justification for amputation in all echelons. Perhaps the fact

that the trauma was bilateral was regarded by the surgeon as contraindication. Since

traction was not possible, the choice of internal fixation probably seemed justified. On the

other hand, plating of the tibia is always hazardous because of the necessary periosteal

stripping and the resulting denudation of bone, for coverage of which highly vascularized

soft parts are not available in this area. The ever-present possibility of massive sequestration such as occurred in this case would seem to indicate that nonplating methods are

preferable in such injuries.
176 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP (Mayo GH) 876-4, 6, 5, 1,

Figure 66.—Management of severely comminuted fracture of right tibia, with nearly

transverse fracture of fibula, by plating of fibula. A. Anteroposterior and lateral

roentgenograms of bones of leg made at general hospital. At reparative surgery

days after wounding, the fibula was stabilized by plating and thus served as strut

for the tibia, the fragments of which were maintained in apposition and alinement.

At the same operation, large wound over the medial aspect of the leg was partly closed,

and the remaining defect was loosel} packed. Two and half weeks later, with the

plated fibula as an aid in maintaining reduction of the tibia, the unhealed portion of

the wound was successfully covered with split-thickness graft. and C. Anteroposterior and lateral views made in general hospital in Zone of Interior several months

later. Fracture is firmly united. D. Frontal view of leg showing healed wounds with

extensive loss of soft tissues. E. Medial view. (This patient was managed by

Maj. Herbert W. Harris, MC, and Capt. Edwin L. Mollin, MC, at the 17th General

Hospital.)
REGIONAL COMPOUND FRACTURES 177

AFIP A—44-522

Figure 67.—Management of transverse fracture of left fibula and comminuted fracture of

tibia, with loss of bone, by plating of fibular fracture. A. Anteroposterior and lateral

roentgenograms before reparative surgery. B. Same as view A, with patient still on

operating table, after plating of fibula. Without benefit of plaster immobilization, the

tibia is now held at almost full length and in almost perfect alinement. C. Compounding wound of tibia 16 days after suture at reparative surgery. Note complete healing.

D. Healed operative incision used for plating of fibula, soundly healed after same

lapse of time. (This patient was managed by Maj. Joe M. Parker, MC, and Capt.

Francis R. Crouch, MC, at the 21st General Hospital.)
178 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

because of knee-joint infection and clostridial myositis complicating severe

fracture of the upper end of the tibia. In the remaining cases, the amputation

was performed for circulatory causes.

Methods of fracture management could be ascertained in 264 cases,

including cases in which the fracture was incomplete and immobilization

was not required. The remaining cases were treated by plaster-cast immobilization in 206, in 22 of which both bones were fractured; by cast traction in 23

cases, in all of which both bones were fractured; and by internal fixation in 26

(14 by screws, by wire, and by both techniques).

The status of the wound when the patients were evacuated was unknown

in 100 cases in this series, because of the tactical necessity for speedy evacuation.

In 40 of the remaining 170 cases (23.5 percent), the wounds were completely

healed. In another 49 cases (28.8 percent), the wounds were healing, and there

was no opening to the bone. In 59 cases (34.7 percent), in all of which the

closed plaster technique had been used, the fracture site was exposed, but the

wound was clean and healing appeared to be in progress. In the other 22

cases, the wound was not healed, and both bone and soft tissue were frankly

infected.

Results accomplished overseas were also studied in series of fractures

of the tibia (132) and of the tibia and the fibula (80) treated at the 33d General

Hospital. These 212 fractures were classified into three groups (table 13) on

the basis of severity of damage to the soft tissue and bone, as follows:

Group A.—Extensive damage to soft tissue, and, usually, severe comminution of bone. In many cases there had been loss of soft tissue or of bone at

wounding.

Group B.—Moderate soft-tissue damage, severe comminution of bone.

Group C.—Slight damage to soft tissues, little or no comminution of bone.

Results were classified as successful or unsuccessful from the standpoint

of wound management and fracture management. Wound management was

Table 13. Severity of injury in relation to location of fracture in 132 compound fractures of the tibia and 80 of the tibia and fibula

Location

Severity of injury

Group Group Group

Total

Proximal third 26 20 16 62

Mid third .. 36 20 61

Distal thirds. 43 22 15 80

Not stated

otal 108 65 39 212

These cases were managed at the 33d General Hospital.
REGIONAL COMPOUND FRACTURES 179

regarded as successful when the wound was either completely healed or completely healed except for small areas of healthy granulation tissue, with the

fracture site well sealed off. Management was regarded as unsuccessful when

there was an open, draining wound or sinus leading to the fracture site. These

criteria were exacting, since in highly comminuted battle fractures sinuses usually led only to sequestra’s forming from fragments of bone partially denuded

at wounding. Leaving these fragments in situ also introduced this possibility.

Wound healing had not been achieved in these cases, however, and they were

considered instances of unsuccessful wound management.

Fracture management was considered successful when the fragments were

held in adequate apposition, length, and alinement for the special bone injury.

It was considered unsuccessful when reduction was inadequate.

By these criteria (tables 14, 15, and 16), wound healing was considered

successful in 167 of these 212 compound fractures of the tibia and fibula.

Fracture management was successful in 207 cases. When the criteria of success

are combined, 166 cases were successful from the standpoint of wound healing

and fracture management, and only were unsuccessful from both aspects.

Table 14.—Results in relation to severity of injury and technique of wound management in 132

compound fractures of the tibia and 80 of the tibia and fibula

Early in the reparative-surgical program, the depths of the wound, including the fracture site, were not routinely exposed, and there is no doubt that

totally detached fragments of bone and tags of dead tissue were left in situ.

As experience increased, it was increasingly appreciated that the entire wound

must be freed of dead tissue. The improved wound healing in the cases in which

Technique

Successful Unsuccessful

Group Group Group Total Group Group Group Total

Revision:

Complete 72 47 21 140 13 17

Incomplete 16 27 20 28

Total 75 55 37 167 33 10 45

Suture:

Complete 45 41 30 116

Partial. 16 27 20 24

No suture 14 24 10 13

otal.. 75 55 37 167 33 10 45

Thesecases were managed at the 33d General Hospital.

Closed plaster technique.
180 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

additional debridement was carried out (89 percent, against 49 percent in the

cases not completely explored) furnished substantiating evidence of this fundamental principle of reparative surgery.

Table 15.—Results in relation to severity of injury and technique of fracture management in

132 compound fractures of the tibia and 80 of the tibia and fibula

Table 16.—Combined results of wound and fracture management in relation to severity of injury in 132 compound fractures of the tibia and 80 of the tibia and fibula

Part IV. Compound Fractures of the Foot

All hospitals in the Mediterranean Theater of Operations had frequent

admissions for compound fractures of the bones of the foot. At first glance,

this fact might seem to violate the axiom that the proportion of injuries in any

given area of the body bears general relation to the proportion ofbody surface

which the area represents. Although the foot constitutes relatively small

portion of the lower limb and an absolutely small part of the total body surface,

admissions for compound fractures of the bones of the foot made up from 18

Technique

Successful Unsuccessful

Group Group Group Total Group Group Group Total

Plaster cast 92 61 37 190

Internal fixation 10 14

External fixation

Total 104 64 39 207

Thesecases were managed at the 33d General Hospital.

Results

Severity of Injury

Total

Group Group Group

Wound and fracture management successful

Only wound management successful

75 54

10

37 166

Only fracture management successful 41

Wound and fracture management unsuccessful

29

Total 108 65 39 212

These eases were managed at the 33d General Hospital.
REGIONAL COMPOUND FRACTURES 181

to 20 percent of all compound fractures managed in general hospitals. At the

45th General Hospital, for instance, during 1944, the 565 compound fractures

of the bones of the foot represented 19.3 percent of all compound fractures

treated during that year. The os calcis was injured in 101 cases, the tarsals in

146, the metatarsals in 224, and the bones of the toes in 94. The explanation

of the large numbers of fractures of the foot was chiefly the extensive and

extremely effective use of land mines by German troops.

On the surface, it would not seem that compound fractures of bones of

the foot would be of great significance. They are not inherently lethal, it is

true, but they account for an enormous amount of disability, even when they

are of minor severity, and, when they are extensive, they may permanently

destroy soldier’s military usefulness. At the best, man with compound

fracture of bone of the foot, unless only smaller toe was involved, could not

be expected to return to duty within the theater holding period of 90 to 120

days. As result, most patients with such injuries had to be evacuated to

the Zone of Interior. It is perfectly fair to say that if an enemy could succeed

in producing compound fractures of bones of the foot in most of their opponents,

very large expenditure of medical service would be required for their management and only an insignificant number of the soldiers could return to fight again.

Of the compound fractures which affected only single toe, fair proportion were the result of self-inflicted gunshot wounds. The battle-incurred

injuries varied all the way from relatively simple fractures to completely disorganized fractures of the tarsus, with massive soft-tissue compounding wounds.

Injuries of this type were most often caused by land mines.

WOUND MANAGEMENT

Initial surgery in wounds of the foot was conducted according to the

general principles of debridement as far as the regional anatomy permitted.

Usually, all that could be done was to remove large foreign bodies and obviously

dead tissue.

The anatomy of the foot, unfortunately, also militated against all but the

most limited application of the program of reparative surgery, for number of

reasons: Some degree of tension is normal in the skin of the foot, particularly

on the plantar surface. For this reason, the swelling which ordinarily occurs

in the tissues after wounding and initial surgery is of more significance in the

foot than in most other areas. Finally, the soft tissues of the foot possess

generally inferior qualities of healing, even when there has been no great loss

of tissue, and in many of these injuries the loss had been considerable.

As result of these considerations, delayed primary closure of wounds

of the foot, even when tissue loss had been small, was usually limited to occasional wounds of the dorsal surface. It was seldom possible to close wounds on

the plantar surface. The best that could be done, in most cases, was to place

few sutures in the angles of the wound, cover exposed cortical bones and

tendons, and accept healing by granulation.
182 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The fact that most wounds could not be closed did not, of course, contraindicate the routine performance of other steps of the reparative operation.

Grossly displaced and rotated fragments of bone could often be replaced

manually in their normal position at this time.

The wounds were dressed with fine-mesh gauze, preferably impregnated

with vaseline or some water-soluble ointment, to promote drainage from the

depths of the wound. Dry gauze, which was preferred in other locations, was

less satisfactory when it was used in wounds of the foot.

FRACTURE MANAGEMENT

Manipulation under full vision, as just noted, was simple and effective

method of management of many fractures of the foot. It was usually effective

in fractures of bones of the small toes, with immobilization maintained by

dressings. It was also sometimes useful in bones of the great toe, but fractures

in this area required special management because this toe is essential for

locomotion, and residual disability is highly undesirable.

Banjo traction was the preferred method of management when the

proximal phalanx of the great toe was comminuted and fragments were overriding or when there was significant displacement of major fragment, particularly fragment which included portion of an articular surface. small

Kirschner wire was introduced into the distal phalanx of the toe from the dorsal

to the plantar surface, passing through the toenail. boot cast extending to

the metatarsal heads was then applied to hold the foot at 90° in neutral version.

heavy loop of wire was incorporated in the cast, and traction was accomplished by rubber bands extending from it to the Kirschner wire. This simple

method permitted access to compounding wounds for dressings and at the same

time minimized the deformity caused by the fracture.

Fractures of the metatarsal bones had to be prevented from uniting in

dorsal angulation. If this were permitted, the metatarsal heads would be excessively prominent in the ball of the foot, and callus formation and pain on

walking would be inevitable. Healing of all metatarsals in full length and in as

nearly perfect alinement as possible was necessary for the heads of these bones

to continue to serve as points of weight bearing. These results could be

accomplished in most fractures of the metatarsals by simple manipulative

molding and immobilization in boot cast. If any significant degree of

shortening was present after manipulation or if it was impossible to maintain

proper alinement, banjo traction was instituted through one or more of the

toes by the technique just described.

Fractures of the tarsus could be managed only by manipulative molding

and immobilization in boot cast. In this type of injury, the healing of the

compounding wound was of greater concern than the management of the

fracture, and the reduction of the fracture had to be conducted with this

consideration in mind.
REGIONAL COMPOUND FRACTURES 183

Compound fractures of the tarsus, especially when the os calcis was involved, were source of prolonged disability. Functional results were seldom

optimal and were often actually poor. Although conservatism was ordinarily

practiced, many orthopedic surgeons, when they reviewed their experience,

wondered whether this had been the wisest course. They could recall many

cases of extensive bony disorganization and persistent infection, with continuing destruction of bone or loss of weight-bearing skin on the plantar surface

of the heel, in which conservative measures had been employed but in which

amputation might have been the wiser course. In some of these cases, amputation was eventually performed in the Zone of Interior but only after the soldiers

had been hospitalized for months and even years.

The same course of events was sometimes observed in fractures of the

astragalus. Early amputation in this type of case would have lessened the

period of disability and saved considerable hospitalization and medical effort

which, in the end, achieved no results at all. It should be emphasized, of course,

that amputation was never carried out in case in which the vascular supply

to the distal portion of the foot appeared adequate and in which there was

reasonable chance of preserving functioning, weight-bearing extremity.

POSTOPERATIVE MANAGEMENT

Postoperative management in compound fractures of the bones of the foot

treated in plaster after reparative surgery required bed rest, with the injured

extremity elevated, for at least to 10 days, to reduce edema of the foot and

toes, prevent infection, and promote wound healing. When this plan was

followed, the edema originally present subsided promptly, often to such

degree that new plaster boot had to be applied.

Since the majority of these casualties were of no immediate military usefulness, they were usually evacuated to the Zone of Interior as soon as possible

after reparative surgery. This was, as rule, within to weeks after wounding. snug boot cast was adequate for transportation splinting.

185

CHAPTER VI

Delayed Internal Fixation of Compound Battle

Fractures—A Followup Study in the Zone of Interior

During the first 16 months’ experience in the Mediterranean Theater of

Operations, manipulative reduction followed by immobilization in plaster

cast or continuous skeletal traction proved satisfactory, or reasonably satisfactory, methods of management for major portion of the combat-incurred

fractures. Inadequate reduction, however, was by no means infrequent. It

was particularly common in fractures involving the condylar and articulating

portions of the large joints, fractures of both bones of the forearm and both

bones of the leg, fractures in which loss of bone had caused segmental defects

without contact of fragments, and fractures accompanied by massive loss of

soft tissue. Even though the position obtained by repeated efforts at manipulative reduction or continuous skeletal traction had often not been satisfactory

in these groups of injuries, inadequate reduction was accepted because of the

fear that operative intervention would incite systemic infection or at least

severe wound infection with prolonged osteomyelitis.

For these reasons, delayed internal fixation of compound battle fractures

was seldom performed during this period. On occasion, when adequate reduction had not been achieved by nonoperative methods, open reduction and internal fixation were performed, even though the wound as unhealed. The results

were encouraging in small series at one hospital, but in another series, at

different hospital, they w'ere poor. study of these cases and of sporadic

cases treated in this way in other hospitals did not produce evidence that

would warrant recommendation or approval of the procedure.

Even though it was realized that there would be place for delayed internal

fixation in the management of problem fractures once wound management

was better understood, its use in the Mediterranean theater was forbidden by

directive in November 1943. Section IV of Circular Letter No. 48, issued

18 November 1943 from the Office of the Surgeon, Headquarters, North African

Theater of Operations, read as follows;

IV. DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF COMPOUND FRACTURES WITH OR WITHOUT SECONDARY SUTURE OF WOUND.

1. This procedure is still under trial with reference to indications, hazards, and incidence

of serious complications. Its use is restricted to special groups authorized to assume the

responsibility as special study.
186 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

At this time, there were no groups in the theater authorized to make such

studies. For one thing, further investigation of the problem and further

experience in wound management as whole were necessary before internal

fixation could be considered an advisable technique. For another, it was

thought desirable to wait to test the technique until adequate supplies of penicillin were available, as safeguard against invasive infection.

The use of delayed internal fixation in the Mediterranean Theater of

Operations as part of the reparative surgery of compound fractures began in

March and April 1944, during the hectic days of Anzio and Cassino. Its use

was first permitted in the 300th, 23d, and 21st General Hospitals, in which

penicillin therapy had been made available as an adjuvant to an aggressive

surgical program. The patients treatedby internal fixationfell into two groups,

as follows: (1) Those with unreduced fractures and unhealed wounds, who had

previously been treated unsuccessfully by other methods; and (2) those recently

admitted from evacuation hospitals after initial wound surgery, with no

previous attempts at reduction of the fractures. The progress of each of these

patients was followed carefully and, when necessary, the theater holding period

was abrogated to permit prolonged observation, in an effort to assure that later

recommendations concerning the use of internal fixation would be soundly based.

The results of the initial test of delayed internal fixation as they were

observed in the spring of 1944 were extremely satisfactory. Moreover, when

the first 14 cases so treated were studied later in the Zone of Interior, it was

found that in 10 instances the fractures had united and the wounds had healed

without removal of the metal. The final results were equally satisfactory in

the other four cases, although ithad been necessary, in order to expedite healing

of the wounds, to remove the metal and sequestra. The results were particularly impressive in seven in which established wound infection had been present

when stabilization of the fracture was undertaken.

The immediate results as obtained in the 300th, 23d, and 21st General

Hospitals by the use of delayed internal fixation warranted its recommendation,

on specific indications, as part of theprogram of reparative surgery of compound fractures. It was pointed out, however, that the use of this technique was

not, in itself, an objective of the program. The measures designed to obviate

infection and achieve wound healing included (1) the excision of dead tissue as

part of revision of wounds in general hospitals; (2) the closure of compounding

wounds, especially to cover denuded bone; and (3) adequate drainage of residual

dead space or of unexcisable bits of devitalized tissue. All these measures

were of greater importance in the program than internal fixation of fractures. Internal fixation would have been doomed to failure if the other essential surgery had been ignored.

Internal fixation was neither advisable nor feasible in the majority of compound battle fractures because of severe comminution. The fractures which

would permit its use were in the minority. Internal fixation was therefore

reserved for specific indications, as will be pointed out shortly (p. 190).
DELAYED INTERNAL FIXATION 187

TECHNICAL CONSIDERATIONS

Internal fixation was frequently used at the first operation of reparative

surgery, but it was also employed later, after other methods had failed. It

was often used at the firstreparative operation (1) in fractures about the joints,

to secure anatomic replacement of the articular surfaces; (2) in fractures of

the long bones located deep in muscle tissue, particularly fractures of the

femoral shaft or upper radius; (3) in fractures which experience had shown

were difficult to hold in reduction by other means, such as fractures of the olecranon process associated with massive soft-tissue loss; and (4) in fractures

in which there had been segmental loss of bone and in which contact of the

fragments could not otherwise be secured.

Internal fixation was accomplished in three ways, as follows: (1) By

standard plating, (2) by multiple screws, and (3) by wire sutures. Slotted

plates and intramedullary pins were postwar developments. The only type of

metal available in overseas hospitals was 18-8 chrome-nickel stainless steel.

Fixation by multiple screws (2 or more) was often particularly useful in oblique

fractures. This technique required little or no additional periosteal stripping

and was therefore associated with minimal trauma. When the fracture could

not be stabilized rigidly because of comminution, one or more wire sutures

were used to hold major fragments in apposition. They could usually be placed

without additional stripping of the periosteum.

Intimate contact of the bony fragments was essential for sound union and

was regarded as of such importance that in occasional cases, in order to secure

it, the extremity was deliberately shortened, to overcome segmental loss and

permit approximation of the fragments. The same plan was sometimes adopted

when there were deficits of nerve trunks or muscles without segmental loss of

bone. Removal of bony fragments permitted approximation of nerve or

muscle bundles in these injuries and was undertaken with the idea of accomplishing maximum functional restoration of the whole extremity rather than merely

achieving united fracture.

Although the operation was sometimes performed through the compounding wound, this technique had two disadvantages: (1) The metal was placed

on bone which was usually devoid of periosteum. (2) It was also placed at the

bottom of dead space created by the excision of devitalized muscle. It was

therefore usually better, especially when plate was applied, to utilize

separate surgical incision, which permitted coverage of the bone and metal by

periosteum and soft parts.

The routine procedure for the management of these casualties in fixed

hospital must be clearly understood. Every patient was prepared for reparative surgery, usually to 10 days after wounding. He was anesthetized in the

operating room, where the plaster cast and dressing applied after initial surgery

were removed. The extremity was cleansed, prepared, and draped. The

operating room was set up for any surgery which might be indicated on compound fracture.
188 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The wound was then thoroughly visualized by gentle retraction. All

residual dead tissue was excised, and the depths of the wound were cleansed

of old blood clot. The fracture site was exposed. In the great majority of

cases, reduction was attempted by traction or manipulation, but internal

fixation could be employed at this time, as part of the first procedure of reparative surgery, if its advantages were evident, as, for instance, in condylar

fractures of joints, oblique fractures of long bones which were easily reducible,

or segmental defects due to bone loss. Wound closure, usually with drainage,

completed this stage ofreparative surgery.

If later roentgenograms showed that adequate reduction had not been

achieved by traction or manipulation and if the contour of the fracture permitted, internal fixation could be performed at another operation, perhaps

after wound healing.

Delayed internal fixation was not reserved for the ideal case. On the

contrary, it was frequently employed in compound fractures that were major

problems under any plan of management, as, for instance, an avulsion of the

soft parts of the arm which exposed the shaft of the humerus for several inches

or grossly displaced, infected fracture of the femur, with huge soft-part

wound, 66 days after surgery. These are situations hardly included in the

realm of reparative surgery.

SURVEY OF RESULTS

After the program of reparative surgery of compound fractures, including

internal fixation on special indications, had been extended to all general

hospitals in the Mediterranean theater, the results of this procedure were

closely checked. In the majority of cases, they were regarded as satisfactory.

The incidence of wound infection had apparently not been increased. Drainage

had usually not been prolonged. Ultimate scar formation was expected to be

less. Fracture reduction was certainly improved. There seemed, therefore, every reason to hope that there would be considerable improvement in both

anatomic and functional end results in the fractures in which this method was

employed.

One disturbing fact was that, in spite of frequent warnings to the contrary,

few surgeons in the theater had accomplished internal fixation by plating in

relatively large number of fractures of the tibia. The consultant in orthopedic

surgery had repeatedly pointed out that anatomic conditions in this area do

not permit satisfactory coverage of the denuded bone by vascular soft parts.

The risk of massive sequestration after the application of plate had also been

emphasized. This was particularly true because of the stripping of the perios- teum necessary when the plate was applied to the anteromedial surface of the

bone. The surgeons who, despite these warnings, attempted to manage fractures of the tibia by plating often found that they had created for themselves

major problems in closure of the wound, even when fixation had been carried

out through separate surgical incision. Results observed in the Mediter-
DELAYED INTERNAL FIXATION 189

ranean Theater of Operations in the management of compound fractures of the

tibia by internal fixation were far less satisfactory than the results achieved

by this method in fractures of any other long bone.

On the whole, the results observed in cases in which internal fixation had

been used seemed highly satisfactory when the patients were examined before

evacuation to the Zone of Interior. The results, in fact, seemed particularly good when they were evaluated in the light of the problems which had to be

solved in these cases. Overseas observation, however, did not settle the question of end results. For that, investigation in the Zone of Interior was necessary. Previous attempts to secure followup data had not been successful. The

Surgeon, Mediterranean Theater of Operations, therefore requested that the

consultant in orthopedic surgery for the theater be ordered to the United States,

to carry out, among other observations, survey of casualties with compound

fractures who had been treated in the Mediterranean theater by delayed

internal fixation and who were then in Zone of Interior hospitals. This survey

was carried out in the spring of 1945, with the cooperation and assistance of the

Surgical Consultants Division, Office of The Surgeon General.

Materials and Methods

The survey was conducted in 24 general hospitals in the United States

between 16 March and 26 April 1945. The 332 fractures surveyed had been

managed in 18 general hospitals in the Mediterranean theater, by approximately

50 orthopedic surgeons. The material thus represented cross section of the

battle experience and surgical proficiency of the theater. The majority of the

patients had undergone operations in which delayed internal fixation had been

performed between June 1944, the date of the fall of Rome, and November

1944, the date of the approximate conclusion of the fighting on the Gothic Line.

Two hundred and ninety-five case reports, representing three hundred

fractures, were assembled as follows:

1. From personal examination of patients still hospitalized or still required

to report for observation to outpatient clinics.

2. From study of records of patients still hospitalized but presently

absent on furlough or pass.

3. From study of the records of patients who had been referred to convalescent hospitals, returned to duty, or given Certificate of Disability

discharge.

In each instance, the total record was studied, from wounding to the date

of the investigation, and all roentgenograms were examined. The case reports

made up as result of these investigations included, as far as possible, the

following data: The precise diagnosis of the bone injury; the diagnoses of

associated injuries which might have influenced fracture management; an

appraisal of the indication for internal fixation; the type of fixation (plate,

screw, wire suture); the time interval between wounding and fixation; the

396961°—57 14
190 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

status of the wound at the time the fixation operation was performed; the

surgical approach to the fracture (through the compounding wound or through

separate surgical incision); the presence of wound infection at the time of

tiie fixation operation; the presence of associated nerve injuries; the results

achieved from the standpoint of wound healing and bony union; the time at which wound healing and bony union were achieved in relation to the time of

the fixation operation; and whetherremoval of metal and sequestra had been

necessary.

Another group of 32 patients consisted of soldiers who had been demobilized, were in convalescent hospitals which were not visited, or had been

returned to duty. Their status indicated, with reasonable assurance, that

their wounds were healed and their fractures united, which meant that optimal

results had been accomplished. Their records, however, were lacking in

certain basic data, including the kind of fixation employed and the indication

on which operation had been done. These cases, therefore, are necessarily

omitted from some of the tabulated presentation of results.

The material secured from this survey is presented chiefly in the form of

tabular data, with special emphasis on the results obtained to the date of the

investigation in relation to (1) the indications for internal fixation, (2) the

technique of fixation employed, and (3) the area of injury. Certain other data

are also discussed.

No true controls exist for this series. In all the hospitals surveyed,

serious effort was made to secure data on comparable cases treated by methods

other than internal fixation, but the information had not been compiled and

could not be obtained. number of patients were observed, however, whose

results might have been improved if internal fixation had been used to stabilize

their fractures. In number of instances of malunion and nonunion in femoral

fractures studied roentgenologically, the contour of the fractures suggested

that this technique might have been feasible and might have given better

results. In number of fractures of the humerus with segmental defects, it

was also thought that union might have been achieved if bony apposition had

been maintained by metallic internal fixation.

Definition of Terms

Indications.—Indications for the internal fixations performed in this group

of fractures were classified as obligate and elective. The terms carry their own

definitions.

Obligate indications included the following:

1. Bone loss which either had produced segmental defect without contact

of the fragments (figs. 38 and 43) or was associated with persistent distraction

of the fragments (figs. 30 and 50). In either event, union could not be expected without corrective measures.
DELAYED INTERNAL FIXATION 191

2. Fractures about the joints, particularly condylar fractures of the knee or elbow. Reparative measures were necessary in this type of fracture to accomplish joint congruity (fig. 53).

3. Massive soft-tissue loss which precluded routine measures of closure and required staged procedures. Fixation of the fracture was part of the attempt to achieve wound healing.

4. Associated nerve injuries which required, for optimum results, early stabilization of the fracture, sometimes with deliberate shortening of the bone

to permit approximation of the severed nerve ends (fig. 39).

5. Failure to achieve and maintain adequate reduction In' manipulative measures or traction (figs. 30 and 50). Malunion, delayed union, or nonunion

was inevitable in such cases in the absence of corrective measures.

The operations performed under the last mentioned indication were obviously performed after failure of other methods of treatment. In all other

operations done on obligate indications, internal fixation was sometimes performed at the first operation of reparative surgery and sometimes later, in many

instances after the wound had healed.

All indications which were not obligate were regarded as elective. Elective

operations were carried out at the first procedure of reparative surgery.

Results.—Results were classified as favorable, unfavorable,and incomplete,

as follows:

Favorable. —This catagory was further divided into

1. Group A.—In this group of optimum results, the fractures united in

perfect, or almost perfect, anatomic alinement, and the wounds healed solidly

and promptly, without sequestration and without removal of the metal used in

the fixation (figs. 31, 34, 35, and 43). In several fractures of the femur and of

the tibia, the metal was removed later, either as prophylactic measure or

because slight evidences of absorption were detected around the screws. Its

removal, however, was not necessary to accomplish either wound healing or

bony union (figs. 30, 36, and 52).

2. Group B.—In this group, the fractures united promptly in adequate

reduction, and wound healing occurred satisfactorily after metal and sequestra

had been removed (figs. 32, 50, and 63).

Unfavorable. —This category was further divided into—-

1. Group C.—In this group, union of the fracture occurred promptly but

with massive sequestration, and metal and large sequestra had to be removed

before wound healing was obtained (figs. 64 and 65). All cases in the group

were fractures of the tibia, bone in which, as already pointed out, plating is

always associated with some risk. The massive sequestration which occurred

threatened bony continuity and introduced the risk of refracture when weight

bearing was resumed. The risk thus introduced, because of loss of bon}'

strength, made it necessary to use braces for several months (fig. 65).

2. Group D.—In this group, wounds healed without sequestration or

removal of metal, but bony union had not occurred at the time of the survey.
192 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The results are classified as unfavorable for this reason. From the standpoint

of wound healing, management was successful. The fact of nonunion, of course,

must be evaluated against the chances of the same result if internal fixation had

not been performed (fig. 44).

3. Group E.—In this group of fractures, wound healing did not occur, and

in most instances fracture union was not achieved, until both sequestra and

metal had been removed. The timerequired for both wound healing and bony

union therefore exceeded normal expectancy.

4. Group F.—In this group, fractures did not unite, and wounds did not

heal. In several instances, wound healing occurred after removal of metal and

sequestra, but it was expected that bone-grafting procedures would be necessary

in all cases to accomplish bony union (fig. 64). As in group D, these results

must be evaluated against the probability of similarly unsatisfactory results if

internal fixation had not been employed.

Incomplete In these fractures (group G), it was thought that satisfactory

end results would eventually be secured, as the fractures were well united.

Wound healing, however, had not occurred at the time of the survey. In some

instances, plastic procedures on the wound would obviously be necessary, in

addition to sequestrectomy and removal of metal, before healing could be

expected to occur. In other instances, it was felt that, if metal and sequestra

were removed, the same excellentresults would follow this secondary procedure

as had followed it in another group (B) in the series (fig. 52).

Results in relation to indications for internal fixation are presented for the

whole series in tables 17 and 18, and for regional injuries in tables 19, 20, 21,

and 22.

Results in Relation to Technique

Results of internal fixation in relation to technique are presented in table

23. As it shows, plating was used in slightly over half of the 332 compound

fractures of the long bones included in this survey. The largest proportion of

entirely satisfactory results (groups and B) was obtained with multiple screws;

results were excellent in 82 of 95 such cases. There were 21 absolute failures (failure of wound healing and nonunion of the fracture) at the time of the survey

in the 168 fractures treated by plating, against absolute failures in 69 fractures

treated by wiring. There were no absolute failures in the 95 fractures fixed

by screws. There were number of instances in the unfavorable categories in

which it was thought that with the passage of time better results than were

then apparent might be achieved.

This category of results was classified as satisfactory in the original report, on the ground that, although the fracture was ununited, the woundwas healed and that the chief purpose of the survey was to determinethe status ofwound healing

in fractures treated by delayed internal fixation. Becauseof the possibility of misunderstanding (since an ununited fracture cannot be considered satisfactory result), this category of results has been moved to the unsatisfactory group of

cases, in the exercise of the editorial function. The author of the volume, who conducted the survey, does not regard the

results achieved as entirely unsatisfactory, since this group of cases demonstrated that the use of delayed internal taxation

in open or compound fractures due to gunshot ounds did not cause high incidence of infection. In the great majorityof

cases, the wound and fracture both healed in due time. It should be remembered that this survey does not represent

study of end results but is rather progress report; in some instances, sufficient time had not elapsed from the date of

internal fixation to permit final evaluation of either wound healing or fracture healing. [Editor’s note.]
DELAYED INTERNAL FIXATION

Table 17.—Residts of internal fixation performed on obligate indications in 135 compound

fractures

Table 18.—Results of internal fixation performed on elective indications in 165 compound

fractures

Table 19.—Results of internal fixation in relation to indications in 67 compound fractures

of humerus

Fracture

Favorable Unfavorable Incomplete

Total

Humerus 24 42

Radius and ulna 11 18

Femur 31 57

Tibia and fibula 18

Total 73 22 16 12 135

See text, pp. 191-192, for code of results.

See footnote 1, p. 192.

Fracture

Favorable Unfavorable Incomplete

Total

Humerus 17 21

Radius and ulna

Femur 51 17 79

Tibia and fibula 27 10 56

Total 101 30 165

See text, pp. 191-192, for code of results.

See footnote 1, p. 192.

Indications

Favorable Unfavorable Incomplete

Total

Obligate

Elective

24

17

42

21

Unknown

Total 45 67

See text, pp. 191-192, for code of results.

See footnote 1, p. 192.
194 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Table 20.—Results of internal fixation in relation to indications in SI compound fractures

of radius and ulna

Table 21.—Results of internal fixation in relation to indications in lfi6 compound fractures

of femur

Table 22.—Results of internal fixation in relation to indications in 88 compound fractures of tibia and fibula

Indications

Favorable Unfavorable Incomplete

Total

Obligate 11 18

Elective

Unknown

Total 21 31

See text, pp. 191-192, for code of results.

See footnote 1, p. 192.

Indications

Favorable Unfavorable Incomplete

otal

Obligate

Elective

Unknown

31

51

10

17

57

79

10

otal 92 24 11 146

See text, pp. 191-192, for code of results.

See footnote 1, p. 192.

Indications

Favorable Unfavorable Incomplete

Total

Obligate

27

14

10

18

56

14

Elective

Unknown

Total 48 15 88

See text, pp. 191-192, for code of results. This table includes 13 fractures in which the fibula was plated.

See footnote 1, p. 192.
DELAYED INTERNAL FIXATION 195

Table 23.—Composite results of internal fixation in relation to technique and location offracture in 332 compoundfractures of long hones

Sequestration was apparently the chief hazard associated with internal

fixation (fig. 64). It occurred in slightly over third of the cases surveyed and,

case for case, seemed more extensive than might have been expected in the

light of cases in which this procedure had not been used. Experience overseas

had shown that in the ordinary course of events sequestration was practically

always limited to areas of bone which had, presumably, been denuded at

wounding; these areas were increased by the periosteal stripping necessary when

internal fixation by plating was used. In some cases surveyed in the Zone of

Technique and location

Favorable Unfavorable Incomplete

Total

Plating:

Humerus 16 25

Radius and ulna 15

Femur 41 12 72

Tibia and fibula 16 10 43

Fibula and tibia 10 13

otal 92 28 21 168

Screws:

Humerus 10 14

Radius and ulna

Femur 39 53

Tibia and fibula 19 26

Fibula and tibia

Total 70 12 10 95

Wire:

umerus 19 28

Radius and ulna 10 14

Femur 12 21

Tibia and fibula

Fibula and tibia

Total 44 12 69

Grand total

Percentage

206

62.

52

15. 2.

14

4. 1.

25

7.

21

6.

332

100. 00

See text, pp. 191-192, for definition of terms.

See footnote 1, p. 192.

Tibia and fibula—plating of tibia. Fibula and tibia—plating of fibula.
196 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Interior, failure of wound healing was clearly attributable to delay in removal of

sequestra as well as metal. Since the fractures were well united in all of these

cases, there seemed no reason for having postponed the secondary surgery which

was obviously necessary.

Sequestration was only occasionally massive when screw or wire fixation

was used. When it occurred with these techniques, it did not seem to interfere

with union of the fracture. In such cases, it would probably have occurred no

matter what method of fracture management had been employed. There was

no doubt, however, of the tendency toward sequestra formation when plating

was employed. It occurred in 69 of the 168 fractures treated by this technique

and was sometimes so massive that the resulting bony defect could be compensated for only by bone grafting.

Sequestration seemed less likely to occur, particularly when plates were

used, if the internal fixation was done through separate incision rather than

through the compounding wound. It was also thought that wound healing

occurred more promptly if the operation was performed through separate

incision.

Other Data

The details of 29 fractures in which internal fixation was performed in the

presence of established wound infection are presented in table 24. The average

time from wounding to operation in these cases was 36 days.

Only 37 nerve injuries were recorded in these 332 fractures, 21 in fractures

of the humerus, in fractures of the radius and ulna, in fractures of the femur,

and in fracture of the tibia and fibula. Only nerve injury in 88 fractures

of the tibia and fibula seems unlikely; other nerve injuries probably occurred

and were not recorded.

Table 24 .—Results of internal fixation in 29 compound fractures with established wound

infection

Fracture

Favorable Unfavorable Incomplete

Total

Humerus

Radius and ulna

Femur 21

Tibia and fibula

Total 10 29

See text, pp. 191-192, for code ofresults.

See footnote 1, p. 192.
DELAYED INTERNAL FIXATION 197

Kefracture, which in each instance involved the femur, occurred times in these 332 fractures. In of the refractures, the second fracture occurred

at point at which there had been bone loss at the site of the original injury. In the seventh refracture, the bone loss had been caused by sequestration.

In four instances, there was no obvious cause for the second fracture. In two

instances, the refracture followed falls, and in the remaining instance it followed manipulations to secure motion of the knee joint. In spite of the complication

of the second injury, the end results were good to excellent in all seven refractures.

Generally speaking, although no statistics were collected to prove it, it

was thought that the range of knee motion following rigid internal fixation

(that is, by plates and screws) of fractures of the femur, when surgery was

supplemented by program designed to achieve maximum functional results,

exceeded the range achieved in comparable injuries managed by other methods.

The range of knee motion, however, varied with the level of the fracture. Knee motion was excellent in some fractures of the upper half of the femur. It was less good in many fractures of the lower half and was particularly

unsatisfactory in fractures of the lower third. In many cases, the explanation

of less than satisfactory knee function was failure to institute program of

knee motion after the patient reached the Zone of Interior in hip spica. The

omission of this program simply failed to capitalize on one of the decided

advantages of internal fixation.

It was interesting to observe the results in patients who had come from

the 21st General Hospital in the Mediterranean theater, which was known to

have an excellent program of postoperative knee motion in effect on its fracture

wards. Whether the patients with fractured femurs from this hospital had or

had not been managed by internal fixation, the range of knee motion, case

for case, was superior to the range of motion observed in patients from other

hospitals.

CONCLUSIONS OF THE SURVEY

It was concluded from this survey of internal fixation carried out in hospitals in the Zone of Interior that, when this procedure is used on correct

indications and is performed by the correct technique, it has definite, if limited, place in the management of battle-incurred compound fractures of the

long bones in fixed hospitals overseas. The term “correct indications” implies

that the operation is performed only as an adjuvant measure and within the

strict limitations of reparative surgery. Failure to institute surgical measures

to forestall infection and favor wound healing invariably prejudices the results.

There were no deaths and no amputations in these 332 fractures. The

overall results were satisfactory to excellent with two groups of exceptions,

fractures associated with massive soft-tissue loss and fractures of the tibia and

fibula managed by plating.
198 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

In the light of the results achieved in this series and evident in this survey,

conclusions concerning the results possible of achievement by delayed internal

fixation may be stated as follows:

1. Nonunion can be prevented in fractures with segmental defects or persistent distraction, as is evidenced by the achievement of bony union in 27 of

39 such fractures in this series.

Varying degrees of malunion, delayed union, or nonunion can be prevented

in many cases in which inadequate reduction was achieved by other measures.

This is evidenced by the achievement of bony union in good apposition and

alinement in 64 of 75 such fractures in this series.

Bony union, with optimal reduction, can be achieved in condylar fractures

about the knee and elbow. This result was achieved in all 15 such fractures

in this series.

The obvious advantages of well-stabilized optimum reduction can be

achieved in fractures which lend themselves to rigid stabilization, and satisfactory wound healing may be achieved in many cases, provided that fixation

is accomplished by multiple screws, with minimal periosteal stripping. Union

was accomplished in good position in all 95 fractures thus managed in this

series. Wound healing was accomplished without sequestration or removal of

metal in 71 of these fractures and was accomplished after their removal in

another 14.

When plating is the method of fixation, bony union and satisfactory

wound healing must be anticipated in smaller proportion of cases. In 168

fractures managed by this technique, bony union was accomplished in 140.

Wound healing was accomplished without sequestration or removal of metal

in 99 fractures and was accomplished after their removal in another 34.

Improved apposition of fragments can sometimes be provided by the use

of wire sutures, and favorable results may be anticipated in many instances.

When this technique was used in this series, bony union was accomplished in

59 of 69 fractures. Wound healing, without sequestration and without removal

of metal, was accomplished in 50 fractures, and in another 12 the wound healed

after metal and sequestra were removed. Four fractures in which wire sutures

were used were absolute failures, and three others were incomplete at the time

of the survey.

2. The chief hazard of delayed internal fixation, namely, increased sequestration, may be explained by the periosteal stripping which the procedure

entails and by its interference with readherence of soft parts to denuded bone.

Other observations indicate that sequestration of bone in nonfixed battle

fractures is practically always limited to bone that was probably denuded at

wounding. Sequestration occurred in little over third of the fractures in

this series, but comparable data in control series are not available.

The sequestration which occurred in this series when screw or wire-suture

fixation was used was seldom massive, did not seem to interfere with union

of the fracture, and probably would have occurred in many cases if the fractures had been managed by other methods.
DELAYED INTERNAL FIXATION 199

Massive sequestration occurred in 41 of the 168 fractures which were

managed by plating, with retardation ofattainment of full strength of the bone. In some fractures managed by plating, massive defect may be created which

is reparable only by bone grafting.

3. Unless the fracture contour permits rigid fixation by screws or unless wire sutures appear advantageous, it is best to attempt reduction by traction

or manipulation and strive for early wound healing. When wound healing

has been accomplished, fixation by plating or some other technique is relatively safe. Wound healing occurred by this plan in 20 of 21 fractures in this

series, without sequestration or removal of the metal.

Excellent results may be expected in fixations of the long bones of the upper extremity if severity of bone loss or of the soft-tissue injury does not

prejudice the chances of union and wound healing. Massive soft-tissue loss had occurred in this series in of failures of internal fixation of fractures of

the upper extremity, and bone loss had occurred in the other fractures.

Fixations of the femur, performed on correct indications, by means of

multiple screws or wire sutures and with minimal periosteal stripping, may be

expected to give excellent results. In this series, there were no failures in fractures of the femur fixed by screws. Bone loss was responsible for the two

failures with wire-suture fixation. One of the patients, in addition, had suffered

massive loss of soft tissue. The risk of the periosteal stripping necessary when

plating is employed makes it preferable to delay fixation until after wound

healing unless the indications and anticipated advantages overshadow the

hazard.

Fixation of the tibia by multiple screws or wire suture may be expected

to give very satisfactory results. Periosteal stripping should be kept to

minimum. There were only two unfavorable results in the fractures in this

series fixed by screws; in both, heavy sequestration occurred. The single

entirely unfavorable result in the fractures fixed by wire sutures was expected,

ultimately, to be favorable; only months had elapsed since wounding, and

it was thought that the fracture would eventually unite. Plating of the tibia

should be reserved until after wound healing. Eight of the nine failures in

fixations of the tibia, and six of the eight massive sequestrations, occurred

after plating of this bone. more extensive use of wire sutures to maintain

approximation might have improved results.

When both tibia and fibula are fractured, plating of the fibula may be

useful procedure, and one which is relatively safe. It maintains length and

alinement, aids in achieving apposition of tibial fragments, and provides some

degree of immobilization of the fracture of the tibia.

4. Internal fixation, when used as an adjuvant to the management of

unreduced, infected compound battle fractures, may aid in the control of

infection and in achieving the best result which can be obtained in the circumstances. In the 29 infected cases in this series (table 24), bony union was

achieved in good alinement in 20, and wound healing occurred without further
200 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

sequestration in 13. In 13 additional cases, wound healing occurred after

removal of sequestra and metal.

This followup study of 332 compound fractures, all but 13 of which were

combat incurred, revealed satisfactory to optimal results in 258 cases (77.7

percent). These 258 fractures illustrate the optimum results which could

have been achieved. They include 21 fractures in which removal of metal and

sequestra had not yet been performed but in which excellent results could be

expected after secondary surgery had been carried out. They do not include

eight fractures of the femur in which massive sequestration had occurred but

in which there seemed reason to hope that satisfactory weight-bearing extremities would eventually be secured.

ANALYSIS OF UNFAVORABLE RESULTS

The 53 fractures classified as unsuccessful fall into groups:

Eight operations, all performed on elective indications (group C). In

this group, union of the fracture occurred promptly, but metal and massive

sequestra had to be removed before wound healing was obtained. All cases in

this group were fractures of the tibia, in which plating is always associated

with some risk. The massive sequestration which occurred threatened bony

continuity and introduced the risk of refracture when weight bearing was resumed. This risk made it necessary to use braces for several months longer

than was necessary in the and groups.

Fourteen operations, nine performed on obligate and five on elective indications (group D). In this group, union had not occurred at the time of the

survey, and, for this reason only, the results are classified as unfavorable.

From the standpoint of wound healing, the result was successful. The fact of

nonunion, furthermore, must be evaluated against the chances of the same result

if internal fixation had not been performed.

Six operations, three performed on obligate and three on elective indications, in which wound healing did not occur and, in most instances, union of the fracture was not achieved, until both sequestra and metal were removed (group

E). The time required for both wound healing and bony union therefore exceeded normal expectancy.

Twenty-five operations, sixteen performed on obligate and nine on elective

indications, in which fractures did not unite and wounds did not heal (group F).

The fractures in this group represent the only absolute failures in the series, and,

even in it, wound healing occurred in several instances after removal of metal and sequestra. It was expected, however, that bone-grafting procedures would

be necessary in all cases to accomplish bony union. As in groupD, these results

must be evaluated against the probability of similarly unsatisfactory results if

internal fixation had not been employed.

See footnote 1, p. 192.
DELAYED INTERNAL FIXATION 201

These unfavorable results, to consider the fractures from the separate

standpoints of wound healing and bony union, include 14 fractures in which wound healing occurred but bony union did not; fractures in which bony union occurred but wound healing was obtained only after metal and massive

sequestra were removed (all fractures of the tibia); fractures in which wound

healing did not occur and bony union was usually not achieved until both sequestra and metal were removed; and 25 fractures in which neither union of

the fractures nor wound healing was accomplished.

In the 53 unfavorable cases, 19 operations were performed on the femur, 20 on the tibia and fibula, on the humerus, and on the radius and ulna.

Twenty-five were performed on elective and twenty-eight on obligate indications.

Certain of these cases warrant special comment:

In operations on the femur performed on obligate indications, managed

by plating and by wiring, the indication was segmental bone loss so extensive

that nonunion was regarded as probably inevitable by more conservative

methods. In third fracture, which was managed by plating, previous management had been unsuccessful. The fracture was double, and the large rotated central fragment could not be reduced. When the patient was surveyed, the

proximal fracture was well united, and it was thought that the distal fracture

might still unite. In spite of the unsuccessful result in this case, the use of

internal fixation was regarded as both justified and advantageous.

In one of the elective operations on the femur, the fracture, which was

mildly comminuted, was only partly stabilized by screws and wire sutures;

the operation had been performed in an infected field. The patient had already

undergone amputation of the foot on this side and amputation of the contralateral leg for infection. He was observed only months after wounding, and

it was thought that the fracture might still unite. In another unsatisfactory

operation, the major fragments of the severely comminuted femur were sutured

in apposition. The wound was infected, the infection extending into the joint,

and the fracture site had to be drained by dependent drainage. The failure

of union in this case could not be attributed to internal fixation.

In one operation on the tibia and fibula, classified as unfavorable because

of nonunion although the wound healed promptly, the failure must be charged

against poor technique; examination of the roentgenograms taken overseas

showed that the bone had been plated with the fragments distracted. In

another operation, 4-inch defect in the tibia had been strutted by plating the

fibula, in expectation of later bone-grafting operation. In third operation,

nonunion was explained by bone loss and unsatisfactory contact of the

fragments.

In three unfavorable operations on the humerus, all managed by wiring,

there was segmental bone loss. It is interesting that in 10 similar operations

in the series union was achieved by the same technique. In another operation,

plating was performed 25 days after wounding, when wound healing was

complete, because conservative measures of fracture management had failed

to achieve satisfactory reduction.
202 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Ill fracture of the bones of the forearm in which internal fixation failed

to produce union even though the wound healed, the indication for operation

was bone loss. The ulna was intact, but there was 1-inch segmental defect

in the radius. wire suture was applied to help maintain alinement, without

any real expectation that union could be accomplished. In another patient,

with fracture of the radius and double fracture of the ulna, the indication

was elective. Steinmann pin which had been passed down the medullary

canal of the ulna had to be removed at the end of weeks, and the radius was

plated at this time. When the patient was observed in Zone of Interior

hospital, neither fracture of the ulna had united and reduction was poor, but

it was thought possible that union of the radius might still be accomplished.

In the 25 operations regarded as absolute failures, 16 were performed on

obligate and on elective indications. The failure in each case must be evaluated in the light of the severity of the problem and the indications for fixation.

When the 25 fractures are analyzed from this standpoint, the conclusion is

reached that fractures had been improved by internal fixation; had not been, though progress had not been retarded; and 13 (3.9 percent of the 332 fractures

in the series) had been harmed by the operation. In the two remaining fractures, final evaluation from this standpoint was not possible at the time

the survey was made.

Editor’s note.—It should be emphasized again, as the author has noted already (p. 191),that fixation of the tibia

with plates and screws yielded the highest percentage and the greatest number of unfavorable results in the open fractures treated by internal fixation. Unfortunately, these techniques are the easiest to accomplish. These facts should

be brought home to every medical officer. Otherwise, the tibia will continue to serve as boobytrap for the unwary, incompletely trained surgeon, with the wounded soldier as the victim.
203

CHAPTER VII

External Skeletal Fixation of Fractures in the

Communications Zone

The experience with external skeletal fixation in the management of

battle-incurred compound fractures in the Mediterranean Theater of Operations

in World War II is of historical interest only. Apparatus for external skeletal

fixation became available in the theater for certain general hospitals and

smaller number of specially authorized station hospitals in the summer and fall of 1943. Almost as soon, however, as the method began to be used, it became

evident that its indiscriminate use in military surgery was attended with

pitfalls and hazards and that its application must be rigidly restricted. For

these reasons, it had very limited use in the Mediterranean theater, and this

report chiefly concerns the special hospitals in which it was employed.

The restrictions placed upon the use of external skeletal fixation in combatincurred compound fractures were specified in Circular Letter No. 48, Office

of the Surgeon, North African Theater of Operations, 18 November 1943.

In substance, they were as follows:

External skeletal fixation is highly specialized technique of fracture

management, to be used only in carefully selected cases, only on special indications, and only by surgeons trained and experienced in its application. If

an indication arises for its employment in hospital whose staff does not include

surgeon with these qualifications, the patient must be transferred to hospital in which trained personnel is available.

Only under emergency conditions may patient be transferred from one

hospital to another with apparatus for external skeletal fixation in place. If the transfer is not avoidable, he must be assigned to hospital whose staff

includes surgeon trained in its use. Evacuation to the Zone of Interior with

the apparatus in place is not permissible. If further immobilization is required,

the patient must be held in an overseas hospital until the pins can be removed

and more conventional methods of splinting substituted.

ANALYSIS OF CASES

Circular Letter No. 48 also provided that the clinical record of each patient

treated by external skeletal fixation must be forwarded, through channels, to

the Surgeon, North African Theater of Operations, after treatment had been

Data for this chapter were collected by Maj. Herbert W. Harris, MC, and Capt. Edwin L. Mollin, MC, 17th

General Hospital.

See appendix, pp. 312-316.
204 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

completed. The record was to cover all details of the case, including the date

and circumstances of wounding; complete description of the fracture and of

the compounding wound if the fracture was compound; the initial treatment; the indications for external skeletal fixation; the length of time required to

apply the apparatus and reduce the fracture; the number of roentgenograms

required; the date, character, and extent of any distraction observed; the

occurrence of infection about the pins; other complications; the date of removal of the apparatus; the subsequent management of the injury; and the

disposition and end results.

These instructions, unfortunately, were not universally carried out, and

the complete data which it had been hoped would be accumulated in the Office

of the Surgeon therefore did not become available. In an effort to supply the

deficiency and determine the extent of the usage of external skeletal fixation

and the results achieved by it, survey was carried out early in 1945, on the

orders of the Surgeon, in each of the general and station hospitals in which the

apparatus had been made available.

Four of the general hospitals in which provision had been made to employ

external skeletal fixation treated no cases at all by it. Another hospital used

the method in few cases early in 1943 and had such poor results that it

abandoned the technique entirely. The records were not available for some

35 cases treated in general and station hospital which left the theater in

August 1944 to support the invasion of southern France.

The final report, therefore, covers only general and station hospitals

and includes only 146 cases, all treated in 1944 and all recorded in sufficient

detail to permit reasonably satisfactory analysis. Some 20 other cases

treated in these hospitals by external skeletal fixation had to be discarded because of paucity of data. Representative experiences are presented in tables

25, 26, and 27.

After full year of experience with external skeletal fixation used according to the instructions set forth in Circular Letter No. 48, there was no unanimity of opinion concerning the merits of the technique. The small group

of surgeons who had seen no place for it in civilian practice had been unwilling

to give it trial under military circumstances. Surgeons who had had an

extensive previous experience with it and had therefore expected that it

would have wide application in both simple and compound combat-incurred

fractures for the most part changed their opinion and restricted or discontinued its use. On the other hand, group of surgeons with limited experience

with the technique in civilian orthopedic practice believed that it offered

decided advantages in carefully selected cases, and number of them, as their

military experience increased, actually broadened the indications.

Complications.—Drainage from the sites of the pins was fairly frequent

in these 146 cases but could usually be terminated by removal of the pins.

Osteomyelitis was reported at the sites of the pins in only two cases in the

series. In one instance, it developed about pin far removed from the wound

and must be considered primary infection. In the other case, it extended
EXTERNAL SKELETAL FIXATION 205

from severely infected compound fracture of the os calcis to lower pin in

the tibia. In both instances, wound healing was obtained after removal of

dead bone and the institution of drainage. The only other serious complication in the series was an abscess which developed about lower femoral pin;

it responded promptly to drainage.

Table 25.—Essential data on 14 jractures treated by external skeletal fixation, 33d General

Hospital, 1944

Table 26.—Essential data on 27 fractures treated by external skeletal fixation, 26th General

Hospital, 1944

396961°—57 15

Fracture Indication Complications Results

Lower third humerus, compound, Elective (plated) Mild infection about Union.

comminuted. Lower third humerus, simple, com- Elective pins.

do Do.

minuted.

Middle third humerus, compound, Comminution, skin grafting Do.

comminuted. Delayed union.

Ulna, compound, comminuted, dis- Malpositionfragments, both bones. Union, stiff elbow.

location head radius. Radius and ulna, compound, com- Comminution, displacement Mildinfection about Union.

minuted. Proximal third radius and ulna, com- pound, comminuted.

pins.

do Nonunion.

Middle third femur, simple, com- minuted.

Elective Unknown.

Proximal third femur, simple, com- Comminution, malposition,short- Mildinfection about Do.

minuted. ening. pins.

Middle third femur, simple, com- Overriding, displacement-, do Do.

minuted. do Early callus at evac- uation.

Do Overriding, displacement do Unknown.

Middle third femur, compound, com- do do Do.

minuted. Do Displacement, shortening do Do.

Fracture site Cases Average duration of fixation

Results

Union Delayed

union Nonunion Unknown

Tibia, fibula

Number

11

Days

68

18

81.

49.

52.

27

Unknown

52

Tibia

Femur

Humerus

Radius, ulna

Radius

Resection knee joint

Total 27 61. 39 13

Amputation was required in case, on indications not related to fracture management.
206 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Table 27.—Essential data on 25 fractures treated by external skeletal fixation, 17th General

Hospital, 1944

Comment

The results of this analysis, together with discussions with the surgeons

who had used the method, confirmed the opinion that external skeletal fixation has only limited application in the management of combat-incurred

Fracture Indication Complications Results

Union.

Do.

Union, full duty.

Union.

Do.

Nonunion ulna, delayed unionradius.

Union.

Do.

Do.

Do.

Unknown.

Union.

Do.

Do.

Unionresected knee,

nonunion tibia.

Union.

Do.

Do.

Do.

Do.

Delayedunion.

Union.

Do.

Do.

Unknown.

Maintenance length and allnement at radial carpal joint.

Vertical fracture, reduction not possible in plaster.

Do...

Radius, wrist, simple, comminuted

Radius, ulna,lower third, compound,

comminuted.

Irritation (no infection).

Do Comminution, bone loss, traction

failure.

Comminution, rotation distal

fragment, to supplement traction.

Osteomyelitis at

site of pin.

Femur, distal third, compound,

comminuted.

Do

Do

Do. Rotation distal fragment, to supplement traction.

Fixation after resection of knee

joint.

do

Fixation after resection of knee

joint.

Femur, compound, comminuted,

intoknee joint.

Femur, tibia, compound, comminuted, infected knee joint.

Femur, lower third into knee joint,

tibia and fibula, compound, com

minuted.

Femur, compound, comminuted,

tibiaand fibula into knee joint.

Femur, compound, comminuted,

into knee joint.

Infection about pin

in tibia.

Traction failure in alinement of

short distal fragment: supplemental to skeletal traction.

Traction alone failure: supplemental to traction.

Failure to control distal fragment

in traction: supplemental to

traction.

Mild irritation

about proximal

pin.

Femur, lower third, compound, comminuted.

Do Bowing fascial

slough at site of

pin.

Femur, proximal third, compound,

comminuted.

Femur, supracondylar, compound,

comminuted.

Femur, condyles, compound, comminuted.

Compound dislocation, Infection

ankle joint.

Traction failure; supplemental to

traction.

To correct rotation distal fragment: supplementalto traction.

Fixation after resection of knee

joint.

Fixation after resection of ankle

joint.

After replacement by skeletal traction.
EXTERNAL SKELETAL FIXATION 207

fractures in overseas hospitals. Under special circumstances, it was thought

to be useful adjuvant to standard methods of treatment, and, in certain

cases it might be the method of choice, but the indications were seldom

regarded as absolute.

There were number of clear-cut contraindications to the use of external

skeletal fixation in simple fractures in which it might have been the method

of choice in civilian practice. They included (1) the length of time required

to insert the pins and reduce the fracture; (2) the exacting care required to

avoid loss of reduction and to prevent the development of complications

during healing; and (3) the necessity for holding the patient in the hospital

in which the pins had been applied until they could be removed. These were

all matters of real importance in busy military hospitals.

The application of external skeletal fixation in compound battle fractures

was similarly limited although under certain circumstances it was thought

that the time and care which the method required might be compensated for

by the results that might be achieved.

The World War II experience suggests that this technique might be

applicable, in carefully selected cases, in the following situations:

1. Fractures of long bones with severe comminution and loss of substance.

Fractures of this kind have always been problem in military orthopedic

surgery. Loss of bone at wounding or the necessary removal at operation of

fragments totally devoid of soft-tissue attachments might leave partial or

complete hiatus, sometimes of or inches. In these circumstances, it was

difficult to maintain apposition of the fragments by plaster or traction, and

comminution made internal fixation impractical. External skeletal fixation

permitted stabilization of the fragments in apposition under direct observation.

There was some loss of length, it is true, but in the upper extremity this is not

matter of importance. In the lower extremity, loss of length is serious.

When it was expected to exceed an inch or an inch and half it was therefore

sometimes considered advisable, even if the fragments could have been approximated, to brace them apart until wound healing had been obtained, in

preparation for bridging bone graft at later reconstructive operation.

In this way, shortening could be minimized. External skeletal fixation sometimes served this purpose very well. It was similarly effective when loss of

substance had been extensive in an occasional fracture of single bone in the

forearm or the leg.

2. Persisting malalinements offractures. External skeletal fixation proved

useful in few subtrochanteric and supracondylar fractures of the femur in

which reduction could not be obtained by skeletal traction, presumably because

of persistent and unopposed muscle tension. An analysis of the cases included in the survey showed that this technique had been the method of choice

in number of such fractures after skeletal traction had failed. It was necessary, however, that additional immobilization be provided by skeletal traction

or by hip spica. Stability was lost in number of cases in which

this precaution was not observed.
208 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-45-770

Figure 68.—Management of compound comminuted fracture of left radius, with loss of

bone substance and median-nerve palsy, by external skeletal fixation. A. Compound

comminuted fracture of distal third of radius. Note loss of bone substance. B.

Maintenance of reduction of fracture by external skeletal fixation.

Five weeks after the fixation apparatus had been applied, the wounds were well healed;

they had been left open at the original operationand were later closed with the aid of pinch

skin grafts. The pins were removed months after wounding, after moderate drainage

had developed about them. Roentgenograms showed only scanty callus at this time, but

the fracture was in excellent alinement, and the patient had good finger motion except for

the area affected by median-nerve palsy.

In this case, external skeletal fixation preserved alinement and bone length while the

soft tissues were healing. It also allowed motion of the adjacent joints to much greater

degree than would have been possible had the extremity merely been immobilized in plaster.

3. Compound comminuted fractures of the tibia and fibula. In this type

of fracture both maintenance of reduction and wound healing were frequently

difficult when the more usual methods of management were employed. In

few cases, the fractures could be reduced under full vision and locked in position

by external skeletal fixation. reinforcing plaster cast was also used. Some

surgeons felt that this combined technique produced better results than

plaster immobilization alone.

4. Comminuted fractures of both bones of the forearm. For number of

reasons, these fractures constituted one of the most difficult problems of military surgery. In few cases, the difficulty was overcome by the use of external skeletal fixation, which produced improved apposition and alinement

of the fragments.
EXTERNAL SKELETAL FIXATION 209

FIP C-45-775

Figure 69.—Management of segmental compound comminuted fractures of proximal third

of left tibia and fibula by external skeletal traction. A. Roentgenogram of fractures.

B. External skeletal apparatus in place.

When the cast was changed month after wounding, the wound was granulating, but

the crest of the tibia was exposed. Ten days later, all bone was covered with granulating

tissue, and clinical union was apparent. The pins were removed as soon as the new cast

had hardened thoroughly. When the cast was again changed at another hospital 30 days

later, the wound was healed, and the fracture site, although notrigidly solid, felt well fixed.

In spite of the severity of the injury, length and alinement were preserved in the tibial

fracture.

5. Comminuted fractures of the lowerradius (fig. 68), in which shortening

and collapse of the fragments often introduced number of problems. External skeletal fixation was occasionally effective in maintaining length and

normal joint alinement in both simple and compound fractures with severe

comminution. reinforcing cast was neither necessary nor desirable. When

the apparatus was in place, motion of the fingers and of the thumb was possible.

The results achieved in this type of injury suggested that external skeletal

fixation was sometimes the procedure of preference.

6. Burns or other wounds which required multiple staged operative procedures and in which repeated access to the wounds was necessary. Windows

cut in casts did not always provide the exposure required, and frequent changes

of cast would have resulted in loss of position of the fracture, while the manipulations necessary to restore position would have prejudiced the healing of both

fracture and wound. External skeletal fixation provided maintenance of

reduction while delayed closure, skin grafts, and other procedures were carried

out.

7. Segmental fractures. Segmental fractures (fig. 69) with displaced

central fragments are usually difficult to reduce. The two such cases included

in this series, one fracture of the tibia and fibula and the other fracture of

the femur, were both managed successfully by external skeletal fixation.
210 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

8. Resection of the knee and ankle joints (p. 231). In an occasional case

of this kind, external skeletal fixation resulted in stable approximation of the

bone surfaces and permitted repeated access to the wound for such procedures

as were necessary to accomplish wound healing. reinforcing plaster spica

was used.

As this list of indications shows, external skeletal fixation had limited

application in the management of battle fractures, its chief use being on few

specialized indications or as supplement to other methods. In the great

majority of cases, combat-incurred fractures were much better managed by

other methods, and there was little or no need for apparatus for this method

in theater of operations.
211

CHAPTER VIII

AX ounds of Joints

HISTORICAL NOTE

Pool, who wrote the section on wounds of the joints in the history of the

United States Medical Department in World War I, stated that the evolution

of the management of these injuries by Allied medical officers fell into three

well-defined stages:

1. Debridement; drainage; irrigation with antiseptic solutions; immobilizations. 2.

Debridement; Carrel-Dakin treatment of the joint; immobilization. 3. Debridement; lavage of the joint with Dakin’s solution or ether; joint suture, with drainage of the joint for

about 24 hours; immobilization; passive movements and massage in to 10 days.

According to Pool, the poor results accomplished in joint injuries in the

early years of World War could be attributed to

an undervaluation, on the part of surgeons, of the resistance to infection which

the synovial membrane of joint offers, failure to comprehend the proper operative procedures, and the universal employment of prolonged immobilization.

Certainly realization of the importance of the three chief features that

characterized the final program; namely, debridement, complete closure of the

joint, and early motion, developed slowly. In the early years of the war,

surgeons hesitated to close wounded joint for fear of enclosing potential

septic process. Drainage tubes were therefore used freely. In November

1917, however, the Interallied Surgical Conference, when it met in its third

session, concluded that “complete closing of joint wounds is universally approved. Early in the war, repeated efforts were made to obtain chemical

sterilization of the joint cavity by the use of various antiseptic methods and

solutions, including, somewhat later, the Carrel-Dakin method. Eventually,

there as general agreement that sterilization could not be achieved by these

methods and that drainage tubes not only failed to drain the joint but also

caused considerable harm by trauma to the intra-articular structures and by

inviting secondary infection. Drainage of the compounding wound was, of

course, an entirely different matter.

The data in this chapter on wounds of the knee joint were collected by Maj. Herbert W. Harris, MC, and Capt.

Edwin L. Mollin, MC, 17th General Hospital; Maj. Howard B. Shorbe, MC, 70th General Hospital; and Lt. Col. George

A. Duncan, MC, and Maj. Benjamin W. Rawles, MC, 45th General Hospital. The data on wounds of the hip joint

were collected by Maj. Spencer A. Collom, Jr., MC, 300th General Hospital.

Pool, Eugene H.: Wounds of Joints. In The Medical Department of the United States Army in the World War.

Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 317-341. Conclusions of the Interallied Surgical Conference, 3d session. In The Medical Bulletin, War Medicine, 1917-18,

vol. I, pp. 77-78.
212 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Finally, immobilization for long periods was the rule in the early days of

the war. Willems, whose work was done chiefly at La Panne in Belgium,

provided the principal exception to this position. He contended that early,

active motion was essential in all penetrating wounds of the joint and particularly in wounds of the knee joint, regardless of whether or not infection

was present. He considered early motion, in fact, as especially essential in

infected wounds of the knee joint, his contention being that by motion purulent

exudate was “squeezed” out of the recesses of the joint, without the traumatizing effect of drainage tubes, while continued motion prevented ankylosis and

favored full functional restoration. Some of his results were brilliant. Pool

mentioned the Willems method approvingly but supplied no supporting data.

In spite of the results Willems was able to achieve, his concepts spread very

slowly, and the general opinion continued to be that early active motion was

even more impractical when suppurative arthritis was present than it was in

uncomplicated penetrating wounds of the knee joint. The theory was generally

accepted, however, that motion should be begun reasonably early, which

usually meant within 10 days of injury.

Resection of joints that were the site of suppurative arthritis following

penetrating wounds had been practiced in all recorded wars preceding World

War I, including the War of the Rebellion. In World War I, the French

used this method extensively. It was sometimes employed as primary

prophylactic procedure, to eliminate the risks of infection and subsequent

generalized sepsis and to avoid the necessity for amputation. In other instances, it was used as secondary procedure in joint wounds complicated by

suppurative arthritis. The high death rate and the high amputation rate

reported for wounds of the major joints in all previous wars and in the early

phases of World War furnished ample rationale for this practice, particularly

in severely comminuted fractures extending into the joint. The operation,

however, found little favor with either British or American surgeons in World War I, though Pool stated that it had limited application, to be determined

by individual indications, in cases of suppurative arthritis not progressing

satisfactorily under more conservative methods of management.

The civilian experience with wounds of the joints between World War

and World War II is in no sense comparable to military experiences. Neither

in number nor severity do civilian wounds compare with battle-incurred

wounds. Furthermore, the suppurative arthritis observed in civilian practice

is usually bloodborne, in contrast to the predominantly traumatic etiology

of the variety observed after battle-incurred wounds.

In peacetime practice, suppurative arthritis continued to be treated

between the wars by parapatellar drainage or, less often, by posterior drainage,

combined with immobilization of the part by splints or by plaster casts. The

Willems method of early mobilization, which some surgeons continued to

use after World War I, gradually lost favor and was eventually discarded

See footnote 2, p. 211.
WOUNDS OF JOINTS 213

entirely. Occasional surgeons practiced aspiration of the joint. Others

advocated small arthrotomy incision and lavage of the cavity followed by

complete closure. Sulfonamide therapy, which was introduced shortly before

World War II began, was thought to be beneficial.

Both Jolly and Trueta, on the basis of their separate experiences in the

Spanish Civil War, had concluded that the best method of management of

war wounds of the joints seen in forward hospitals was (1) adequate debridement and removal of foreign bodies, (2) thorough lavage of the joint cavity,

(3) suture of the synovial membrane or the capsule, and (4) immobilization of

the part either in plaster or in standard splint. There were differences of

opinion as to how long immobilization should be continued in fixed hospitals,

but there was general agreement that either passive or active motion should be

instituted after the danger of suppurative arthritis had passed and as soon as

the state of the soft-tissue wound permitted it. Joint injuries that were

essentially compound fractures of the bones entering into the articulation

were immobilized in the position least undesirable from the standpoint of

future function, it being accepted that in such cases some residual limitation

of motion was inevitable. Operation was not regarded as necessary in instances of perforating bullet wounds; in these cases it was assumed that bone

damage was minimal.

In World War II, just as in World War I, joint resection was rather

extensively practiced by French surgeons, who employed it, as in the earlier

war, to forestall amputation due to infection in severely damaged joints, as

well as in suppurative arthritis. Russian and German surgeons also employed resection of the joint, but the British seldom resorted to it.

GENERAL CONSIDERATIONS

It is surprising, in view of the extreme seriousness of wounds of the joints

in military surgery, how few directions for their management were provided

for LTiited States Army medical officers. Technical manual Guides to Therapy

for Medical Officers (TM 8-210), published 20 March 1942, merely stated

that wounds of the joints should be treated as compound fractures. The

item was even less useful than it might have been because the text was not

indexed. Orthopedic Subjects, one of the Military Surgical Manuals published by the Subcommittee on Orthopedic Surgery of the Committee on

Surgery, Division of Medical Sciences, National Research Council, contains

less than half page on the subject:

If the wound involves joint, this should be opened widely at the time of the incision

of the skin and fascia and the joint should be thoroughly explored. Loose fragments of

Jolly, D. W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941.

Trueta, J.: Treatment of War Wounds and Fractures With Special Reference to the Closed Method as Used in

the War in Spain. New York: Paul B. Hoeber, Inc.

Orthopedic Subjects. Prepared and edited by the Subcommittee on Orthopedic Surgery of the Committee on Surgery of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals, Philadelphia

London: W. B. Saundets Co., 1942.
214 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

bone and any foreign material present in the joint should be removed. Any soiled bone

exposed in the wound should be excised. The joint may or may not be irrigated with

physiologic salt solution, depending on the choice of the surgeon. In most instances it is

possible to clean the joint adequately without irrigation. The wound should then be dried,

the joint cavity should be sprinkled liberally with one of the sulfonamide drugs and the

wound should be treated as has been described in the case of fractures not involving joints.

The vaseline gauze packing should extend down to the joint cavity. In most instances the

synovial membrane can be closed with fine catgut. In wounds which are not very recent,

or which are in questionable condition, the joint should be left open. As rule, no attempt

should be made to suture the capsule or ligaments exposed in the wound and severed. The

joint should be immobilized in plaster-of-paris cast as described previously.

An accurate record of wounds of the various joints does not exist for World

War II. This is chiefly because compound fractures adjacent to and involving

the joints were so often present concurrently. When this happened, the injuries

were likely to bo recorded as fractures rather than as wounds of the joints.

Certain corrections, of course, can be read into certain statistics. Thus

compound fracture of the femoral condyles necessarily involved the structures

of the knee joint, just as compound fracture of the head of the humerus

necessarily involved the structures of the shoulder joint. These adjustments,

however, were not possible when the level of the fracture was not stated, as

it frequently was not, and in these circumstances the record of joint involvement was permanently lost.

There was never any question as to the potential seriousness of all wounds

of the joints in World War II. Any damage, no matter how slight, had to be

regarded as prejudicial, in some degree, to future function. The injuries varied

from small penetrating depressions which carried the articular cartilage into

the underlying cancellous bone to extensive compound comminuted fractures

of the bone ends making up the joint. Often the damage amounted to complete destruction of all articular structures. Even if the damage was slight,

suppurative arthritis was possibility in every wound of joint. At the best,

its development invited ankylosis. At the worst, it endangered the survival

of the extremity and sometimes the survival of the patient. Every injury

of joint had to bo managed with the possibility of these consequences in

mind.

Since the overwhelming majority of wounds of the joint were compound

fractures of the bones entering into the articulation, the management of these

wounds by United States Army surgeons in World War II, as might have been

expected, went through the same process of evolution as has been described

for the management of compound fractures. Since wounds of the knee joint

are far and away the most important of these injuries, the development of

standard policy of management chiefly concerned them and can be most

conveniently and logically described in connection with them. The management of wounds of the hip joint also introduced certain special considerations

which are briefly described in separate section.
WOUNDS OF JOINTS 215

WOUNDS OF THE KNEE JOINT

Since the knee joint and the hip joint are the major weight-bearing joints

of the body, any injury to either joint is serious. penetrating wound produced by missile usually results in intra-articular damage. The trauma is

usually sufficient to affect future function to some degree, and each wound

is potential instance of suppurative arthritis. Once suppurative arthritis is

established, the infectious process often endangers both life and limb, and

fusion of the joint is often the best that can be hoped for.

Frankau, who wrote the section on gunshot wounds of the joints in the

official British history of World War I, confirmed these generalizations. In

the first months of the war, he said, the results were “lamentable.” The

amputation rate for wounds of the knee joint not complicated by fractures

was 60 percent. It rose to at least 80 percent when concurrent fracture

was present. The case fatality rate was always high, though, as methods of

management improved, it fell to percent. The amputation rate was also

reduced; it fell from 25 percent in 1916 to percent in 1917.

In view of the results in World War I, one can understand the point of

view expressed in Buxton’s report on 273 wounds of the knee joint treated

in one fixed hospital during the second and third Libyan campaigns in World

War II; namely, that an incidence of 34.8 percent for suppurative arthritis,

an amputation rate of 4.4 percent, and death rate of 1.8 percent could well

be regarded as “excellent.” Buxton attributed these results to the small

size of the causative missiles in this series, as well as to the feasibility of early

operation and the availability of systemic sulfonamide therapy. When, however, such results as these are fairly regarded as “excellent,” it is easy to

see why wounds of the knee joint should be classified among the most serious

of all battle injuries.

The majority of wounds of the knee joint in World War II were caused

by high-explosive shell fragments, including artillery and mortar shells, grenades, mines, and boobytraps. These missiles were responsible for 222 of the

271 wounds of the knee joint observed at the 45th General Hospital in the

Mediterranean theater. Forty-two of the remaining forty-nine injuries were

caused by bullet wounds, six were noncombat injuries which had occurred in

traffic accidents, and one injury was incurred in an airplane crash.

Early Plans of Management (Before February 1944)

In the early months of United States participation in World War II,

wounds of the knee joint ere managed as the judgment and experience of the

individual medical officer dictated, rather than by theaterwide policies. In

Frankau, C. F. S.; Gunshot Wounds of the Joints. In History of the Great War Based on Official Documents.

Medical Services Surgery of the War, London: His Majesty’s Stationery Office, 1922, vol. II, pp. 297-325.

Buxton, St. J. D.: Gunshot Wounds of the Knee Joint. Lancet 1:681-684, 20 May 1944.
216 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

the best treated cases, the plan of management included prompt, thorough

debridement; through lavage of the joint cavity; the introduction of sulfonamide powder into the cavity; closure of the synovial membrane or capsule;

and immobilization, usually in long leg plaster cast. If initial surgery had

been greatly delayed or if frank infection was present when the patient was

first seen, closure of the synovial membrane was usually omitted, in an attempt

to provide drainage. If the joint was severely damaged, the wound was

usually extended and left open for drainage, but at this period in the war

extensive intra-articular debridement was not performed. Primary resection

as practiced by the French in this type of injury was not carried out, even

when the joint had been destroyed. Although this program of management

was extremely conservative, few secondary amputations seem to have been

necessary.

Even in the early days of United States participation in World War II,

the importance and desirability of complete closure of the joint were fully

established, though the practice was not extended to infected cases. Once the

joint was closed, the intra-articular cartilage was protected, the hazard of secondary intra-articular infection was obviated, and better subsequent function

could be hoped for. It was also thought, though no direct proof existed, that

closure of the joint permitted the presumptive bactericidal properties of the

synovial fluid to act more effectively.

When the casualty reached fixed hospital, the plaster was removed;

the wound was dressed and again left open for drainage; and immobilization,

usually by plaster, was reinstituted. It was not until the principles of reparative surgery had become firmly established that it became customary to suture

the wounds of the soft part at the second operation, sometime between the 5th

and 10th days after wounding, as surgical limitations permitted.

The duration of immobilization varied with the extent of bone damage.

When itwas not extensive, passive and active motion was instituted as promptly

as it was thought to be safe in the special case. The Willems principle of

immediate motion was almost never used. The feeling was that the advantages of few days of additional immobilization and rest for the part

would expedite wound healing and that the advantages of prompt wound

healing would outweigh any advantages likely to be derived from early forced

active motion.

Complications were infrequent when damage to the joint was minimal

or even moderate, especially in joints without cartilaginous or bony damage.

Even in these favorable cases, however, it \cas noted at the general hospitals

that, when closure of the synovial membrane had been omitted, healing was

frequently slow and there was more impairment of joint function than might

have been predicted from the degree of initial damage. In other cases of

minimal or moderate damage, prolonged infection, with slow destruction of

the joint, sometimes occurred. In such cases, though the joint was doomed,

open drainage usually prevented the development of toxemia and systemic

sepsis. Precise figures are not available, but it was recognized that cases of
WOUNDS OF JOINTS 217

this sort were not infrequent, both in overseas hospitals and in hospitals in the United States.

On the whole, joints operated upon early and thoroughly, with closure

of the synovial membrane and institution of immobilization, were usually

free from infection (fig. 70). The term “early,” however, was relative. The

timelag from w'ounding to initial surgery usually exceeded 12 hours. In one

typical series of 384 wounds of the knee joint, it averaged 16.5 hours. When

operation was done so long after wounding, forward-area surgeons in the early

months of the war, fearful of the consequences of infection in closed joint,

frequently assumed that infection might already be present and therefore

left the joint open for drainage. Observations at the hospitals in the rear

showed that patients who were treated in this way sometimes did well but

that in many cases infection as prolonged and the joint as completely

destroyed. These could not be regarded as satisfactory results, even though

few amputations were necessary and loss of life as negligible.

Idie Formative Stages in Development of Standard Concepts of

Management (March-April 1944)

In the early spring of 1944, there was sharp rise in the incidence of suppurative arthritis following wounds of the knee joint treated in several

of the general hospitals in the Naples area. It was possible to trace the cause,

at least in part, to wave of surgical conservatism among forward-area surgeons at the Anzio beachhead. Part of this conservatism was apparently

deliberate. Part of it was to be explained by the extremely difficult combat

conditions under which forward surgeons were then working. Whatever the

explanation, the results were the same. In many instances, surgical exposure

of the joint was inadequate, intra-articular debridement was incomplete, and

infection in the joint was the consequence.

The increased incidence of suppurative arthritis in the group of casualties

just described focused particular attention upon wounds of the knee joint and

their possible complications. Shortly afterward, as part of the early formative

stages of the program for the adjuvant use of penicillin in the management

of battle wounds, number of wounds of the knee joint with potential infection or early established infection were studied in several general hospitals

in the Naples area. All the wounds had been sustained from few days to

few weeks earlier. Observations made on these 35 cases brought out the

following facts: 1. No infection had occurred in cases which had been treated by complete

initial surgery, closure of the synovial membrane or capsule, and adequate

immobilization.

2. Suppurative arthritis of varying degrees of severity, with prolonged

drainage and slow destruction of the articular surfaces, as observed in several

cases in which intra-articular damage at wounding had been only minimal

to moderate but in which excisional surgery had been inadequate and in which
218 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-45-872

Figure 70.—Staged management of wound of left knee joint. and B. Anteroposterior

and lateral roentgenograms made in evacuation hospital before initial surgery, showing

damage to lateral condyle of tibia. At initial surgery, the knee joint was opened

medially and laterally and thorough debridement was performed. The synovial

membrane and capsule were closed, penicillin solution was instilled into the joint, and

immobilization was provided by single hip spica. and D. Anteroposterior and

lateral roentgenograms made in fixed hospital days later. The hip spica used as

transportation splinting is still in place. Aspiration of the joint at this time showed no

evidence of infection. The soft-part wounds were therefore sutured, and immobilization was continued. E. Appearance of healed wounds weeks after reparative surgery.

Because the wounds healed promptly, active and passive motion could be instituted

promptly. F. Range of flexion and extension (90°) weeks after wounding. The

application of the principles of staged surgical management to this injury prevented

wound infection and produced highly satisfactory functional result.
WOUNDS OF JOINTS 219

the joints had been left open for drainage. The reaction closely resembled that

observed in joints destroyed by the missile.

3. Compound comminuted injuries of the patella were particularly likely to be followed by infection.

4. In each of 15 cases complicated by infection of varying degrees of severity, unexcised, devitalized, traumatized intra-articular cartilage was

present.

Nineteen patients with wounds of the knee joint (all then available)

were managed by an aggressive regimen of surgery, blood transfusions, and

penicillin at the 21st, 23d, and 45th General Hospitals in the medical center at Naples and at the 17th General Hospital several miles away, as follows:

1. Blood transfusions were given in amounts sufficient to maintain the

hematocrit level at 40 or over.

2. Penicillin was given intramuscularly in doses of 25,000 to 50,000 units

every hours. Systemic administration was supplemented by local instillations into the knee joint in amounts of 5,000 units per cubic centimeter of

physiologic salt solution. Systemic administration was always continued until

all danger of continuing infection was past and, as rule, until the wounds

were healed.

3. Surgically, these 19 cases were managed as follows:

In eight cases, in which there was roentgenologic evidence of intra-articular

trauma, the knee joint was explored. There was no definite evidence of infection in any of these cases, but exposure at initial wound surgery had not been

complete and exploration was undertaken to be certain that debridement had

been adequate. In four cases, it had been. In the other four cases, potential

foci of infection, in the form of devitalized areas of articular cartilage, were

excised (fig. 71). The joint cavity was then thoroughly irrigated, the joint

was closed, and penicillin was instilled into the cavity. Suppurative arthritis

did not ensue in any of these eight cases, and in each case joint function was

no more greatly affected than it had already been by the trauma of the

original wound.

In six wounds, in which definite, established suppurative arthritis was

present but in which joint destruction had not yet occurred, the knee joint

was widely exposed. The joint was cleansed ol all devitalized tissue, debris,

and foreign material, after which blood clot and purulent exudate were removed

by thorough irrigation. The synovial membrane w*as sutured, and, finally,

penicillin was instilled into the joint cavity. For the next week, at intervals

of 24 to 48 hours, aspiration, irrigation, and reinstillation of penicillin were

carried out. Attempts at aspiration were usually fruitless because remarkably

little fluid accumulated between treatments. Infection was controlled in all

six cases, and, again, the ultimate function of the joint was limited only by

the damage caused by the missile at the time of wounding (figs, 72, 73, and 74).
220 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-265, CA-44-322

Figure 71. {See opposite page for legends.)
WOUNDS OF JOINTS

In two cases, in which subacute infectious processes had been present for

several weeks, the knee joint was reopened. comminuted fracture of the

patella was present in one of these cases. In the other, purulent exudate was

dripping into the joint cavity from an infected fracture of the lower third of the

femur. In both cases, necrosis of the articular cartilage had been caused by

the infection and was not the direct consequence of wounding. All necrotic

areas were curetted, and the edges of the cartilage left in situ were trimmed

free of loose tags. The menisci, which were devitalized and friable, were also

removed. The patella was resected in the first of the cases. After the cavity

had been thoroughly irrigated, the synovial membrane was closed, and the

aspiration-instillation regimen just described was instituted, beginning with the

instillation of penicillin solution on the operating table. Results in both

these cases were good. Infection was promptly controlled, and satisfactory

healing followed delayed wound closure. The desirable program of postoperative mobilization was hampered in both cases by the complicating femoral

fractures, but each of these patients had 10° to 20° of motion when he was

transferred to the Zone of Interior, as well as at later examination.

In the three remaining cases, infection which endangered the limb was

eradicated by resection of the knee joint (figs. 75, 76, and 77). In one of these

cases, which was associated with contralateral amputation in the upper third

of the thigh, sepsis was severe enough to endanger the patient’s life. It had

resulted from infection of compound fracture of the medial tibial condyle,

in which the line of fracture extended into the joint. The injury had looked

relatively innocent but was poorty debrided. All three cases were treated by

excision of the infected, necrotic bone and cartilage; resection of the joint;

and staged procedures directed at wound healing. The infection was controlled, the wounds healed satisfactorily, and bony fusion was progressing when

the patients were evacuated from the theater.

4. The joint was immobilized after operation by single plaster spica

or Tobruk splint. Movement was permitted when healing was progressing

satisfactorily and it was thought that all danger of flareup of infection was past.

Figure 71. —Staged management of penetrating wound of right knee joint associated with

comminuted fracture of lower third of femur. A. Wounds of knee and lower third of

thigh observed in operating room just before reparative surgery. The small size of the

wound of the knee joint makes it clear that intra-articular surgery has not been adequate.

B. Extensively damaged medial condyle of femur seen on adequate exposure of joint.

All devitalized articular cartilage was removed through this wide arthrotomy incision.

The incision was extended proximally, and the comminuted fracture of the femur was

fixed with multiple screws. C. Steps of reparative surgery. The aggressive surgical

attack on this injury, which had been inadequately treated at initial wound surgery,

undoubtedly forestalled suppurative arthritis and was followed by prompt wound

healing. The femur united firmly and in perfect condition.

396961°—57 16
222 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-292

Figure 72.—Management of early established suppurative arthritis superimposed on

multiple penetrating wounds of left knee. For reasons which are not clear, possibly

because of the multiplicity of the penetrating wounds, this knee joint was not explored

and debrided at initial surgery. A. Anteroposterior and lateral roentgenograms made

in fixed hospital 10 days after wounding. B. Appearance of knee on same date. Note

the bulging of the knee and the multiple wounds, from all of which pus oozed. C.

Medial arthrotomy incision through which several areas of damaged articular cartilage

were excised, together with several metallic foreign bodies embedded in the condyles

of the femur and the partially devitalized medial meniscus. Areas of devitalized articular cartilage and the friable lateral meniscus were removed through lateral arthrotomy incision. After thorough irrigation of pus and exudate, the synovial membrane

was sutured in each incision, and the joint was filled with penicillin. hip spica was

applied for immobilization. The synovial fluid was aspirated, and the joint was irrigated and filled with penicillin daily during the next days, through window in the

cast. Systemic and local signs of infection rapidly subsided. Skin closure of each

wound was carried out 12 days after the arthrotomy incisions were made. All signs

of infection disappeared, and the wounds healed promptly. When the patient was

evacuated to the Zone of Interior 5}4 weeks after wounding, the range of motion was

30° from full extension. He was furnished with removable splint for use at night, to

maintain full extension of the leg at the knee as precaution against flexion contracture.
WOUNDS OF JOINTS 223

Standard Plans of Management (After May 1944)

In the first months of the Mediterranean theater, as already noted, there

was no theaterwide policy for wounds of the knee joint; each surgeon managed

them in the light of his individual experience and training. As might have been

expected, however, the differences between methods were more in details than in the basic pattern, which was generally as has just been described. The

results accomplished during this early period seemed susceptible of improvement,

particularly in the cases in which infection was present. That results could

be improved was evident in the 19 injuries of the knee joint in which penicillin

was tested in the Mediterranean theater and which were observed at about the

time the reparative-surgery program for wounds of the soft tissues was becoming theaterwide. It was natural that this plan should be extended to wounds

of the knee joint and that it should eventually become the standard plan of

management for all wounds in this area, whether penetrating or perforating and

whether or not they were complicated by infection. At the end of World War

II, the surgical management of wounds of the knee joint had for all practical

purposes come back to the concept enunciated by Pool in World War I; 10

that is, thorough debridement and immediate closure of the joint wound. The

contribution of World War II was the extension of this program to the infected

knee joint.

Initial wound surgery.—Wounds of the knee joint, which were priority-two

injuries, were treated at initial wound surgery by the same regimen as all other

wounds, with such modifications as the location and character of the injury

required. It was essential, for instance, to perform the operation on an operating

table which could be broken at the knee; satisfactory exposure was otherwise

difficult. Circumferential draping was used. tourniquet was often applied

to secure dry surgical field.

The incision and its extent were determined by the necessities of the special

case. separate arthrotomy incision was frequently better than approach

through the battle wound. It was essential that the excisional procedure should

include the removal of all foreign bodies, including loose bone chips; damaged

menisci, and loose, fragmented and devitalized cartilage. Defects in the condyles were trimmed evenly. It was usually the wisest plan to excise comminuted patella.

After thorough irrigation of the joint cavity, the synovial membrane, with

the capsule, if possible, was sutured, and penicillin solution was instilled into

the cavity. When loss of soft tissue precluded suture of the membrane or

capsule, flaps of fascia or skin were rotated to secure the desired coverage.

The joint was left open only when the extent of the damage made return of any

joint function obviously impossible. In cases of this kind, it was always best

to excise the remaining cartilage, which, since it was poorly nourished, avascular,

10 See footnote 2, p. 211.
224 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fd-448

Figure 73.—Management of early established suppurative arthritis following wound of knee joint and comminuted fracture of patella. Ten hours after injury, wound as opened and

foreign body removed; joint was irrigated, capsule closed, penicillin instilled into joint and

given systemically; immobilization by long leg cast. Initial debridement had been incom- plete. Signs and symptoms of suppuration developed and persisted after patient was

admitted to fixed hospital eek later, in spite of continuation of penicillin. A. Swollen

joint, granulatingwound, and draining pus, 15 days after wounding. B. Medial arthrotomy

incision, with inflamed synovial membrane and partially necrotic cartilage of comminuted patella visualized. Bit of cloth showm on gauze sponge as removed from joint, together wdth coagulated fibrinous exudate in quadriceps pouch. Severely comminuted fragments

(Continued on opposite page.)
WOUNDS OF JOINTS 225

AFIP Fd-448

of patella were excised. C. Fragments of patella, some fibrinous exudate, and bit of cloth removed from joint. D. Instillation of penicillin into joint, through arthrotomy incision,

after closure of synovial membrane and capsule. Old wound, which had broken open as

result of infection, was excised; capsule closed. E. Wounds, after suture, through

window in cast, days later. F. Degree of active extension and flexion of leg at knee

weeks later. Quadriceps power is sufficient to extend knee. Hand supports foot for

photograph. Wounds healed promptly.
226 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP A-44-523, C-44-454, 92494, 92493

Figure 74.-—Management of suppurative arthritis superimposed on moderately severe

high-explosive shell fragment wound of left knee. At initial surgery hours later, the

knee joint was opened, and foreign body embedded in the articular surface of the

medial femoral condyle was removed. The joint capsule was sutured after irrigation

of the cavity, and penicillin was instilled. In the fixed hospital days later, local and

systemic signs of suppurative arthritis were observed. The joint was aspirated and

irrigated on two occasions, and penicillin solution was instilled into it. Four days

later the temperature was 101° F.; the knee was swollen, boggy, and tender, and

seropurulent discharge exuded; maggots were crawling in the wound. A. Exposure of joint through proximal extension of old wound. Note intense hyperemia of

synovial membrane and edge of damaged articular cartilage. Maggots were present in

the joint cavity, which was thoroughly cleansed by irrigation. piece of woolen

cloth was removed, together with the devitalized area of articular cartilage, about an

inch in diameter, which lay beneath it and which had been depressed into the condylar

defect. The defect was trimmed evenly. The medial meniscus, although dull in

(Continued on opposite page.)
WOUNDS OF JOINTS 227

and traumatized, was potential focus of infection. The remaining joint

injury was then really only compound fracture.

The same principles of exposure and debridement were employed in indirect

injuries of the joint produced by fractures extending into the joint, to insure

that no debris, loose fragments of bone, or blood clots were left in the cavity.

Immobilization was accomplished by single hip spica or Tobruk splint,

with the knee in 10° to 15° flexion. Systemic penicillin therapy and the aspiration-instillation regimen of joint management were instituted and were continued as long as indications existed. Postoperative instillation was carried

out with large needle, through window in the cast.

Reparative wound surgery.—Reparative surgery was undertaken at the

general hospital to days after wounding. At this time, the cavity was

again aspirated and irrigated, and penicillin was reinstilled, but the joint was not

reopened unless there was reasonable doubt concerning the adequacy of initial

wound surgery. If there was doubt, exploration was undertaken, as precaution

against the development of suppurative arthritis, and such additional excisional

surgery as proved necessary was performed (fig. 71). The joint was well irrigated before it was closed, and skin closure was effected by the usual technique.

If for any reason reparative surgery could not be performed promptly

after the patient’s arrival at the general hospital, the aspiration-instillation

routine was carried out until operation could be performed.

Immobilization was continued for 10 to 14 days after delayed primary

suture. Then active mobilization of the joint was instituted, usually with the

patient in balanced suspension in an Army half-ring leg splint, with Pierson

attachment. Motion was progressivly increased from the position of full

extension, to avoid flexion contracture.

Figure 74. (Legend continued from opposite page.)

appearance, was not friable and was left in situ. The synovial membrane and capsule

were closed, and the joint was filled with penicillin. Immobilization was accomplished

by Tobruk splint. B. Appearance of region of joint weeks later. The operative

wound is healed, but there is an unhealed area of partial loss of skin overthe patella. This

loss occurred at wounding. For days after operation, synovial fluid had been aspirated through window in the cast, the joint cavity irrigated, and penicillin instilled.

Wound closure was possible days after operation, by which time all signs of infection

had subsided. It was necessary, however, to leave small gap in the center unclosed,

to avoid excessive tension on the skin margins of the lateral surgical incision. Immobilization was discontinued weeks later; meantime, quadriceps exercises had been instituted. Six weeks after the operation for suppurative arthritis, the patient was

evacuated to the Zone of Interior W'ith removable splinting for use at night as precaution against flexion contracture. At this time the range of active motion was only

10° to 15°. C. Anteroposterior roentgenogram made year after wounding, showing

extent of damage to medial condyle of femur. D. Range of active motion in knee

year later. Complete extension is possible but is not shown in this photograph.
228 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-298

Figure 75. (See opposite page for legends.)
WOUNDS OF JOINTS 229

Figure 75.-—Management of suppurative arthritis of right knee joint, superimposed on

damage resulting from severe perforating wounds. Injury included compound comminuted

supracondylar and condylar fractures of femur and patella, with laceration of patellar tendon.

Resection of joint. At initial surgery, it was recognized that the joint had been partially

destroyed, and the comminuted patella was excised. In an endeavor to stabilize the condylar fragments as much as possible, Steinmann pin was passed through them and brought

out through the medial and lateral wounds, though the use of skeletal fixation in forward

areas was not recommended policy. When the patient was received at the general hospital on the 11th day after wounding, the joint and fracture site were bathed in purulent

exudate. Efforts to control the suppurativeprocess were not successful. A. Anteroposterior

and lateral roentgenograms made just before reparative surgery. B. Appearance of knee

just before reparative surgery, weeks after wounding. C. Exposure of joint. The

degree of destruction is such that restoration of function is obviously impossible. The

Steinmann pin was removed, and the fracture site in the lower end of the femur was reduced

and fixed by screws. The almost totally destroyed condyles of the femur and the proximal

end of the tibia were then excised. An external skeletal-fixation apparatus was applied to

the extremity to maintain apposition of the femur and tibia. The operative wound was

partly closed, so as to cover all exposed bone, and rubber-tissue drains to the dead space

were inserted. single hip spica was applied, incorporating the external skeletal-fixation

apparatus. D. Articular surfaces of resected femur and tibia. Note destruction of articular cartilage. E. Anteroposterior and oblique roentgenograms of resected knee joint in

plaster cast. Note wire suture used to help maintain apposition of fragments. Nine days

after resection, the wounds were clean, but the edges were not suitable for suture. The

wound margins were trimmed back to healthy tissue, and old granulation tissue was excised.

Five days later, at third operative procedure, small protruding portion of the external

condyle was chiseled away, and the wounds were closed. Wound healing was obtained

except for persistent small sinus to the region of the internally fixed fracture. This man

was evacuated to the Zone of Interior weeks after operative resection of the infected knee

joint. When he was observed several months later by the consultant in orthopedic surgery

for the Mediterranean theater, the fracture had united, and the knee joint was fused. The

wounds were well healed except for the small sinus just mentioned. When the fixation screws

and sequestrum to which the sinus led were removed, prompt healing occurred. In this

case, knee joint hopelessly destroyed by the initial injury and superimposed suppurative

arthritis was managed by early resection, and the optimal result which could be expected

for such an injury was achieved within minimum period of time. Internal fixation of the

fracture of the distal end of the femur was an essential part of the surgery; for technical

reasons, stabilization of the fracture was necessary before resection could be performed.

External skeletal fixation, while useful in maintaining stability during the staged surgical

procedure, was insufficient in itself for adequate immobilization, so after each operation the

apparatus was incorporated in single hip spica.
230 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

IT. S. Army photos

Figure 76.—Management of severe suppurative arthritis superimposed on moderately severe

damage to articular cartilage of left knee joint. Compound comminuted fracture of

middle third of right femur. Resection of left knee joint. At initial surgery, high-explosive shell fragments were removed from the joint, which was irrigated and closed.

Penicillin solution was instilled, and penicillin was given systemically. hip spica was

used for immobilization. At the fixed hospital, the right femur as placed in skeletal

traction after the compounding wounds were closed. Aspirations, irrigations, and reinstillations of penicillin, the correct routine for the management of such wounds in

fixed hospital, were not instituted, and an infectious process developed and continued

until the patient was extremely ill and the knee joint was grossly infected. A. Anteroposterior and lateral roentgenograms before initial surgery. Size and location of foreign

bodies indicate considerable trauma to the articular cartilage. B. Anteroposterior and

lateral roentgenograms months after wounding, showing ravages of infectious process

in joint. After proper preoperative preparation, the knee joint was resected. The

resected surfaces were stabilized in reduction by the use of external skeletal-fixation

apparatus, over which single hip spica was applied. All wounds were left open for

drainage but were closed weeks later. C. Anteroposterior and lateral roentgenograms

ofresected knee joint, showing incompletebony fusion about months later. The bone

destruction by the infectious process in this instance amounted to inches and can be

attributed not only to incomplete initial surgery but to failure to institute the proper

regimen promptly in the fixed hospital when infection became evident. Re-arthrotomy

should have been done at once. D. Healed wound several months later in the Zone of

Interior.
WOUNDS OF JOINTS 231

Management of infected knee joints.—The signs and symptoms of im- pending or established infection within the joint were chiefly pain, swelling,

fever, and malaise. In the occasional case, if the manifestations were slight and if it appeared that initial wound surgery had been adequate, the aspirationinstillation routine with penicillin solution was carried out for day or two,

in the hope of aborting the infection. If the attempt was unsuccessful, no

further time was lost. The joint was opened widely, was thoroughly cleansed of dead tissue and blood clot, was completely closed, and was filled with

penicillin before it was immobilized (figs. 72, 73, and 74). Only when hope of functioning joint had been entirely abandoned was the arthrotomy wound left open for drainage. The edges of the skin wound were freshened at this

time, but closure was delayed until or days later. The usual postoperative

regimen, including instillations of penicillin solution, was instituted.

Resection of the knee joint.—Resection (figs. 75, 76, and 77) was limited

to joints hopelessly destroyed either by the initial trauma or by infection.

If it was performed on the indication of joint destruction, it was preferably

carried out at the evacuation hospital, with the objective of preventing chronic

infection and promoting wound healing. Resection for infection was occasionally necessary in forward hospital, but the necessity for it on this

indication more often became evident in fixed hospitals. The amount of bone

excised at operation and the resultant shortening of the limb were predetermined by the extent of bone loss and the degree of destruction inherent in

the trauma or the infectious process. Because of the shortening which resulted

from the operation, the resected surfaces were designed to conform in extension

rather than in slight flexion.

Results of the Reparative-Surgery Program

The reparative-surgery program for wounds of the knee joint had its

first theaterwide application in May 1944, with the beginning of the CassinoRome campaign. Its results were immediately apparent. The incidence of

wound infection in wounds of the knee joint dropped sharply. If infection

was already present when patients were received in general hospitals, appropriate surgery and intensive postoperative care almost always controlled

the process. functioning joint, limited only by the damage done at wounding, was the usual result. Chronic infection seldom occurred except in joints

hopelessly destroyed by trauma. For all practical purposes, the chief problem

of wounds of the knee joint had been solved. The surveys described below

furnished data to substantiate these conclusions.

Disposition-board proceedings.—An examination of disposition-board

proceedings for 1944, on file in the Office of the Surgeon, Mediterranean

Theater of Operations, showed that in none of the 1,073 amputations performed

for all causes had the operation been required for infection or sepsis following

properly managed wound of the knee joint (fig. 71).
232 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-236

Figure 77.—Management of long-standing suppurative arthritis of right knee joint superimposed on penetrating wound which damaged proximal end of tibia. Radical resection

of joint. The left lower extremity had been amputated traumatically in the middle

third of the thigh by the same shell explosion that caused the injury to the right knee.

Forty hours after injury, the traumatic amputation was completed by the open circular

method and other wounds were debrided, but little was done to the penetrating wound

compounding the injury of the knee joint. After the patient was admitted to the fixed

hospital 14 days later, signs and symptoms of sepsis were constant, there being no

response to bilateral parapatellar incisions, penicillin therapy, blood transfusions, and

immobilization. Pus extended up the fascial planes of the thigh, and incision and

drainage were necessary. A. Anteroposterior and lateral roentgenograms 10 weeks

after injury, showing complete destruction of right knee joint. At this time, the patient

was quite toxic, temperature elevations to 102° and 103° F. occurred daily, and amputation was seriously considered as lifesaving measure. B. Interior of knee joint after

exposure at operation 76 days after wounding through longitudinal incision extended

proximally to drain another abscess in the thigh. The patella, which has been excised, is

held beside the destroyed femoral condyle for demonstration purposes. All articular

surfaces in the joint were found totally destroyed by the septic process. The healthy

ends of the femur and tibia left after excision ere held in approximation by suture of

stainless-steel wire placed anteriorly. Old wound edges were excised, but closure was

not done. hip spica provided postoperative immobilization. C. Resected joint.

Shortening was of no consequence in this case because the opposite leg was already

amputated. D. Dead, infected bone and cartilage excised from joint.
WOUNDS OF JOINTS 233

AFIP C-44-236

Figure 77. (See opposite page for legends.)
234 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP C-44-259. C-44-329

Figure 77—Continued. E. Partial closure of medial wound, with drainage, days after first

operation, after evident control of septic process. F. Closure of lateral wound at same

operation. Drainage of abscess of calf. The depths of each wound were thoroughly

irrigated before suture. and H. Healed medial and lateral wounds weeks later. Healing

was entirely satisfactory, except for occasional small granulating areas. There were no

sinus tracks. Local and systemic sepsis had been eliminated, and the patient was

rapidly gaining weight and strength. new hip spica was applied for transfer of the

patient to the Zone of Interior.
WOUNDS OF JOINTS 235

In 271 wounds of the knee joint studied from the same disposition-board

proceedings, the cases were divided into those treated before the final drive for Cassino and Rome, which began 11 May 1944, and those treated after

that date.

In the 73 cases which made up the earlier group and which were treated

by the original techniques, the incidence of infection in general hospitals was

27.4 percent. In the 198 cases treated after the reparative program had

become effective, the incidence of infection was 5.4 percent.

In the earlier group, the infectious process continued in 8.2 percent of

the cases until the joint had been completely destroyed, while in another 8.2 percent of the infected cases the end result was not known. There were

only instances (2 percent) of complete joint destruction in the later series,

and in of these the recommended regimen for the management of early

infection had not been instituted. In the remaining case, damage at wounding

had been so severe that resection of the knee joint was necessary.

General hospitals.—Reports from individual hospitals showed that when initial wound surgery had been adequate, results in wounds of the knee joint

were greatly improved.

At the 17th General Hospital, 194 wounds of the knee joint were analyzed,

in 128 of which initial surgery had been adequate and in 6G of which it had

not been.

In 119 of the 128 cases in which initial surgery had been adequate, there

was no evidence of infection when the patients were received in the fixed

hospital, and closure of the wounds of the soft parts could be proceeded with

at once.

In of the other cases, in all of which infection was present, the process

was controlled without surgery by the aspiration-instillation routine with

penicillin solution. In two cases, secondary arthrotomy was performed, with

excision of intra-articular devitalized tissue, and in another case incision and

drainage controlled the infection. In these seven cases, functioning knee

joint was obtained. In the two remaining cases, bone damage had been

extreme. Resection of the knee joint was necessary in one case and amputation of the limb in the other, primarily because of trauma.

In the 66 cases at the 17th General Hospital in which initial wound surgery had apparently not been complete, 16 joints were found to be infected

when the wounds were exposed. In eight cases, infection was controlled

satisfactorily by arthrotomy and secondary debridement. In another case, in

which bone damage was severe, prolonged drainage was instituted through the

open wound, without expectation that satisfactory function would ultimately

be obtained. In the other seven cases, in all of which bone damage was

extreme, resection of the joint was necessary in five cases and amputation in

the other two. The results in the five resections were as satisfactory as this

procedure permits.
236 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The 70th General Hospital received 45 patients with wounds of the knee

joint after the Po Valley campaign, at the end of the fighting in Italy. Reparative surgery was rendered on an average of 7.7 days after wounding. In

eight of these cases, arthrotomy was performed for exploratory purposes and

to complete intra-articular debridement, on the indication of impending infection. Recovery was uneventful in all. In the only two cases in the whole

group in which infection became established, the process spread from infected

fractures adjacent to the joint, supracondylar fracture of the femur in one

instance and fracture of the upper tibia in the other.

Resection of the knee joint.—It is known that 31 resections of the knee joint (figs. 75, 76, and 77) were performed in the Mediterranean Theater of

Operations by United States Army surgeons; 24 of the operations were on

United States Army personnel.

Two of these operations were performed at initial wound surgery on the

indication of extensive trauma.

In six operations, all on French colonial soldiers and all at the 9th Evacuation Hospital, which was then serving as fixed hospital, initial wound

surgery had not been adequate, and severe suppurative arthritis had followed

relatively minor injuries caused by penetrating wounds. In each of these

cases, it was thought that the infection present seriously endangered the

vitality of the limb.

In otherresections, the indication was also severe suppurative arthritis,

superimposed in case on minimal intra-articu)ar damage and in cases on

moderate damage.

In the remaining 20 cases, the indication for resection was traumatic

destruction of the joint, with impending or early established infection.

The results in these 31 cases were satisfactory within the limitations of

resection of the knee joint. There were no deaths. Rapid improvement

invariably followed the operation. Most of the patients were evacuated to

the United States with well-healed wounds, and nine are known to have had

clinically stable limbs before they left the theater. In every case, it had been

possible, without special difficulty, to achieve apposition of the bony structures in the position of function. The shortening of the limb, which varied

from to inches and which averaged inches, was dictated by the bone

loss from trauma or infection.

In followup survey of various procedures conducted in the Zone of

Interior early in 1945, it was possible either to examine or to secure accurate

information about eight patients who had been subjected to resection of the

knee joint overseas. In seven cases, the indication for the resection was

traumatic destruction of the joint, followed by infection. In the eighth case,

the original damage was moderate, but the joint had been destroyed by

infection.

In this case, as well as in six others, the wounds were healed. In the

remaining case, there was sinus to condylar fracture just above the joint.
WOUNDS OF JOINTS 237

Fusion was satisfactory in six cases, including the case in which the joint

had been destroyed by infection; one of these patients was at convalescent

hospital and ready for Certificate of Disability discharge. In another case, fusion seemed to be occurring, but only months had elapsed since operation. In the remaining case, in which there was no evidence of fusion, it was thought

that bone grafting would be required.

The results in this small group of cases further confirmed the impression

thatresection of the knee joint has definite, but fortunately limited, application in the management of severely traumatized and infected wounds of the

knee joint encountered in military surgery.

WOUNDS OF THE TU JOINT

Wounds of the hip joint (figs. 78, 79, and 80) presented even more difficult problems in military surgery than wounds of the knee joint. Because

they affected one of the two major weight-bearing joints of the body, they

were always serious, even when the injury was not extensive. The immediate case fatality rate was high, probably not because of the injury to the hip

joint but because of associated injuries to overlying and adjacent major blood

vessels. Later deaths were the result of associated intra-abdominal wounds,

particularly wounds of the rectum or the urinary bladder. Such combinations

of injuries were frequent, and their management taxed the ingenuity of forward- and rear-area surgeons alike.

The management of wounds of the hip joint produced the least satisfactory results obtained in skeletal injuries in World War II. For this, there

were number of reasons: (1) The damage at wounding was often sufficient to

destroy the joint and in itself was often enough to cause ankylosis. (2) Infection was frequent. If the articulating surfaces of the femur and acetabulum

had been damaged, as they had been in many cases, drainage was likely to be

prolonged, and there was often evidence of systemic absorption and toxemia.

(3) The high incidence of suppurative arthritis observed in general hospitals

in cases in which trauma had been slight or moderate suggested that initial

wound surgery had frequently not been adequate. In some of these cases,

the joint was completely destroyed by the infectious process. (4) The principles of excisional surgery were the same for the hip joint as for all other joints,

and their application to wounds in this area was equally necessary.

On the other hand, the hip joint is not readily accessible, and adequate

debridement required wide exposure and precise anatomic orientation. Initial wound surgery, in short, was procedure of magnitude, with which the

average forward surgeon had usually had limited experience if he had had

any at all. The availability of consultant in orthopedic surgery to the

army surgeon (p. 5) might have contributed to the improvement of initial

wound surgery in compound fractures of the hip joint and to consequent

improvement in the end results of these complicated injuries.

396961°—57 17
238 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

U. S. Army photos

Figure 78.—Management of suppurative arthritis superimposed on high-explosive shell

fragment injury of hip joint. Initial surgery in this patient was inadequate; the hip

joint was not opened, and the foreign body was not removed. Suppurative arthritis

ensued, not controlled by removal of the foreign body 10 days later, without thorough

intra-articular debridement. A. Anteroposterior roentgenogram of pelvis and hip

joint in evacuation hospital showing high-explosive shell fragment lying in articular

cartilage of head of femur. B. Anteroposterior roentgenogram of pelvis and hip joint

weeks later, showing hip joint totally destroyed from infection.

Survey of Cases, January 1945

The results achieved in the treatment of wounds of the hip joint in the

Mediterranean theater were recognized as so unsatisfactory that, in January

1945, survey was undertaken, on orders of the theater surgeon and at the

request of the consultant in orthopedic surgery, to collect precise data concerning them. At this time, 15 casualties with injuries of the hip joint were hospitalized in the general hospitals of the Naples base area, the ratio being to

250 patients then hospitalized for all battle-incurred injuries. In addition,

search revealed 24 previous admissions for this cause in which the hospital

records contained data sufficiently detailed for analysis. The material for the

survey thus consisted of 39 cases.

No case was accepted for this analysis unless there was roentgenologic

evidence of trauma to bone or cartilage, on the reasonable assumption that

missile which penetrated the hip joint would inevitably produce some skeletal

damage. joint was classified as infected (1) if there was roentgenologic evi-
WOUNDS OF JOINTS 239

AFIP C-44-358

Figure 79.—Management of suppurative arthritis superimposed on high-explosive pene- trating wound of left buttock, hip joint, and neck of femur. Life-endangering thoracic

injury permitted only minimal debridement of wound of buttock in initial surgery. Ar- throtomy of hip joint was omitted. Suppurative arthritis could not be controlled, even

after removal of intra-articular foreign body week after wounding. No effort was made

at this time to cleanse joint of debris or to insure good posterior drainage. A. Anteropos- terior roentgenogram showing foreign body overlying neck of femur. lateral view demonstrated that missile had perforated femoral neck and come to rest anteriorly. B. Antero- posterior view of left hip joint, showing total destruction by infection weeks after wounding.

Patient was transported to ZI in hip spica before infection was controlled.
240 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP FB-447, Fd-45-19

Figure 80.—Management of suppurative arthritis of right hip joint, following damage to

neck and head of femur by high-velocity missile. A. Anteroposterior roentgenogram

of pelvis and hips made in evacuation hospital, showing fracture of neck of femur and

retained foreign body. At initial wound surgery, the wound of entry was debrided,

after which the joint was explored and the bullet and some loose bone fragments were

removed. hip spica was applied as transportation splinting. In the fixed hospital,

the extremity was placed in balanced-suspension skeletal traction. Infection was

persistent, and wound healing was not obtained. B. Anteroposterior roentgenogram

made in fixed hospital weeks after wounding, showing dead femoral head and destruction of hip joint by infectious process. Soon after this film was made, the joint

was opened through posterior approach, and all dead bone was removed. The joint

cavity was thoroughly irrigated, and the operative wound was sutured. drain was

inserted down to the old hip-joint cavity. Immobilization was obtained by hip spica

which extended to the knee on the opposite side. C. Dead head of the femur, which

was removed along with other fragments of bone and cartilage. D. Healed wound,

weeks after surgery on infected hip joint. The drain was removed days after this

operation, and healing occurred promptly. All signs of systemic toxemia also disappeared promptly.
WOUNDS OF JOINTS 241

dence of progressive destruction, (2) if the patient presented the manifestations

of toxemia, or (3) if there had been prolonged drainage from the joint. An

unhealed compounding wound was not regarded, in itself, as evidence of joint

infection.

It is unfortunate that little precise information could be secured concerning

the initial wound surgery performed in these 39 cases. In 13 cases, in which no

infection had occurred, it could be ascertained that foreign bodies had been

removed in several instances and that the joint capsule had been closed in two

instances. In most of the 39 cases, however, including 26 cases of undoubted

infection by the criteria just stated, the location and extent of the wounds suggested that exposure sufficient to permit adequate excision of devitalized tissue

had seldom been accomplished.

Certain observations made in this survey seemed highly significant. They

are as follows:

1. All six patients with concurrent intra-abdominal injuries also had infections of the hip joint. The origin of the infection seemed obvious; it was

assumed to have resulted from cross-infection from the associated injuries, in

most of which the intestines were involved.

2. Eighteen of the 19 patients with damage to the articular cartilage, 17

of the 21 with involvement of multiple components of the hip joint, and 15 of

the 19 with severe comminution had infections of the hip joint. These data,

especially in the light of the similar data available for wounds of the knee joint

(p. 219), clearly pointed to traumatized, devitalized, poorly nourished, unexcised

articular cartilage as the focus of infection.

3. The timelag from wounding to initial wound surgery, while prolonged,

was substantially the same, on the average, in both the infected and the uninfected group of cases (16 versus 17 hours). The timelag from wounding to

reparative surgery was, however, considerably longer in the infected group, 12

days compared with days in the uninfected group.

4. It was known that penicillin had been given in 22 of the 26 infected

cases and in 12 of the 13 uninfected cases.

5. In the 13 cases in which no infection was present, surgery in general

hospitals had consisted only of wound closure.

6. In 10 of the 26 infected cases, no additional surgery was performed in

the general hospitals. The procedures performed in the other cases, after

infection was evident and in an attempt to accomplish wound healing, included

additional debridement (3 cases); additional drainage (3 cases); sequestrectomy

(4 cases); excision of the head of the femur (2 cases); removal of foreign bodies

and drainage, exploration of sinus, and skin grafting (1 case each); and

closure of the wound (1 case). In spite of these additional operations, wound

healing was accomplished in only of the 26 infected cases.
242 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Early Plans of Management

Before the development of the program ofreparative surgery, in the spring

of 1944, patients with wounds of the hip joint, after initial wound surgery in

forward hospital, were transported to general hospitals in double hip spicas,

extending only to the knee on the intact side. Transportation was usually

possible within to days unless concurrent wounds required that the holding

period be extended to 10 or 15 days, or even longer. Since established infection

of the hip joint may become evident within to days, some wounds were

infected before the patients ever left forward hospitals.

After the patients reached the general hospital, the transportation spica

wasremoved, the wound was dressed, and another spica was applied to hold the

joint in few degrees of abduction and external rotation and in about 30°

flexion. Should ankylosis occur, this was the most desirable position. In occasional cases, skin traction or skeletal traction was used for few weeks before

the spica was reapplied. If suppurative arthritis developed, it was usually

managed by open drainage, after which the patient was put up in plaster

immobilization or in skeletal traction.

Later Plans of Management

The results of the survey undertaken in January 1945 confirmed the

impression that the unsatisfactory results secured in wounds of the hip joint

in the Mediterranean theater were chiefly caused by an inadequate approach

to the problem. Confirmatory evidence was secured later in the year, when the

theater consultant in orthopedic surgery was able to question the

chiefs of various orthopedic sections in the hospitals in the Zone of Interior

visited for another purpose (p. 189). Formal data were not compiled, but the

unanimous opinion was expressed that, in the great majority of cases, infection

of the hip jointwas the result ofretention of dead tissue and that it could not be

controlled until this tissue had been removed by direct surgical attack.

Early in 1945, an ideal regimen was worked out for wounds of the hip

joint, based on aggressive surgery, adjunct chemotherapy, and liberal blood

replacement. It was to include the following:

1. Adequate exposure of the articulation, which, as already mentioned,

was frequently difficult technical procedure.

2. As complete debridement as possible, followed by immobilization of

the extremity.

3. Transportation to general hospital as rapidly as possible.

4. Reparative operation as soon as preoperative preparation could be

completed. If there were no evidences of infection, the operation was to be

limited to closure of the wound.

5. If signs of infection became evident in the forward hospital, radical

secondary surgery was to be performed, as in wounds of the knee joint (p. 231).
WOUNDS OF JOINTS 243

Wide exposure and thorough redebridement were recommended, with, if necessary, dislocation of the hip to secure adequate exposure. Since the operation

was not an emergency, the services of an orthopedic surgeon qualified to undertake such extensive surgery were to be obtained. They were practically

always available in the same or at some nearby hospital.

6. If infection became evident after the patient reached the general

hospital, the same sort of aggressive surgery was recommended. Here,

qualified orthopedic surgeons were always available. Removal of devitalized

bone and cartilage and of foreign material was to be carried out, as at initial

wound surgery. Sometimes the removal of the dead and fractured femoral

head would constitute, in effect, resection of the joint. Elective resection for suppurative arthritis, as practiced by continental surgeons, is not known to

have been performed by United States medical officers.

It was realized that the proposed regimen represented radical solution

of the problem of wounds of the hip joint. It was also realized that the excision of devitalized bone and cartilage, with dislocation of the hip, if necessary,

to secure adequate exposure, might be followed by partial or complete restriction of joint function. On the other hand, it was felt that the hazard of secondary surgery, under the protection of penicillin and blood replacement, could

not possibly exceed the risk of severe infection of the joint, which might destroy

life as well as limb.

In the isolated cases in which this plan was followed, the results were as

good as could have been expected under the circumstances, which were frankly

disadvantageous. The program had, however, no theaterwide application.

Almost as soon as it had been set up, the German armies in Italy capitulated,

and fighting ended. In the light of the knowledge available at the end of the

war, this program was felt to be the best plan possible for the management of

wounds of the hip joints in future conflicts.

WOUNDS OF THE SMALLER JOINTS

In the great majority of wounds of the shoulder, elbow, wrist, and ankle

joints, the policy of closing the synovial membrane or capsule, which eventually

became theater policy, could not be practiced at initial wound surgery because

of the extensive loss of soft parts and the bony destruction which had occurred

at the time of wounding. Whenever it was possible, closure was effected after

thorough excisional surgery had been carried out and the joint cavity had been

irrigated. Transportation splinting was in accordance with the practices

outlined for wounds in the special areas affected.

Primary resection of the smaller joints was seldom if ever performed as

deliberate procedure at initial wound surgery. In many instances, however,

what was in effect traumatic resection had already occurred when the articulating components were blown away at wounding. This frequently happened

at the elbow joint and happened less often at the shoulder and wrist joints.
244 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

As the importance of complete excisional surgery became more and more

clearly understood, debridement of the badly damaged joint, in the occasional

case, at least, amounted to resection.

The management of wounds of the smaller joints in general hospitals was

essentially the same as the management of compound fractures in the special

region affected. Early in the war, the plaster was removed; the wound was

dressed and left open; and immobilization was again instituted, usually by

plaster of paris. Later, when the principles of reparative surgery had become

established, it became the practice, as in all other soft-tissue wounds, to suture

the wound of the soft tissue over the joint if possible, preferably between the

5th and 10th days after wounding. The closure was more often closure over

compound fracture extending into and involving joint than closure over

joint injury.

The old Willems method of early active motion was almost never employed

in wounds of the shoulder, wrist, elbow, and ankle joints, though immobilization was discontinued just as soon as it was considered surgically sound from

the standpoints of wound healing and fracture healing. This was usually

between the second and third weeks after wounding, unless fracture made

further immobilization necessary.

Suppurative arthritis was seldom complication of penetrating wounds

of the smaller joints of the upper extremity unless intra-articular damage had

been considerable. In the ankle, suppurative arthritis was frequently superimposed on the original wound if destruction of the articulating portions of

the joint had been extensive. The infection was usually treated by open

drainage and immobilization by piaster in the position of election. The best

that could be hoped for in most cases was spontaneous or surgical fusion of

the joint.

Secondary resection was seldom done as an elective procedure for suppurative arthritis of the shoulder, wrist, and ankle joints. In most of the cases

in which it was performed, it was, in effect, little more than delayed excisional

surgery. At the 21st General Hospital, in which it was employed in number

of cases on the indication of severe infection, it was thought that the operation

probably had limited field of usefulness in suppurative arthritis of the elbow

joint superimposed on severe trauma.
245

CHAPTER IX

Amputations

Throughout the 2% years of land warfare in the Mediterranean Theater of Operations, the attitude toward amputation was one of extreme conservatism

on the part of all medical officers—in mobile medical units as well as fixed

hospitals in rear areas. Because of the tremendous possibilities of modern

reconstructive surgery, the operation was almost never performed unless the

extremity was damaged beyond salvage or unless, after salvage had been

attempted, conditions developed which endangered life or made further efforts

to save the limb futile. Severe compound fractures of the heel bone and of

the bones of the leg or thigh associated with extensive loss of bone were clearly

extremely serious injuries, but they were not, in the absence of other indications,

considered indications for amputation. United States practices of conservatism in such severely wounded lower extremities were in some contradistinction

to the surgical policies practiced by medical officers of some of the other warring nations.

The theater policy for amputations was set forth explicitly in Circular

Letter No. 46, 29 August 1944, Office of the Surgeon, North African Theater

of Operations. This letter was merely the official statement of policy which

had been in effect for more than year and the general principles of which had

been established earlier in 1943. Details of technique were described in this

circular letter, and it was emphasized that casualties who required amputation

should be told before operation, whenever their condition permitted, why this

procedure was necessary. It was also suggested that, as soon as the patient

was surgically comfortable and mentally receptive, an interview with psychiatrist or chaplain might be useful. These instructions were based on the

fact that about in every patients could be expected to exhibit psychic

reactions, often depressive in type, few days after operation.

Particular attention was to be paid in this and other interviews to what

the soldier might reasonably expect in the way of aid. He was to be told

of the amputation centers which had been established in the Zone of Interior,

the prosthetic appliances which were available, and the economic and other

aid which he could be assured of receiving. Fortification of this kind before

the patient became the target of sympathetic family and friends, the circular

letter pointed out, might tip the scales in favor of rehabilitation, while its

omission might result in lifelong disability and resentment.

The data in this chapter on amputations in United States Army casualties were collected by Maj. Benjamin W. Rawles, MC, 45th General Hospital. The data on amputations in German prisoners of war were collected by Maj.

George S. Hopkins, MC, and Capt. C. R. Brott, MC, 2dAuxiliary Surgical Team.

See appendix, pp. 326-331.
246 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-44-158

Figure 81.—Destructive injury of entire left leg from landmine explosion. Note how the foot has been driven

halfway up the leg. An injury of this sort is true traumatic amputation.

INDICATIONS

Amputations were performed either primarily or secondarily. The

great majority (p. 269) were performed primarily, at initial wound surgery,

and chiefly in forward hospitals.

Indications, which did not differ from the usual indications for amputation except from the standpoint of the degree of trauma, were as follows:

1. Trauma at wounding (figs. 81, 82, and 83), in which the extremities

were blasted off, blown off, torn off, or shot away. In such cases, the surgeon’s function was merely revision of an amputation that had already occurred. Damage to the extremity of such degree that future function was

obviously hopeless also warranted amputation. In many cases of this kind,

major blood vessels w-ere interrupted, but vascular insufficiency per se was not

considered the indication for amputation; the damage to the extremity, aside

from vascular damage, was regarded as sufficient indication for the operation.

2, Vascular insufficiency per se. In this type of case, the reason for

amputation was the interruption of major blood vessel, with resulting impending or actual gangrene. Amputation on this indication was usually

performed in fixed hospitals, though in some cases it was secondary operation

in an evacuation hospital.
AMPUTATIONS 247

U. S. Army photo

Figure 82.—Bilateral traumatic amputations of legs resulting from land-mine explosion. Appearance of the

injuries before initial wound surgery, which obviously

can consist only of completion of the traumatic amputations.

3. Infection. In this group of cases, amputation was necessary to control

infectious processes, usually clostridial myositis, or was indicated because

excision of tissue which had become necrotic had been so extensive that the

extremity which was left was damaged beyond hope of function. Amputation

on this indication was often undertaken to prevent loss of fife.

4. Disease, including malignant tumors, trenchfoot, thrombosis, tuberculosis, and other conditions. Amputation for these causes was uncommon

in an overseas theater.

TECHNICAL CONSIDERATIONS

It was the official surgical policy in World War II that the open circular

(so-called guillotine) amputation he employed routinely. This policy was

set forth explicitly in Circular Letter No. 46, Office of the Surgeon, North

African Theater of Operations, as already noted.

The technical details of the operation were fully described in this circular

letter, the basic direction being that open circular amputation be used routinely

and that it be performed at the lowest possible level of viable tissue. The

only exceptions to the latter requirement were that proximal amputation

Circular Letter No. 91, Office o? he Surgeon General, U. S. Army, 26 Apr. 1943, subject: Amputations.
248 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-44-634

Figure 83.—Bilateral injuries of lower extremities resulting from land-mine explosion.

On the left side, there has been traumatic amputation through the thigh. On the

right side, damage to the thigh and leg is so extensive that only primary amputation

is possible. A. Appearance of injuries before initial wound surgery. B. Appearance

of injuries after initial wound surgery. The right lower extremity has been amputated through the middle third of the thigh by the open circular technique. The stump

of the left thigh has been shaped so as to present similar circular stump.
AMPUTATIONS 249

might be performed in preference to disarticulation and that such modifications as good judgment dictated were permitted in amputations of the upper

extremity.

In practice, amputation at the lowest level of viable tissue not infrequently

came into technical conflict with amputation by the open circular technique

(fig. 84). These recommendations, in practice, could be applied concurrently

only in cases in which the saw line was determined by the level of viability of

soft tissue. This was generally true in amputations performed on the indication of vascular insufficiency, as well as in some amputations for clostridial

myositis. When trauma was the indication, as it was in the great majority of

amputations, especially those performed in forward areas, the extensive compound fractures present almost invariably determined the level of the saw

line. Only in the very occasional case was it found expedient to amputate

through long bone which was the site of proximal fracture. Some viable

muscle and skin were, as rule, present below the level of the fracture or fractures that determined the saw line, and the use of the circular technique necessarily meant their sacrifice. In such cases, therefore, amputations were not

performed at the lowest level of viable tissue.

It was not easy, in some instances, to ascertain the true lowest level of

viable tissue. This was well expressed in the report of an orthopedic team

attached to the 2d Auxiliary Surgical Group, which pointed out that “where

to amputate” sounded simple when it was followed by the statement “at the

lowest possible level.” In extremities that had been blasted off or undergone

extremely severe trauma, the report continued, muscle tissue might be found

damaged for distance of several inches above the site of the wound, and

selection of the amputation site might be matter of considerable difficulty.

Often the muscle varied in color from deep red to purple and was congested,

swollen, and noncontractile while its blood supply was apparently adequate.

In most such cases, it was the policy not to select the higher level of undamaged

and clean tissue for the amputation site but to choose, instead, the lower level,

where there was no doubt that the muscle, while damaged, was still viable.

The risk involved in this policy was overcome by watching the patient very

carefully for signs of further necrosis or of the development of clostridial

myositis.

That these and other problems were usually solved with discretion and

judgment is shown by the infrequency of reamputations in the Mediterranean

theater (fig. 85), The conservative attitude expressed in the report just cited

was theaterwide, and it is doubtful that any appreciable number of amputations were done at an unnecessarily high level.
250 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-I4-600

Figure 84.—Traumatic amputation of right leg, multiple penetrating wounds of left leg,

caused by high-explosive shell fragments. A. Appearance of wounds in evacuation

hospital after removal of emergency splinting and dressings. B. Appearance of

wounds after preparation for initial surgery. Note large posterior flap of apparently

viable skin on right leg. The tibia is completely fractured in the mid third. C. Appearance of stump of right leg after amputation by prescribed open circular technique,

with sacrifice of flap of skin seen in view B. The level of amputation approaches the

critical level at the junction of the upper and middle thirds of the leg. The salvage

of the presumably viable flap of skin might have permitted delayed wound closure and

avoided later undesirable reamputation at higher level in Zone of Interior hospital.
AMPUTATIONS 251

AFIP CA-44-403

Figure 85.—Amputation stump of left forearm, at junction of upper

and middle thirds. The severe compound fracture of the lower end

of the humerus, associated with the loss of soft tissue, was considered

an indication forreamputation just below the middle of the upper arm.

The required technique of circular amputation was as follows:

circular incision is made through the skin at the lowest level compatible with viable

tissue and the skin is allowed to retract; the fascia is then incised at the level to which the

skin has retracted. The superficial layer of muscle is then cut at the end of the fascia and

permitted to retract. At its point of retraction, the deep layers of muscle are cut through

to the bone. After the deep muscles have retracted the periosteum of the bone is cleanly

incised and the bone sawed through flush with the muscles. No cuff of periosteum is removed as in closed amputation. Bone denuded of periosteum will sequestrate if infection

is present and ring sequestrum often results when the periosteum has been removed. It is

important also that no periosteum be elevated or torn from the bone in the stump by rough

handling.

The standard technique for the open circular type of amputation was

followed in the theater (fig. 86). Early in the war, some surgeons were inclined to use the so-called meat-cleaver method, but this error was corrected

by educational endeavors to demonstrate the proper inverted-cone stump.

As experience increased, this error disappeared.

Circular Letter No. 46 directed that the end of the stump be dressed with

fine-mesh gauze, so applied that the gauze did not overlap the skin edges.

Skin traction was then applied immediately (fig. 87) either by stockinet

cuff attached with ace adherent or by adhesive tape. Traction was best

obtained by light plaster cast with wire ladder banjo (fig. 88). The cast
252 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fd^4-2

Figure 86.—Technique of open circular amputation. A. Severe injury in region of right

ankle, with established infection, for which secondary amputation was performed in

fixed hospital. Note destruction of heel. B. Lateral view of circular incision through

skin, which has retracted. C. Medial view of incision of fascia and muscles at level

to which skin has retracted in view B. D. Incision of periosteum, sawing of tibia, at

level to which muscles have retracted in view C. E. Lateral view of section of fibula

with Gigli saw at level slightly proximal to stump of tibia. In the open circular technique, no particular effort is made to section the fibula to inch above the end of the

tibia, as is done at definitive reamputation or revision of the stump. F. Open concave circular stump at completion of amputation. G. Stockinet applied in fixed hospital

after dressing of open circular stump. H. Skin traction provided by means of weight

attached to rope which passes over pulley and extends from stockinet attached to

skin; lower extremity rests on half-ring leg splint. This is the most effective means of

traction on the skin following open circular amputation.
AMPUTATIONS 253

Figure 87.—Steps in application of skin traction after amputation of leg.

always incorporated the joint above the amputation; spica, for instance,

would be used after thigh amputation. Alternatively, if an Army half-ring

splint was used in amputations of the lower leg, posterior plaster-of-paris

splint was provided from the mid thigh to beyond the stump, to prevent

flexion contracture of the knee. The plasma tubing formerly employed was

generally replaced by the elastic cord provided for this purpose in 1944 (fig. 89).

Reparative surgery.—Circular Letter No. 46 directed that all amputations

in the thigh and all in the leg at or near the site of election should be treated

by continuous skin traction after the patient reached general hospital.

Secondary suture or skin grafting of the terminal defect, with or without

revision, was forbidden. It was recommended that the cast or splint be

removed in the fixed hospital and that to 10 pounds of traction be maintained

over pulley at the foot of the bed. Traction was to be continued for at

least weeks, until all layers of soft tissue had been firmly fixed by scar

formation.

Traction during evacuation to the Zone of Interior, for which amputees

were given priority by air as soon as they became transportable, was provided

by stockinet and banjo plaster.

Closure of wounds in the lower third of the leg, which was well below the

site of election, and in the upper extremity was permitted by secondary suture

in general hospitals provided that the wound was clean and the operation was

done under penicillin protection. If closure was not feasible, skin traction

was maintained.

When the reparative-surgery program proved successful in the Mediterranean theater, it was natural that enthusiasm for it should lead to an extension

of its principles to the amputation stump. The application of these principles

in the management of compound fractures had amply demonstrated that

closure of muscles and other soft parts over exposed bones prevented the access

of organisms to the deeper tissues and fracture site, reduced scar formation, and

simplified as well as shortened the period of healing (figs. 90, 91, 92, 93, 94, 95,

and 96). In deference to the recommendations of The Surgeon General and

the judgment of surgeons at the amputation centers in the Zone of Interior, an

extensive clinical trial of reparative surgery as applied to circular flaps was

396961°—57 18
254 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-44-633, CA-44-199, Fd-44-2S

Figure 88.—Use of plaster cast incorporating banjo made of wire ladder splint or steel rod,

to which elastic traction is provided from stockinet fixed to skin. and B. Upper

extremity. and D. Lower extremity.

not undertaken. Delayed closure was strictly forbidden in Circular Letter

No. 46 in amputations of the thigh and of the leg unless it could be carried out

well below the site of election. In amputations of the lower third of the leg

and of the upper extremity, closure by suture was permitted whenever it was

surgically feasible. As matter of fact, as already mentioned, modifications of

technique were permitted in all amputations of the upper extremity in order

to secure early closure.

The number of cases in which the reparative-surgery program was applied

in amputations was far too small to permit any conclusions concerning results.

The data from three general hospitals, however, are recorded, for this small

group of cases, all handled in 1944, might serve as reference point should the

problem arise in another war.

At the first hospital, 77 of 338 casualties with major amputations (22.7

percent) were submitted to suture of the stump before evacuation to the Zone
AMPUTATIONS 255

AFIP CA-45-736, CA-15-738

Figure 89.—Traumatic amputation of right leg, compound fracture of both bones of left

leg, caused by land-mine explosion. A. Appearance of wounds in evacuation hospital.

B. Anteroposterior roentgenograms of both legs before initial surgery. C. Transportation splinting after initial surgery, which included completion of the traumatic amputation

of the right lower extremity by the open circular technique. After the ace adherent

used to fix the stockinet to the skin has dried, elastic traction to the wire ladder splint

will be provided.

of Interior. Twenty-one of the stumps were covered by skin grafts after

fixation of the tissues had been obtained and skin traction was no longer

effective. Healing was regarded as satisfactory in all of these cases.

At the second hospital, 39 of 251 amputation stumps (15.5 percent) were

sutured, 18 before the 12th day after wounding and 21 after that time. Wound

healing was regarded as satisfactory in all of these cases.

At the third hospital, delayed primary suture or skin grafting was carried

out in 63 of 129 major amputations (49 percent). The results are unknown in

28 of the 63 cases. In 29 of the other 35 cases, healing was known to be complete; 27 of the 35 were managed by delayed primary suture. It should be

understood that failure of healing in the remaining six cases did not imply infection but merely that granulating areas, most of which were inconsequential,

were present. The hospital records were incomplete in the 28 cases in which
256 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Figure 90.—Open circular amputation

through middle third of forearm. A.

Appearance of stump days later. Note

that sufficient skin is available to justify

closure by suture. B. Appearance of

stump after easy closure of skin over

stump by interrupted vertical mattress

sutures. Note absence of tension on

suture line. C. Provision of elastic skin

traction, as additional safeguard against

tension after suture closure of stump.

AFIP CA-44-540

the results are listed as unknown, but such data as could be secured suggested

that healing was also likely to be satisfactory in most of this group.

Whenever the stump was closed, skin traction was maintained for to 10

days after amputation, in order to reduce tension on the suture line.

An important point about the cases just discussed and about the other cases

in the theater in which delayed primary suture was employed is that there was

no known fatality in any of the series. No instance of clostridial myositis or

other serious infection was reported, and there was no reported reamputation.

Even though the end results are unknown in so many of the cases in which

reparative surgery was employed, the facts which have just been stated are
AMPUTATIONS 257

AFIP CA^4-543

Figure 91.—Healed stumps 3}i weeks after amputation by

open circular technique. Both patients had sufficient skin

available for closure of the wound at reparative surgery

days later.

significant. The good results and, more important, the absence of fatalities

and of invasive infections, were accomplished under definite handicap, that

the stump after circular amputation is not plastically adapted to early

closure of the skin and soft tissues by suture. For fair test of the program, it

would have been necessary to preserve normal skin, in the form of short flaps,

when the initial operation was performed. This was not permitted. Moreover, as already mentioned, the specified technique of amputation not infrequently required the deliberate sacrifice of normal skin extending below the

level of the saw line which had been determined by trauma to the bone.

For these reasons, many surgeons in the Mediterranean theatre were of the

opinion that the directive forroutine amputation by the open circular technique

might well have been somewhat modified. There was no desire to shorten the

bone in order to permit the fashioning of flaps. It was merely desired to preserve as flaps all viable skin and soft parts, to facilitate early staged repair

without tension.

Traction during evacuation,—Early in the war, the skin traction secured

with adhesive tape and the Army half-ring or full-ring hinged splint proved

unsatisfactory for transportation. Universal adoption of the banjo traction

cast, with stockinet and skin adherent (p. 25), greatly improved the situation.

Traction was examined just before the casualty was evacuated and was reapplied if necessary. The apparatus also had to be checked at regular intervals

during the course of transportation and readjusted if it became displaced.

Priority air evacuation to the Zone of Interior was provided for amputees as

soon as they became transportable.
258 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-44-539, CA-44-538; U. S. Army photos

Figure 92.—Closure of amputationstumps. The soldiers whose amputated lower extremities are shown in these illustrations sustained their injuries at the same time, from the

same shell, while they were in the same foxhole. A. Appearance of granulating stump

of upper third of left leg weeks after amputation. Skin traction had been maintained

since operation. B. Healed stump of mid third of right leg in same patient shown weeks

after amputation and about weeks after suture. C. Healed stump of upper third of

left leg in second patient month after suture. D. Healed stump of right thigh in same

patient month after suture. E. Stumps of same patient after revision and conditioning

for prostheses in amputation center in Zone of Interior. F. Rehabilitated patient shown

in views C, D, and after fitting of prostheses.
AMPUTATIONS 259

AFIP CA-44-500, -44-542

Figure 93. —Closure of amputationstump. A. Closed stump

of thigh days after amputation by open circular technique

and application of skin traction. B. Completely healed

stump 26 days after closure.

Revision of the stump.—It is known that revision of the amputation stump

was necessary in the Zone of Interior in 95 percent or more of all amputations.

Whether wider use of closure of the stump by reparative surgery would have

reduced this proportion substantially is matter of speculation. reduction

of any consequence might not have been achieved. Revision of the stump

before the fitting of the prosthesis might still have been desirable. The objective of overseas surgery, to accomplish healed wound before evacuation of the

patient to the Zone of Interior, would, however, have been achieved to greater

degree than was accomplished under the directives in effect.
260 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP CA-44-360, CA-44-428

Figure 94.—Closure of amputation stump. A. Appearance of stump ofright leg after amputation just below the middle. The stump had been in traction for weeks. B. Appearance of stump 16 days after closure by suture. Note that healing was complete except

for two small granulating areas. There was no sinus formation.

It seemed likely that there would be relative technical advantages at the

revision operation if the defects had been completely healed for several weeks; if scar formation was negligible; if infection was absent; and if skin was ample,

in comparison with revision when the scar was firm and when granulation areas

were present. The crucial test would have been in revision of amputations at

critical levels in the lower femur and upper tibia, when further sacrifice of bone

length was undesirable but would have been unavoidable if the end of the stump

was covered with scar tissue and if normal skin was not available.

ANALYSIS OF CASES

The data discussed in the next several pages are derived from the following sources;

1. Two hundred and eighty-three major amputations performed on 271

United States Army casualties in 1943, and 1,096 major amputations performed

on 1,000 United States Army casualties in 1944-45, total of 1,379 amputations performed upon 1,271 casualties.

These cases were secured, without selection, from the proceedings of

hospital disposition boards for the years in question. Since disposition boards

are created only in fixed hospitals, it is obvious that the cases concern only

those amputees who had survived the shock of wounding and who had recovered

sufficiently to become transportable to the rear. There were no fatalities in
AMPUTATIONS 261

U. S. Army photo

Figure 95.—Amputation by open-flap technique, with closure of

flaps without tension days later, at reparative surgery. Appearance of stump showing complete healing 23 days after wounding.

either the 1943 or the 1944-45 series. Deaths of amputees in fixed hospitals

were infrequent, and fatal cases did not reach disposition boards.

2. After captured German military hospitals came under control of the

Surgeon, Fifth U.S. Army, at the end of hostilities in the Mediterranean theater

in 1945, 1,389 major amputations were performed on 1,332 German prisoners.

As soon thereafter as practical, all prisoners of war who required medical care

were collected in large hospital center previously established by German

forces in Merano, Italy. The maximum enemy patient census during the

period of United States Army responsibility for medical care was in the neighborhood of 20,000.

The statistics analyzed do not include amputations of the hand distal to

the wrist joint or amputations of the foot distal to the junction of the middle

and distal thirds of the metatarsal bones. Disarticulations at the ankle, knee,

wrist, and elbow were tabulated as proximal amputations, while disarticulations

at the shoulder were tabulated as amputations of the upper arm. As in all

collected scries, many items are lacking in many cases, particularly in the

prisoner-of-war series and, to lesser extent, in the series from 1943 dispositionboard proceedings.

Site of amputation.—The site of amputation in both United States and

German casualties was usually the lower extremity (tables 28 and 29). The

large number of amputations of the lower extremity among United States

troops in 1944-45 is to be explained by the increasing use of land mines by

the enemy as they retreated up the Italian peninsula in the last year of the

war. In the 1943 series (table 30), land mines accounted for about 15 percent

of all amputations, while in 1944-45 they accounted for almost 36 percent.
262 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

AFIP Fd-45-17

Figure 96.—Amputation through leg near site of election,

with preservation of long posterior viable flap of skin.

Seven days after amputation, the flap was sutured to

the anterior skin margin. Healed stump 24 days after

wounding.

This same explanation may hold for the slightly higher proportion of lowerextremity amputations in United States as compared with German troops.

The land mines which the Germans used so extensively as defensive weapons

often played havoc with United States troops, but some Germans were also

injured in their own minefields (table 31).

The 1,096 amputations performed on 1,000 United States soldiers in

1944-45 represented 927 amputations of single limbs, 84.6 percent of the total

number. There were 73 double amputations (146 limbs) and 23 second-level

amputations (reamputations). In the German series of 1,389 amputations,

there were only 57 double amputations (114 limbs), representing 4.1 percent

of the total number. In addition, one German soldier suffered the loss of

three limbs; both forearms had to be amputated, and one leg was amputated

at the thigh. There was no similar instance in the United States Army series,

and there were no quadruple amputations in either series.

Numerous other serious injuries complicated the wounds for which

amputation was required in the 1944-45 United States Army series (table 32).

The majority of injuries, fortunately, were limited to the skeletal system and

could be treated by ordinary methods of fracture management. In 12 instances, the additional fracture was in the same extremity as that in which

amputation was necessary. Comparable data were not available for the 1943

United States Army series or for the prisoner-of-war scries.

Causative agents.—There were only amputations for disease in the

combined United States Army series (table 30), of them in the same patient,

for trenchfoot. This is about what would be expected, since soldiers with
AMPUTATIONS 263

Table 28.—Sites of amputation in 1,379 separate operations on United States Army troops

Site of amputation

1943 1944-45

Amputations Percent Amputations Percent

Arm:

Upper third 14

13

43.

40.

15.

47

24

29

47.

24.

29.

Middle third

Lower third

Total 32 100. 100 100.

Forearm:

Upper third 16

17

32

24.

26.

49.

Middle third

Lower third __ __ __

Total 48 65 100.

Thigh;

Upper third

28

52

10.

31.

58.

34

61

162

13.

23.

63.

Middle third

Lower third

Total 89 100. 257 100.

Leg:

Upper third __ 53

61

46. 118

157

363

18.

24.

56.

Middle third

Lower third 53.

Total __ 114 100. 638 100.

Foot:

Upper third _____ __ 19

17

52.

Middle third __

47.

Total 36 100.

Total, upper extremity. 80

203

28.

71.

165

931

15.

Total, lower extremity __

84.

Total, both extremities 283 100. 1, 096 100.

Including amputations at the shoulder joint.

Including amputations at the elbow joint.

No cases in the specialcategory or no data on breakdown of the site available.

Including amputations at the wrist joint.

Including 18 amputations at the knee joint.

Including amputations at the ankle joint.
264 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Table 29.—Sites of amputation in 1,389 separate operations on German prisoners of war

recognized diseases are not sent into combat zone. There were 29 amputations for disease in the German prisoner-of-war series (table 31). No details

concerning these operations were available.

In both the United States Army and the German series, the great majority

of amputations were performed for trauma, and most of the trauma was

battle incurred (tables 30, 31, and 33). Although the number of United States

Army troops in the theater was smaller in 1943 than in 1944-45, the proportion

of accidental injuries was larger (table 30), fact which can be explained in

two ways: In North Africa, where most of the early fighting occurred, supply

lines were long, and extensive travel by train and motor vehicle was necessary.

This was also period of extensive training for combat, and the number of

soldiers injured by accidental explosions of live ammunition might be expected

to be greater than in period of more active combat.

Site of amputation Amputations Percent

Arm 190 13.

Forearm _____ 125 9.

otal 315 22.

Thigh:

Upper third 114 8.

Middle third 193 13.

Lower third 200 14.

Total _____ 507 36.

Leg:

Upper third ______ 128 9.

Middle third 175 12.

Lower third _____ 142 10.

Total ____ 445 32.

Foot 122 8.

Total, upper extremity ___ 315 22.

Total, lower extremity 1, 074 77.

Total, both extremities 1, 389 100.

Including 11 disarticulations at the shoulder joint and at the elbow.

No data on breakdown of site.

Including 41 disarticulationsat the wrist.

Including 24 disarticulationsat the hip joint.

Including 79 disarticulationsat the knee joint.
AMPUTATIONS 265

Table 30.—Agents of wounding and causes of amputation in 1,271 United States Army troops

The explanation of the slightly larger proportion of amputations caused by

shell fragments and similar agents in the German prisoner-of-war series, than

in the United States Army series, is probably heavier United States Army fire.

The effect of land mines has already been mentioned. The larger proportion

of injuries from small-arms fire in German prisoners of war is perhaps to be

explained by the strafing from United States planes which the German troops

suffered while they were retreating in the last months of the war.

Except for the category of trauma, all these groups are small, and the

statistical differences are not significant. On the other hand, personal observaAgents and causes

1943 1944-45 Total

Cases Percent Cases Percent Cases Percent

Wounded in action:

Shell fragments, artillery, mortar,

grenade 132 48. 534 53. 666 52.

Mines 41 15. 359 35. 400 31.

Small arms, machinegun, etc 21 7. 36 3. 57 4. Other. 13 4. 21 1.

Total 207 76. 937 93. 1, 144 90.

Accidental injuries:

Vehicles 15 5. 15 1. 30 2.

Explosions, live ammunition 19 6. 13 1. 32 2.

Bullets 3. 13 1. 21 1.

Train, trolley 2. 15 1.

Mines 1. 10

Machinery (crushing injuries)

Thermal burns

Other. 3.

Total 63 23. 59 5. 122 9.

Disease:

Trenchfoot

Osteogenic sarcoma fibula

Thrombosis

Tuberculosis.

Total

Grand total 271 100. 1, 000 100. 1, 271 100.

These 1,271 troopsrequired total of 1.379 amputations.

Ofpopliteal artery, secondary to ligation of saphenous vein.
266 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

tions indicate that most of the explanations which have just been advanced

are valid.

Indications. —When the indications for which individual amputations

were performed are considered (tables 33, 34, and 35), certain differences

between German and United States surgical practices suggest themselves.

To consider only the operations for which indications are known in the United

States Army series (table 33), 1,027 amputations—more than three-quarters

of the total number—were performed for trauma, both combat connected and

accidental. In the German prisoner-of-war series (table 35), the corresponding

figure was 874 operations, not quite two-thirds of the total number. In the

United States Army series, 195 operations (14.5 percent) were performed for

Table 31.—Agents of wounding and causes of amputation in 1,332 German prisoners of war

Table 32.—-Complicating injuries in 1,000 United States Army amputees, Id^-J+B

Agents and causes Cases Percent

Wounded in action:

Shell fragments, artillery, mortar, grenade, bomb 804 60.

Mines 242 18.

Small arms, machinegun, etc 182 13.

Total 1, 228

48

92.

Accidental injuries 3.

Disease. 29 2.

Unknown causes ___ ____ 27 2.

Grand total 1, 332 100.

These troopsrequired total of 1,389 amputations.

Site of amputation

Complicatinginjury

Leg Thigh Foot Forearm Arm Leg and

thigh

Both

legs

Thigh

and forearm

Fracture opposite extremity

Additional fracture same extremity

77 22

Fracture upper extremity 16 10

Fracture lower extremity.

Spine, abdomen, chest, or combined 12

Total 111 36 15

Fracture of humerus in same extremity as injuryrequiring amputation.
AMPUTATIONS 267

Table 33.—Indications for amputation in 1,344 of the 1,379 operations following wounds or

injuries in United States Army troops

Table 34.—Indications for 843 'primary and 243 secondary amputations in United States Army troops, 1944~4&

vascular insufficiency. In the German series, the number of operations performed for this reason was 82, not quite percent. The differences in the

proportions of cases performed on the indication of infection is striking. In

the United States Army series, 122 operations, about percent, were performed

on this indication; in 86 instances the infection was clostridial myositis. In

the German prisoner-of-war series, 403 operations, almost 30 percent of the

total number, were performed for infection. All 86 primary operations performed on the indication of infection were for clostridial myositis.

Indication

Combat-connected Accidental

Total

1943 1944^5 1943 1944-45

Amputations

Percent

Amputations

Per

cent

Amputations

Percent

Amputations

Percent

Amputations

Percent

Trauma. 121

43

24

2(21)

(3)

64.

22.

12.

803

131

93

(61)

(32)

78.

12.

9.

53

11

(2)

80.

16.

3.

50

10

(2)

(1)

79.

15.

4.

1, 027

195

122

(86)

(36)

76.

14.

9.

Vascular insufficiency

Infection

Clostridial myositis

Other

Total 188 100. 1, 027 100. 66 100. 63 100. 1, 344 100.

Data were not available for the other 35 operations.

Figures in parentheses are subtotals.

Indication

Primary Secondary Total

Amputations Percent Amputations Percent Amputations Percent

Trauma

Vascular insufficiency _____

Infection

Clostridial myositis __

Other

805

35

(1)

(2)

74.

3.

44

106

93

(62)

(31)

4.

9.

8.

849

141

96

(63)

(33)

78.

13.

8.

Total. 843 77. 243 22. 1, 086 100.

Exclusive of amputations performed for disease and operations in which the indications are unknown.

Including amputation for thermal burn.

Figures in parentheses are subtotals.
268 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Table 35.—Indications for 962 primary and secondary amputations in German prisoners

of war

It should be pointed out again that vascular insufficiency was considered

to be the indication for amputation in primary operations when the records

indicated that the limb woidd have survived if the blood supply had not been

interrupted. This group of operations, therefore, includes all instances of

gangrene, including wet gangrene with superimposed infection, and all instances

of infection in which the infection followed the interruption of major artery.

In the United States Army series, the proportions of amputations done

on various indications changed in the following manner as the war progressed: In 1943, trauma of all kinds was responsible for 174 amputations, slightly

under two-thirds of the total number of operations (283) (tables 28 and 33).

In 1944-45 the proportion had risen to more than three-quarters (853 of 1,096

operations) (tables 28 and 33).

In 1943, injury to major artery was responsible for just over 19 percent

of all amputations (54 of 283) (tables 28 and 33). In 1944-45, the proportion

was 12.9 percent (141 of 1,096 operations) (tables 28 and 33.)

Infection was responsible for about the same proportion of amputations in

both series, 9.2 percent (26 of 283 operations) (tables 28 and 33) in 1943, and

8.8 percent (96 of 1,096 operations) in 1944-45 (tables 28 and 33).

The increasing proportion of amputations in which trauma was the indication and the decreasing proportion in which vascular insufficiency was the

indication may fairly be assumed to reflect the better judgment and increased

skill of United States Army surgeons as their experience increased. With

increased experience in the management of vascular injuries, the limb was

undoubtedly saved in some of the later cases in which, if they had been observed

earlier, amputation would have been performed. The decrease in this category

of indications may also be attributed to better control of infectious processes

after initial surgery became more competent, penicillin had become available,

and the practice ofliberal blood replacement had become general.

Indication

Primary Secondary Total

Amputations Percent Amputations Percent Amputations Percent

Trautna 874

86

63.

6.

874

82

403

30

63.

5.

28.

2.

Vascular insufficiency

Infection

Disease

80

317

30

5.

22.

2.

Total 962 69. 427 30. 1, 389 100.

Clostridial myositis.

Variety of infection unknown.
AMPUTATIONS 269

One not too speculative explanation for the disproportionately large

number of amputations for infection in the German prisoner-of-war series is that the quality of United States Army medical care was better. An extremely important part of the explanation is that all of these German wounded were

managed under the adverse conditions of wholesale retreat and surrender,

when medical care can never be on high professional level.

Timing.—More than three-quarters of the United States Army casualties

who required amputations were operated on primarily, with trauma as the

chief indication (table 34). Trauma was also the principal reason for about

20 percent of the secondary operations (44). In almost two-thirds of the

secondary amputations for infection, the indication was clostridial myositis.

In the German series (table 35) the proportion of casualties operated on

primarily was somewhat less than in the United States Army series (table 34),

and the proportion of cases in which infection was the indication for immediate

amputation was considerably larger. In the cases in which secondary amputation was performed, infection was responsible for considerably larger proportion of cases than vascular insufficiency, which is the reverse of the situation in the United States Army series.

Multiple amputations.—In the 85 multiple amputations in the combined

United States Army series (table 36), there are separate combinations of

operation. In 74 cases, however, the amputations were both on the lower

limbs, and in all but of the remaining cases one of the amputations was

also on lower limb.

Table 36.—Combinations of levels in 85 multiple amputations in United States Army casualties

Primary amputations were performed on the indication of trauma in 147

of the 170 limbs, and limbs were removed secondarily for the same reason.

One amputation was done primarily for clostridial myositis, and seven of the

secondary operations were done for this cause. All of the remaining operations were performed secondarily, for other varieties of infection, for gangrene following trenchfoot, and the other for vascular insufficiency.

396961°—37 19

Levels 1943 1944-45 Total

Both legs 30 37

Leg and thigh 18 21

Both thighs__ 12 13

Leg and foot

Thigh and forearm

Leg and forearm

Arm and forearm

Thigh and arm_

Total 12 73 85
270 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

In the German prisoner-of-war series, the indications for the 114 multiple

amputations were trauma in 68 limbs, infection in 28, and vascular insufficiency

in 7. The causes in the remaining 11 operations are unknown.

Seventy-six of the eighty-five double amputations in the United States

Army series (90 percent) were required by combat-incurred trauma, shell

fragments and land mines being responsible in all but one case. The comparable figures for the German series of multiple amputations are 54 cases

(94.7 percent) with shell fragments (30) and land mines (22) responsible for

all but of the cases.

Reamputation.—Reamputation was necessary at higher level in only 23

of the 1,096 amputations performed in United States Army hospitals in 1944-45.

All but two were on the lower extremity. The majority of the secondary

operations were for infection (16), chiefly clostridial myositis (13), which was

usually superimposed upon the trauma for which the first amputation had

been done. The original trauma had been caused by mines in 15 cases and

by shell fragments in 7. In the remaining case the trauma was accidental.

Details on reamputations are not available in the 1943 United States

series nor in the prisoner-of-war series.
271

CHAPTER

Noncombat Orthopedic Lesions

In addition to wounds involving the bones and joints, patients in the

hospitals of the Mediterranean Theater of Operations presented, almost from

the day it came into existence as the North African Theater of Operations, two other groups of orthopedic lesions.

The first of these lesions was the simple type of fracture which resulted

from the many kinds of trauma to which soldier in an overseas theater was

subjected behind the fighting lines. These injuries were sustained, for the

most part, in the performance of such tasks as are commonly part of noncombat activities. considerable number were sustained during athletic contests and otherrecreational activities.

This type of fracture needs no extended discussion. Most of them were

treated by simple manipulation and plaster immobilization, supplemented,

occasionally, by simple forms of traction. Open reduction and internal fixation

were performed on the same indications as in civilian practice. The attitude

was conservative, and these special techniques were not resorted to unless

adequate reduction had not been accomplished by simpler measures.

The second group of non-combat-incurred lesions comprised the orthopedic

disabilities ordinarily seen in civilian practice, including painful feet, painful

backs, painful and unstable knees, recurrent dislocations of the shoulder, and

old fractures of the carpal scaphoid bone. Some of these conditions were

known to exist before the soldiers were inducted. They sometimes caused only

minimal disability during the training period in the Zone of Interior but produced sucli disability under conditions of combat that the soldiers frequently

reported on sick call and had to be hospitalized for investigation, evaluation,

and treatment. In some cases, the disability was of such long standing and so

evident that one wondered how the patients had ever been classified for overseas duty. These lesions were of military importance because of the disability

which they caused, their chronic and recurrent character, and the two serious

consequences to which they gave rise in an active theater of combat; namely,

loss of manpower and utilization of hospital-bed space and of other medical

facilities.

Early in the North African experience, it was not at all unusual for soldiers

hospitalized with these complaints to state that they had suffered considerable

The material in this chapter is largely based on survey made by Maj. Newton C. Mead, MC, 12th General Hos- pital, after V-E Day.

The injuries described in this chapter were sometimes produced during combat, as the result of falls and other accidents, but they were notproduced by missiles, and for convenience of reference they are therefore described as noncombat

lesions.
272 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

difficulty from them during training but that appropriate therapy had permitted

them to continue on duty. Sometimes soldier would state that he had duly

reported his trouble when he was given his final physical examination before

embarking for overseas, and that the existence of the condition had been verified, but that the examining officer had said that he would be reclassified overseas for limited duty. Many of these men were never of combat usefulness.

Some of them were of limited usefulness even on limited duty. few were

promptly returned to the United States, as being completely unfit for any sort

of duty in an overseas theater. There are no supporting statistical data for

any of these statements, but they are substantiated by the observations of

many of the orthopedic surgeons who served in the theater.

The early confusion in respect to these noncombat orthopedic conditions

was probably unavoidable. As the war progressed, the situation was gradually

rectified and in the last year only small percentage of the soldiers who reached

the Mediterranean theater had conditions of sufficient seriousness to warrant

classification to limited duty. If policy of similar strictness had been in effect

throughout the war and if these disabilities had been diagnosed and properly

evaluated in the Zone of Interior, time, effort, and expense would have been

saved, and badly needed hospital-bed space would have been conserved

overseas.

GENERAL PRINCIPLES OF MANAGEMENT

Soldiers with the noncombat type of orthopedic lesions were more closely

studied in fixed hospitals. When the difficulties became apparent in forward

areas, every effort was made to screen out those whose complaints were trivial

and functional and to return them promptly to duty. Under the stress of

heavy combat load, however, this was not always possible, for these complaints

frequently required great deal of time for investigation and evaluation. As

result, the majority of the patients had to be transferred back to fixed hospitals.

This was unfortunate. Experience in all fields throughout the war clearly

indicated that the farther to the rear soldiers were evacuated, the more difficult

it was to return them to combat duty.

As this statement suggests, the psychogenic factor played an important

part in these complaints and greatly increased the problems of management

and disposition. This group of patients did not consist of malingerers in the

ordinary sense of the term. These men honestly regarded their disabilities

as sufficiently serious to prohibit their participation in heavy duty and in

combat. Liaison between orthopedic and neuropsychiatric medical officers

was obviously called for and proved very profitable, though it was not until

the winter of 1945 that concrete steps were taken to stop the practice of sending numbers of these soldiers from forward areas to fixed hospitals. At this

time, as part of the neuropsychiatric program in the theater, reinforced

field hospital platoon was designated and set up under the supervision of

Maj. (later Lt. Col.) Calvin S. Drayer, MC, consultant in neuropsychiatry,
NONCOMBAT ORTHOPEDIC LESIONS 273

Office of the Surgeon, Fifth U.S. Army, close to the division area, to receive

patients with chronic or vague complaints directly from clearing stations.

The professional staff of this field hospital platoon consisted of various specialists, among them an orthopedic surgeon. All were men of judgment and

experience. When soldiers complaining of orthopedic conditions were admitted to this platoon, they were quickly but thoroughly studied and screened.

When observation seemed to establish or made it seem likely that there was

ground for the soldier’s complaints, he was evacuated to fixed hospital in

the rear for further investigation and possibly for treatment. Otherwise,

he was promptly sent back to the line. This plan of management made it

possible to return large number of soldiers to combat status without their

ever leaving the forward area.

At the fixed hospital, the emphasis was always upon rapid evaluation

of the complaints of these patients, with an equally prompt decision as to

their disposition. In civilian practice, the emphasis in such conditions is

upon precise diagnosis and the institution of therapy. Only later is any prognosis made as to the duration of temporary disability or the extent of permanent disability. In overseas hospitals, the first consideration was whether

the complaints had physical basis and, if so, whether it was of sufficient

seriousness to prevent the soldier’s immediate return to duty status. If the

answer was “No,” the surgeon’s first duty was to discuss his condition with

the patient and to make it clear to him that his disability was not sufficient

to prevent him from performing his military duties. The question at issue

was whether he could perform them adequately. If it was thought that he

could, he was promptly returned to combat duty.

If clear-cut decision could not be arrived at promptly, detailed routine

of investigation was begun, including roentgenologic examination and laboratory studies. While it was in progress, physical therapy was often instituted,

in an effort to relieve symptoms and shorten the period of hospitalization.

When the diagnostic routine was completed, the patient was again evaluated, and disposition was accomplished, the preference being given to duty status

whenever it was felt that he could assume the necessary duties and could

continue to perform them. Patients who could not be returned to duty at

once were kept in the hospital and were treated as intensively as possible.

Reevaluation was carried out after the lapse of 10 days to weeks, and final

disposition was then accomplished. soldier who could not be rehabilitated

within this period was unlikely to be ol further combat usefulness.

The essential factor in this routine of evaluation, treatment, and disposition was the promptness with which it was carried out. The whole military

experience showed that, in such conditions as these, prolonged hospitalization

and treatment were seldom more effective in salvaging soldier for duty than

were shorter periods. The more prolonged the hospitalization, in fact, the

more difficult it was to return soldiers to duty status, whether the condition

was acute, chronic, or recurrent.
274 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The soldier who really needed treatment was given the benefit of all the

standard treatment appropriate to his condition, but he was disposed of just

as promptly as good orthopedic practices permitted. The first and paramount

mission of the Medical Corps is to maintain the fighting strength of the Army.

This objective required the salvage of all possible manpower, together with

the most efficient possible use of all hospital and other medical facilities, including the time of medical officers. Undoubtedly, in an occasional instance,

some injustice was done, and soldiers were returned to active duty too soon.

This worked no individual hardship, however, for those who had real complaints promptly reported to sick call again. The general policy was considered highly effective. It provided full medical care for those who really

needed it, while at the same time it reduced the days lost from duty for soldiers

who had mild forms of orthopedic lesions and who really needed no hospitalization and no treatment beyond explanation and reassurance.

THE MANAGEMENT OF PAINFUL BACKS AND FEET

Lesions of the back and the feet were the two non-combat-connected

orthopedic complaints most commonly encountered in overseas theaters.

They accounted for considerable loss of manpower but need no extended

discussion because, in spite of their importance, no new techniques were developed for their management and no special studies were made from which

conclusions concerning them could be drawn.

Painful Backs

When soldier complaining of back pain was admitted to general or

station hospital, the routine was (1) to take careful history, with particular

reference to the time and circumstances of the first appearance of the disability;

(2) to make physical examination; and (3) to obtain anteroposterior, lateral, and oblique roentgenograms of the lumbar and sacral spine. In many cases

in which there was organic reason for the complaint, the chief diagnostic

evidence was roentgenologic. Mild arthritic changes were not considered

disabling in themselves. Moderate or extensive changes were considered confirmatory of the clinical complaints, and treatment was promptly instituted.

If the symptoms were not promptly relieved, possible transfer to limited-duty

status was considered. Congenital anomalies, other than spondylolisthesis or

evidence of extensive structural weakness, were not considered disabling in

themselves. Bone tumors and destructive lesions were practically always

regarded as justification for evacuation to the Zone of Interior for continued

hospitalization and definitive treatment. clinical syndrome suggesting

rupture of the intervertebral disk was special problem, which is discussed in

the neurosurgical volume of this series.

Treatment for painful backs was usually limited to bed rest on hard

bed, with movement minimized by the use of board between the mattress and
NONCOMBAT ORTHOPEDIC LESIONS 275

the springs, and physical therapy consisting of infrared heat and massage.

Simple braces and supporting canvas belts were sometimes made in the hospital

braceshops. They were useful for soldiers who had been on limited duty or

who were being assigned to it, but these devices were never effective in returning

soldier with painful back to combat duty.

In the majority of chronic complaints referable to the back, maximum

symptomatic improvement was usually obtained in about weeks, and with

few exceptions it was possible to determine by this time whether disposition

should be to combat duty or to limited-duty status. In acute back strains,

longer period of treatment was often justified, but maximum symptomatic

improvement was usually obtained by the end of the third or fourth week, and

disposition could be made with assurance by that time.

Painful Feet

Painful feet were more of problem than painful backs. Soldiers with

symptomatic flat feet who were admitted to clinics or hospitals raised questions

of disposition rather than treatment. Such measures as rest and physical

therapy were of no value. Arch supports did not reach the Mediterranean

theater until early in 1944. They provided some relief for soldiers on duty in

rear areas but appeared to be of little value in returning to combat duty

soldiers who complained of their feet. There were numerous complaints about

these supports, the most frequent being that they were too high in the longitudinal arch and often caused pain from excessive pressure. It was frequently

possible to remedy these defects in the braceshops of general hospitals, but the

general impression was that the use of arch supports was of limited value in the

management of painful feet in theater of operations.

Surgical intervention for hallux valgus was seldom undertaken overseas.

The operation only occasionally made possible the return of patient to

combat duty, and after the first months of the war it became the rule to assign

patients with this condition to limited duty if they proved unfit for combat

and to make the disposition without surgery.

Operation on single hammertoe on an otherwise normal or almost normal

foot was frequently carried out by standard techniques. In most such cases,

the soldier could be returned to full duty. Operation was seldom undertaken

for hammertoes associated with flat metatarsal arch and with dorsiflexion of

all the toes. Experience promptly showed that surgery seldom permitted

full-duty disposition and that the wisest plan was to assign the soldier to limited

duty without surgery.

March fractures accounted for certain proportion of painful feet observed

overseas, though most such fractures occurred during training in the Zone of

Interior. This subject is discussed in detail elsewhere in this series. It might

be said here that while weight bearing was not permitted if it was painful,

there was an increasing tendency overseas to omit prolonged immobilization

from the routine of treatment. In some instances, plaster boot was worn

for few weeks, but many times only metatarsal pad was applied.
276 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

SURVEYS OF MANAGEMENT OF NONCOMBAT

ORTHOPEDIC LESIONS

Surveys were carried out in the Mediterranean theater for three special

types of injuries; namely, recurrent disabilities of the knee, including injuries

of the semilunar cartilage and loose bodies in the joint (osteochondritis dissecans) recurrent dislocations of the shoulder; and simple fractures of the carpal

scaphoid bone. The purpose of each of these investigations was the same—to

determine what success had been achieved in restoring to useful duty status

the patients who had been subjected to surgery. The cost of treatment to the

Army, in terms of utilization of hospital days, was investigated in each survey.

An attempt was made to follow up patients who had received surgical

treatment for meniscus injuries, in order to determine, at least by inference, how they had stood up under the duties to which they were assigned. Results

in other lesions were evaluated simply on the basis of hospital disposition. The

classification and disposition of patients employed in the Mediterranean theater

in 1944 and 1945 were as follows:

Category covered soldiers whose physical condition was considered as

qualifying them to perform full military duty, without any restrictions. Those

who required preliminary period of conditioning, up to weeks, before being

returned to full-duty assignments, were temporarily classified as

Category covered soldiers who were capable of limited service, according

to the degree and manner specified by the hospital disposition board. This

classification was frequently invalidated by failure of the units to which they

were assigned to observe the specifications. The subcategory temporary

covered soldiers who were expected to prove eligible, after certain period of

conditioning, for reclassification to Category A. Only disposition boards in

general hospitals were authorized to place officers in class B.

Category covered soldiers who could not be restored to any duty status

within the holding period permitted in the theater. These patients were evacuated to the Zone of Interior. Disposition to category was authorized only in

general hospitals or in station hospit als acting in the capacity of general hospitals.

Soldiers who were classified to full duty in the Army had to be able to

perform full duty. In the very nature of ground combat, there could be no

relief from certain strenuous duties and no halfway performance of them. In

the Army Air Forces, the situation, for obvious reasons, was rather different,

and disposition in hospitals devoted exclusively or almost exclusively to Army Air Forces personnel could be carried out by somewhat different criteria. For

one thing, patients returned to duty with the Air Forces were quartered in

relatively comfortable barracks, easily accessible to the hospital, in sharp

contrast to the foxholes and pup tents which were usually the lot of infantrymen. The situation was roughly similar to that of civilian industrial community. Hospitals supporting the Army Air Forces were not usually in the

direct chain of evacuation from the front lines and were therefore not constantly crowded with battle casualties, as were the other hospitals included in
NONCOMBAT ORTHOPEDIC LESIONS 277

these surveys. Their work, for this reason, could be conducted somewhat

along the lines of civilian hospital.

There were also other differences. The Army Air Forces had its own

flight surgeons, whose responsibilities were entirely toward its own personnel.

These surgeons had opportunities to become acquainted with the men, they

were familiar with their duties, and they could control and supervise their

activities during periods of rehabilitation. Because they were in position to

judge what duty patient just released from the hospital was capable of

assuming, disposition of Army Air Forces personnel was often made to class

duty, with the tacit understanding that there would be period of conditioning

and rehabilitation under the flight surgeon’s supervision before full duty was

actually attempted. This arrangement eliminated the period of reconditioning

at replacement center which ground troops often had to undergo and which

was always unpopular. Furthermore, there was never any necessity in the

Army Air Forces for heavy marching or for ground operations over unfavorable

terrain. Finally, although precise evaluation is impossible, the morale factor

undoubtedly played an important part in the generally better results secured

in elective surgery in the ArmyAir Forces.

In 1944, the Army Air Forces discontinued class duty and placed personnel returning to duty in either class or class C. This was feasible plan

in that branch, whose duties, while exacting and hazardous, were very different

from the duties of ground troops. Many patients who were placed in class

in the Army Air Forces would have been placed by practical necessity in

class had they belonged to other branches of the service.

IN FERNAL DERANGEMENTS OF THE KNEE

1943 Survey

Early in the North African campaign, the management of internal derangements of the knee joint in theater of operations was recognized by

certain orthopedic surgeons as problem which needed investigation. An

investigation of series of operations performed before 15 July 1943 was

therefore undertaken (by Maj. Oscar P. Hampton, Jr., MC) in general and

station hospitals in the Mediterranean Base section. Special attention was

paid to the followup, which was concluded as of November 1943. Whenever

possible, the patients were traced to their current assignment.

This investigation covered 150 arthrotomies of the knee joint, 140 undertaken for lesions of the semilunar cartilages and 10 on the indication of osteochondritis dissecans. The medial cartilage was removed in 120 cases, the

lateral cartilage in 12, and both cartilages in 4. In four cases, although the

joint was opened, neither cartilage was removed. These 150 patients spent

an average of 72 days in the hospital. At the time the survey was concluded,

five were still hospitalized, the average period of hospitalization to that date

being 95 days.
278 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The results of the remaining 145 arthrotomies were as follows:

Returned to full duty after spending an average of 53 days in the hospital,

67 patients (46 percent).

Returned to limited duty after spending an average of 89 days in the

hospital, 56 patients (39 percent).

Evacuated to the Zone of Interior after spending an average of 83 days

in the hospital, 22 patients (15 percent).

Of the 84 combat troops included in the 150 cases, 28 were returned to

full duty and 42 to limited duty, 12 were evacuated to the Zone of Interior,

and were still hospitalized at the conclusion of the survey.

These figures require further analysis. They show, first of all, that, after

the expenditure of an average of 72 days of hospitalization per patient, there

was less than an even chance of restoring the soldier to combat duty or, if he

had been on limited duty, of making him fit for combat duty. They show,

next, that of every patients who had been combat troops could not be

returned to their former status.

Finally, the hospital-stay days require analysis. The average period of

hospitalization for the whole series, 72 days, is low because it includes number of extremely early dispositions. One combat soldier, for instance, was

returned to his infantry division on the eighth postoperative day, and 10

others were returned in less than 30 days. Obviously, these dispositions

cannot be accepted at their face value; any duty disposition made within less

than or weeks after arthrotomy must have necessitated some restriction

of duty. In number of the hospitals surveyed, other patients were observed

whose disposition had been effected within unusually short periods and who

had had to be hospitalized for reclassification.

In the light of these facts, it was concluded that arthrotomy for torn

semilunar cartilage in an overseas theater of operations was often of very

doubtful value. If soldier had disability of such seriousness that he could

not perform combat duties, it was probably more sensible to downgrade him

to limited duty, without operation, than to spend the timeand effort and utilize

the hospital-bed space required to restore him to full duty, since the chances

of success were no more than 50 percent and since the chances of his being

able to perform full duty further reduced the percentage.

Establishment of Theater Policy

Circular Letter No. 48, Office of the Surgeon, North African Theater of

Operations, published 18 November 1943, took full cognizance of these facts. Its substance was as follows:

1. Operations for repair or reconstruction of the collateral or cruciate

ligaments of the knee or for recurrent dislocation of the patella were forbidden.

See appendix, pp. 312-316.
NONCOMBAT ORTHOPEDIC LESIONS 279

2. Excision of semilunar cartilage or of joint mice was permitted, but

only in selected cases, in which there had been careful evaluation of the

patient’s age; the findings on roentgenologic examination; the relative stability of the joint; and, most important of all, the soldier’s mental outlook.

3. Operation was not to be performed for primary injuries of the semilunar

cartilage unless the knee was locked and could not be unlocked either by gentle

manipulation or by skin traction for or days. In all other cases, treatment

was to be limited to pressure support, rest, graduated to protected weight

bearing and then full weight bearing, and carefully supervised quadriceps exercises for to 10 weeks. These soldiers were to be returned to duty as soon

as symptomatic relief was obtained.

4. Arthrotomy was to be performed only for (1) persistently locked knees

and (2) unlocked knees if the disability made it impossible for the soldiers to

perform noncombat duty. The latter indication was to be employed only in

exceptional cases.

5. Soldiers with recurrent disability in which the knee was not locked

or in which it could be unlocked by conservative management were to he returned to duty. If, however, the total disability in any calendar year exceeded

90 days, they were to be returned to the Zone of Interior.

6. Operations for the removal of cartilage from each knee or for the

removal of both cartilages from one knee were to be performed only on the

written recommendation of disposition board in general hospital.

7. Elective arthrotomy was to be performed only on the orthopedic services

of general hospitals. The patient was to be held, for minimum of weeks in

the hospital in which the operation was performed, to permit the operating

surgeon to supervise the regimen of postoperative exercises and graded motion

which were essential to good results. If prevailing evacuation policies did not

permit holding for this length of time, the operation had to be performed in

hospital farther to the rear. After weeks in general hospital, the patient

was to be transferred to convalescent hospital for further supervision. Full

instructions for the continuation of corrective exercises were to be sent with

him. The implications of these policies were perfectly clear. If soldier with

an injured meniscus or other knee disability could perform any type of duty

in his present condition, he was to be placed in the appropriate classification

and returned to duty. If he could not perform even limited duty satisfactorily

because of frequency of recurrence of the difficulty or persistent locking of the

knee, he was to be considered possible candidate for surgery unless there

were contraindications to operation. If these existed, he was to be returned

to the Zone of Interior. Among these contraindications were arthritic changes

of any considerable degree, definite cruciate relaxation, and age (usually over

30 years). Operation was not to be undertaken if the soldier showed any signs

of hypochondriac tendencies or emotional instability. In short, all cases for

surgery were to be selected on an individual basis, and no elective surgery on

the knee was to be done routinely.
280 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

1944 Survey

In order to secure additional statistical data concerning the management

of knee disabilities, the Surgeon, Mediterranean Theater of Operations, directed

all general and station hospitals in the theater to submit specified information

for 1944 for inclusion in Essential Technical Medical Data for March 1945.

Similar requests were made of the general and station hospitals which were

formerly in the Mediterranean theater but which had been sent to the European

theater after the invasion of southern France. Hospitals which did not submit

the data as directed were visited by Maj. Newton C. Mead, MC, on the order

of the Surgeon, Mediterranean Theater of Operations, in the summer of 1945,

after the fighting had ended, in order to secure the required statistics.

direct followup of these patients would not have been practical, but

an indirect followup was possible. The Central Postal Directory Service supplied their current Army or civilian addresses, with the dates of transfer, and

also supplied information concerning the dates of transfer to other theaters

or of evacuation to the Zone of Interior. If the soldier had been sent to the

Zone of Interior, it was frequently possible to determine whether he had been

evacuated from hospital, sent home on furlough, or assigned to new duty.

These data permitted reasonable assumptions as to the type of duty performed

since operation and, in many cases, based on the length of time spent on each

assignment, permitted assumptions as to the efficiency of his performance.

The reports of the Adjutant General’s Office on theater strength and on

the number of weekly admissions for injuries provided background material

against which the importance of injuries of the meniscus could be assessed.

Material from the 26th General Hospital (129 cases) was analyzed separately. This hospital supported the Army Air Forces, and such hospitals, as

already pointed out, occupied somewhat special position.

Essential data.—In the 14 general and 22 station hospitals of the Mediterranean theater which were surveyed by the plan just described, there were

1,527 admissions for injuries of the meniscus during 1944. Elimination of

duplicate admissions, of cases in which the records were too fragmentary for

use, and of the 129 Army Air Forces cases reduced the number to 960 cases.

Six hundred and eighty-four of these nine hundred and sixty patients were

treated conservatively in the theater or returned to the Zone of Interior for

surgery, and 276 wore submitted to arthrotomy in the theater. The 684 patients treated conservatively spent 18,588 days in the hospital,

an average of 27.2 days per soldier. Their disposition was as follows:

Discharged to category (full military duty), after spending total of

5,961 days, and an average of 22 days, in the hospital, 271 patients (40 percent).

Discharged to category (limited duty), after spending total of 9,922

days, and an average of 30.72 days, in the hospital, 323 patients (47 percent).

Thedata could not be secured early enough for publication in the Marchreport and were analyzed personally later,

after all the material became available.
NONCOMBAT ORTHOPEDIC LESIONS 281

Classified to category (evacuation to the Zone ofInterior), after spending

total of 2,705 days, and an average of 30 days, in the hospital, 90 patients (13

percent).

The 276 patients treated by arthrotomy were classified as follows on their

discharge:

To category A, after spending an average of 57.2 hospital days, and an

average of 46.15 postoperative days, in the hospital, 132 patients (48 percent).

To category B, after spending an average of 74.61 hospital days, and an

average of 60.15 postoperative days, in the hospital, 120 patients (43 percent).

To category and returned to the Zone of Interior, after spending an average of 86.71 hospital days, and an average of 69.79 postoperative days, in the

hospital, 24 patients (9 percent).

The proportion of patients returned to category duty after arthrotomy

was substantially the same in both 1943 (46 percent) and 1944 (48 percent).

The difference in those returned to category duty in the years was also not

great (39 percent in 1943 and 43 percent in 1944). What is more significant

is that these percentages do not differ very greatly from the percentages of

patients returned to category duty (40 percent) and category duty (47

percent) in 1944 without operation. To express it differently, even the very

careful selection of cases practiced in 1944 did not materially improve the

chances of returning soldier to useful duty in the theater after arthrotomy,

while it took at least twice as long to accomplish by surgical measures substantially the same results as could be achieved without surgery.

The reduction in hospital-stay days, including postoperative-stay days,

in 1944 as compared with 1943, undoubtedly reflected better selection of cases

for surgery. The averages were often considerably increased by unsuccessful

attempts at conservative therapy, which in some instances lasted as long as 90

days. It is not entirely accurate to charge this time against surgical cases, but the error, such as it is, cannot be avoided. more or less prolonged trial of

conservative therapy will usually be necessary in the management of condition so difficult to evaluate as the recurring meniscus syndrome. The decrease

in hospital-stay days in 1944 was largely due to the elimination from the surgical

series of patients with atrophic quadriceps muscles, relaxed collateral ligaments,

and tendency to psychoneurosis and emotional instability. These are the

patients who always remain in the hospital for long periods of time after operation.

It is unfortunate that the basis of comparison and the estimation of results

in these two series must be classes of disposition, but in the 1943 series no figures

on actual duty performance could be secured for comparison. Furthermore,

the classification to duty at the time of discharge from the hospital did not

necessarily indicate the type of duty to which the soldier would be assigned when

he left the replacement depot or conditioning camp.

When the 1944 survey was undertaken, there was general feeling in the

theater that the performance of the patients returned to duty—and particularly

to full duty—was probably less good than the discharge classifications would
282 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

seem to imply. The attempt at followup studies in the 1944 survey was intended to settle this question by the indirect evidence of the length of timethe

soldier remained in the particular duty to which he had been assigned.

This information was available in 269 of the 276 cases in which arthrotomy

was performed. The length of the followup ranged from less than months

to months. Duty of less than months was not regarded as evidence of

satisfactory performance. On these criteria, when the investigation was concluded, 109 of the 132 troops assigned to full duty (82.6 percent) were still

performing their duties satisfactorily, as were 105 of the 120 assigned to limited

duty (87.5 percent). If these figures can be accepted at their face value, the

results of arthrotomy in selected cases in 1944 were reasonably satisfactory.

Results of arthrotomy in the 26th General Hospital.—The 26th General

Hospital, as already noted, was surveyed separately because of its predominantly air personnel. The orthopedic section of this hospital made the diagnosis of injury of the semilunar cartilage 224 times in 1944. One hundred

and nineteen patients were hospitalized, of whom 65 were treated conservatively and 54 by surgery. Fifty-two of the surgical histories were sufficiently

detailed for analysis.

The 65 patients treated conservatively spent an average of 15.74 days in

the hospital, as compared with an average of 27.2 days for the 684 patients

treated conservatively in other branches of the service. total of 95 percent

were discharged to full or limited duty (chiefly full duty) as compared with

total of 87 percent (chiefly limited duty) in ground troops.

The 52 arthrotomized patients spent an average of 42 days in the hospital

and an average of 29 postoperative days, against 64 days and 52 days, respectively, for ground troops. Ninety-eight percent were discharged to full or

limited duty (chiefly full duty) against 91 percent for ground troops. At the

end of the survey, 76 percent of those discharged to duty were known to be

performing their duties, against 71 percent for ground troops. The probable

reasons for better results in elective surgery in Army Air Forces patients have

already been discussed (p. 277).

Previously arthrotomized soldiers.—Seventy patients who had previously

been subjected to arthrotomy were admitted to hospitals in the Mediterranean

theater during 1944. It had been expected that great deal of useful information coidd be obtained from this group, but the expectation was not realized.

The surgery had been performed in overseas hospitals in only 16 cases, and

only in these cases was it possible to learn the details of the previous operations.

If, however, this small group is representative, it suggests that arthrotomy in

an overseas theater is an operation of doubtful value, for only of the 16 could

be returned to duty after their period of hospitalization. The other 11 were

sent back to the Zone of Interior, in instances specifically because of unstable

joints or severe synovitis.

In 19 other cases, the soldiers had demonstrated their ability to perform

useful duty after surgery, at least for certain period of time. Most of them

had done full duty, for an average of 15 months. The results of surgery,
NONCOMBAT ORTHOPEDIC LESIONS

however, were not permanent. When they were discharged from the hospital

on their second admissions in 1944, only of the 19 could be reassigned to

full duty, and had to be returned to the Zone of Interior. Moreover, of the

12 assigned to some duty in the theater, only were still assigned to it at the

time of the followup investigation in 1945.

Comment.—Although the statistical data in this survey were disappointing, they were sufficient to indicate trends and to substantiate, in large part,

clinical impressions. The important considerations of the studywere as follows:

1. The frequency of these knee injuries was greater than had been realized.

Statistics furnished by the Adjutant General’s Office, Mediterranean Theater

of Operations, indicated that on any given day in the theater 4,811 patients

were hospitalized as the result of nonbattle injuries and that injuries of the

meniscus were responsible for approximately 2.81 percent of these admissions.

These figures took no account of the large number of patients with this type

of injury who were under treatment while on duty status in the orthopedic

clinics throughout the theater. The inclusion of these figures would have

increased the proportion of meniscus injuries, though by how much is not known.

2. Many of the difficulties were the result of old athletic injuries. surprising number were blamed on obstacle courses in basic training. good

many of the more recent injuries were caused by falling or by twisting the knee

on night problems or on patrols on rough or mountainous terrain. Some

injuries were traced back to precipitate motions while under fire and in this

sense were combat incurred. Drunkenness was an influential factor in few

cases.

3. Accurate diagnosis was often difficult because the history, sometimes

deliberately and sometimes unconsciously, was colored by the soldier’s desire

to use the knee injury as means of avoiding combat dangers. The symptoms

of trick knee were sufficiently well known to occasional soldiers for them to

be able to recite histories which, although false, were extremely convincing.

The surgeon had to keep an open mind, so that his experiences with actual

malingerers and with patients who exaggerated their complaints would not

lead him, unconsciously, into considering all soldiers in this unfavorable light.

4. The diagnostic problems raised by the unreliability of many histories

were increased by the meager objective evidence which these patients so often

presented. One of the most useful objective signs was atrophy of the quadriceps; this process tends to occur rapidly after any knee injury, and its absence

always led to suspicion of the seriousness of the soldier’s complaints.

5. Although roentgenograms were made routinely, they were usually

negative. They were chiefly useful in ruling out chip fractures and osteochondritis dissecans.

6. Generally speaking, patient who presented himself with locked knee

which could not be unlocked by few days of traction became an automatic

candidate for surgery. He was totally disabled, and he could become of military usefulness only when the acute condition was relieved. Manipulative

reduction under anesthesia was substituted for arthrotomy if there was any
284 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

contraindication to the joint operation. If the roentgenograms revealed osteoarthritis, manipulative reduction was usually used.

The patients whose knees were either unlocked on admission or could be

readily unlocked with traction sometimes told story of recurrent locking.

The problem in these cases was not one of diagnosis but one of expediency.

The decision to perform operation or withhold it had to be based on the possibility of the individual soldier’s future usefulness in the theater and the length

of time it would take in the hospital and in rehabilitation for him to achieve

duty status. Statistics for the theater indicated that even in carefully selected

cases, return to full military duty could be accomplished in less than half of all

arthrotomized patients. Of the surgical cases surveyed in 1945, 82.6 percent

of the 132 troops assigned to full duty were successfully performing their duties

from to months after operation. Only 16 of the 109, however, 14.7 percent,

were serving with infantry units, in which the need was greatest and combat

was most arduous and most dangerous.

Routine classification for temporary limited duty for all arthrotomy cases,

with special care in assignment to duty, might have been better solution than

the attempt, so soon after surgery, to distinguish between soldiers fit for full

duty and those fit only for limited service. This plan would have been effective, however, only if each case could have been carefully reviewed within

minimum of 90 days by board of medical officers well versed in knee-joint

surgery. Such policy would have resulted in shortened hospitalization and

more satisfactory final disposition of these patients. Without specially

qualified disposition board, it would not have been effective, and the system

employed probably gave about as good results as could have been expected.

7. The prognosis for arthrotomy for knee injuries was much less favorable

in overseas hospitals than civilian experience might suggest. One reason was

that the patients could notreceive the close personal attention from the surgeon

which is so desirable in such operations. postoperative routine of quadriceps

exercises, for instance, often had to depend for its success on such attention as

overworked ward personnel could give to it; when battle casualties were numerous, attention to such refinements was necessarily scant. The chief difference

between military and civilian practice was that some soldiers regarded the

hospital as haven from the dangers of battle, and their cooperation in rehabilitation exercises was good deal less than enthusiastic.

The comparison between football player with knee injury and soldier

with the same type of injury, although often made, was never sound. Because

athletes can return to violent activity on the football field within to weeks

after menisectomy, it did not follow that soldiers could return to combat duty

within similar period of time. The circumstances are widely different. The

injured athlete, outside of the game, is in the hands of trainer and has access

to heat lamps, massage, and otherforms of therapy. When he goes on the field,

his knee is well strapped. He remains in the game for only brief periods at

first and may be removed on the first indication of trouble. Even at its
NONCOMBAT ORTHOPEDIC LESIONS 285

roughest, football game is divided into alternate periods of action and rest,

and at the most only an hour is spent in actual play.

The lot of an infantryman is very different. He must carry heavy packs

and equipment many miles over rough ground or mountainous terrain, often

in darkness, often in rain, snow, or mud. He cannot, like the football player,

leave the game. He must continue until his mission is accomplished, even if

his knee swells and is painful. When he has an opportunity to rest, it is likely

to be in wet foxhole, often in cold and freezing weather. The commanding

officer of combat unit cannot always, like football coach, consider his men

first and the outcome of combat next. He must utilize every man at his dis- posal. man unable to keep up with his comrades is liability.

The chief fallacy of the comparison concerns morale. The football player,

anxious to retain his place on the team, cooperates in every effort at rehabili- tation. The infantryman has only his sense of duty to urge him back to combat.

Every instinct of self-preservation makes him call attention to any symptom

from his knee. It requires man of strong character to return to combat and

to stay in it in spite of knee which swells and becomes painful when it is

overtaxed. This is why such stress was put upon favorable mental attitude as

an absolute prerequisite to surgery of the knee joint in any theaterof operations.

Technical considerations. —Techniques of menisectomy were practically

the same in all hospitals in the Mediterranean. Tourniquets were used universally. straight, short incision medial or lateral to the patella was also used

universally; sometimes it was curved into or reverse J. Retractors were

employed, of such shapes as to minimize intra-articular trauma.

An attempt was always made to remove as much of the cartilage as possible through the anterior incision. separate posterior incision was sometimes made to insure that it had been entirely removed. The trend to total

removal of the cartilage through two incisions became somewhat more marked

as the war progressed. When the cartilage was entirely in the intercondylar

notch or when it could be placed in it after lateral dissection, total removal

was effected, for all practical purposes, through an anterior incision only. If

half inch or so was left in situ, no difficulties need be expected. When, however, the cartilage could not be displaced into the notch, it was best to make

separate incision posteriorly to remove the remaining inch or inch and half.

The majority of surgeons excised the fat pad only if it was swollen and appeared

chronically inflamed. Routine removal was not practiced because postoperative effusions, which required aspiration, seemed somewhat more frequent when

the pad was removed.

One hospital which used sulfanilamide powder in the joint in about half

of its cases discontinued the practice when postoperative synovial thickening

was found to be more frequent than in the cases in which the sulfa drug was

omitted. One or two hospitals used posterior plaster slab for week, but

pressure dressings alone were most often employed.

396961 57 20
286 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Preoperative and postoperative quadriceps exercises were always stressed.

One or two hospitals permitted weight bearing on the second or third postoperative day and encouraged rapid return to complete ambulation. The majority of surgeons preferred to delay weight bearing until to 10 days after

operation and to keep the patient on crutches for the next or weeks. Whatever the practice, care was always taken to see that the ability to extend the

knee completely was not lost.

JOINT MICE (OSTEOCHONDRITIS DISSECANS)

Loose bodies in the joint and osteochondritis dissecans are conveniently

discussed together. They are related clinically and the terms were often used

interchangeably on the histories examined in Mediterranean-theater hospitals.

It must not be inferred, of course, that all loose bodies observed were the result

of osteochondritis dissecans. The term is technically reserved for those cases

in which definite defect of the articular surface is demonstrable by roentgenograms or at operation. The defect may contain an avascular osteocartilaginous body, or the affected nodule may have been extruded into the joint

cavity.

Osteocartilaginous loose bodies were not seen frequently enough in Mediterranean-theater hospitals to be regarded as common cause of disability.

They were, however, encountered often enough to warrant the adoption of

policy for their management.

Data sufficient for evaluation of the usual methods of treatment in this

condition were secured from the 12th, 33d, and 45th General Hospitals.

total of 29 arthrotomies was performed for joint mice in these hospitals over

the same period in which about 84,500 patients were admitted for all causes.

Of the 29 operations, 22 were on the knee, on the elbow, and on the ankle

joint.

Avascular nodules were removed from craters in the femoral cond}de in

of the 22 arthrotomies on the knee joint; the crater was then curetted, and

overhanging articular cartilage was removed. Two patients were discharged

to limited duty, and the other two were evacuated to the Zone of Interior.

Ten of the remaining patients, who presented defects of the patella or who required no treatment of the crater, were discharged to full duty, and five others

with the same conditions were discharged to limited duty. The disposition of

three other patients in this category is unknown.

Three of the four patients operated on for loose bodies in the elbow joint

were returned to full duty. The disposition of the fourth case is unknown.

All three patients subjected to arthrotomy of the ankle joint were classified

to limited duty.

Statistical conclusions would not be warranted in so small number of

cases, but discussions with many orthopedic surgeons in the Mediterranean

theater permit certain generalizations. Disposition to appropriate duty without arthrotomy was recommended when the loose body was not producing
NONCOMBAT ORTHOPEDIC LESIONS 287

symptoms and did not change its position on repeated roentgenologic examina- tion. This policy avoided the loss of service time and conserved hospital space

and medical effort. If the symptoms were troublesome, the policy depended

upon the joint affected. In non-weight-bearing joint such as the elbow, which was otherwise adequate, the results of surgery were likely to be good

and return to duty reasonably prompt. If weight-bearing articular surface

was affected, especially if the defect was large, it was unlikely that the results

would be good enough and return to duty prompt enough to justify operation

in an overseas theater. In any event, surgery for joint mice and osteochondritis dissecans was permitted only by qualified orthopedic surgeons, only in

general hospitals, and only after complete investigation of the patient as well

as his orthopedic status.

RECURRENT DISLOCATIONS OF THE SHOULDER

The lack of uniformity in the management of recurrent dislocations of

the shoulder in the hospitals of the North African theater early in the war was

officially eliminated in November 1943 when Circular Letter No. 48 was issued

from the Office of the Surgeon, North African Theater of Operations.

previous history of recurrent dislocation of the shoulder was not to be accepted

per se if it rested on the soldier’s testimony. Instead, diagnosis was to be

made only if history of one or more episodes, preferably with supporting

roentgenologic evidence, appeared on the Army medical record. Operation

was to be undertaken only with the written approval of the disposition board of

general hospital following demonstration that the disability was such as to

prevent noncombat duty and then only when the soldier’s age and mental

attitude offered reasonable prospect of military rehabilitation.

Guided by these general instructions, an experienced surgeon was permitted to formulate his own policies of management and select such surgical

techniques as he preferred.

Survey of cases.—In an effort to determine the effectiveness of this policy,

survey of the cases observed in the theater in 1944 was carried out in 1945,

by the plan already described for derangements of the knee joint. The survey

covered the experiences of 16 general and 25 station hospitals. Five other

hospitals were not surveyed, for one reason or another, but it was not thought

that the small number of patients missed would in any way alter the value of

the investigation. Data were not available from all hospitals for all items

desired.

In all, there were 314 admissions for this cause during 1944, 71 of which

were duplicate admissions, which reduced the number of cases to 243. Thirtyeight of the 243 patients were treated by surgery and 205 by conservative

measures. Operation would have been justified in almost all of these patients

in civilian life, and the fact that only 15 percent were submitted to surgery

indicates an extremely conservative attitude toward surgery for recurrent

dislocations of the shoulder in theater of operations.
288 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

The 205 patients treated without operation on whom information as to

disposition was available spent total of 3,566 days in the hospital, which is

an average of 17.4 days. Disposition was as follows:

Discharged to full duty, after spending total of 1,224 days, and an

average of 13.02 days, in the hospital, 94 patients (46 percent).

Discharged to limited duty, after spending total of 1,736 days, and an

average of 21.17 days, in the hospital, 82 patients (40 percent).

Classified to category C, after spending total of 606 days, and an average

of 20.9 days, in the hospital, 29 patients (14 percent).

The 30 (of 38) patients treated surgically on whom information as to

disposition is available spent total of 1,874 days in the hospital, which is an

average of 62.47 days. Disposition was as follows:

Discharged to full duty after spending total of 515 days, and an average

of 51.5 days, in the hospital, 10 patients.

Discharged to limited duty after spending total of 1,359 days, and an

average of 67.95 days, in the hospital, 20 patients.

There were no category dispositions in this group. If the original

category and dispositions could have been maintained, on which matter

there is no information, these are reasonably satisfactory results.

One hundred and twenty of the 205 patients not operated on were discharged from general hospitals and 85 from station hospitals. The proportionate distribution of the various types of disposition showed considerable

differences in the two types of installation. In the 16 general hospitals included

in the survey, 30 percent (36) of 120 patients were classified as category A,

50 percent (60) as category B, and 20 percent (24) as category C. In the 25

station hospitals, the respective proportions were 68 percent (58) category A,

26 percent (22) category B, and percent (5) category C. Both the total- and the average-stay days were also materially fewer in the station hospitals.

At first glance, it is hard to see why the results in the station hospitals

should be, apparently, so much more favorable than in the general hospitals.

Superiority of treatment does not explain it, for the same conservative measures, chiefly rest and physical therapy, were used in both. Analysis of the

preliminary figures seems to furnish the explanation, which is that considerable

number of the patients discharged from the general hospitals had been transferred to them from station hospitals, chiefly, it would seem, because they

presented problems of management and disposition. These patients required

longer time for investigation and in general represented less favorable

group of cases. They therefore, it. is reasonable to assume, not only increased

the average period of hospitalization in general hospitals but also required

greater percentage of category and dispositions in those institutions. It

also seems probable that the attitude toward disposition was more conservative in general hospitals and the criteria for category disposition somewhat

stricter, than in station hospitals. Disposition in noncombat injuries of

all sorts was always matter of judgment, not of rules, and neither documentary

nor statistical data are available to confirm or disprove this reasoning.
NONCOMBAT ORTHOPEDIC LESIONS 289

It should be borne in mind, in interpreting these statistics, that most admissions to station hospitals were noncombat troops and that admissions

to general hospitals were combat troops plus transfers from station hospitals.

Station hospitals would therefore be expected to make more category dispositions.

Comment.—The relative frequency with which recurrent dislocation of the

shoulder was encountered in the Mediterranean Theater of Operations was

frankly surprising to some orthopedic surgeons, who regarded the number of

cases as disproportionately great in comparison with civilian experience. As

matter of fact, the actual number of cases observed was considerably greater

in 1944 than the 243 upon which this discussion is based. This number makes

no allowance for the soldiers treated on duty status in dispensaries and outpatient clinics. What proportion of the total cases is represented by the 243

cases treated in hospitals it is not possible to say. It is clear, however, that

these soldiers furnished serious medicomilitary problem. Their disability

made them an actual loss to their organizations and also required the utilization

of medical personnel and hospital facilities, sometimes for long periods of time.

Before the management of any case ofrecurrent dislocation of the shoulder

was decided upon, it had to be evaluated individually, in the light of the following considerations:

1. It had to be established that the lesion was true dislocation. It was

not uncommon to find that what patient called dislocation was simply

relaxation of the joint, associated with frequent subluxations and general

feeling of instability. An occasional soldier could produce, at will, luxation of

sufficient extent to be demonstrated to the medical examiner. Some, who were

malingerers at heart, could furnish glib history of numerous previous recurrences. careful series of questions and careful physical examination usually

settled the matter, but many medical examiner, in these circumstances, was

glad to be able to fall back on the instructions in North African Theater of

Operations CircularLetter No. 48, that there must be definite Medical Department record of previous dislocation or supporting roentgenogram before the

diagnosis was made or concurred in.

2. The degree of disability caused by the lesion had to be determined.

Intelligent management and disposition were impossible without such an evaluation. Dislocation of the shoulder was seldom completely disabling except

for brief period following the actual luxation. The type of dislocation followed

by partial disability for few days or even few weeks was the variety most

often seen in Army orthopedic clinics. Itrendered the soldier unfit for combat

infantry duty, as well as for certain other types of duty, but still permitted

him to handle many useful assignments without danger of serious or permanent

injury to himself.

In some cases, the dislocation recurred frequently, sometimes every few

weeks. There was no pain between the episodes, and no disabling muscle

atrophy occurred. Fear of recurrence, however, materially reduced the

soldier’s efficiency and in sense made him chronically disabled; he tried not
290 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

to abduct his arm because he was afraid of producing recurrence. This type

of lesion was amenable to surgery; it was fear rather than the lesion per se

which disabled the patient. On the other hand, surgery promised very little

from the standpoint of returning him to useful duty if muscle atrophy or painful

tendonitis was part of the clinical picture. In such cases, it was best to defer

disposition as long as possible and permit the soldier to continue in his current

assignment. patient in this condition was practically never found in frontline service, and the outcome of operation sometimes resulted in his further

downgrading.

3. When case suitable for surgery was encountered, two points had to

be settled before operation was recommended. The first was whether the

prognosis with surgery was good for some form of duty in the theater. If it

was not, operation was not justified overseas, and the correct policy was either

to continue the soldier in his current assignment, if he were capable of performing his duties, or to return him to the Zone of Interior for surgery. The second

point was related to the first. What was the man’s mental attitude? This

consideration always had at least as much to do with the decision to undertake

surgery as did the physical lesion, and in some instances it had more to do

with it.

4. The final consideration was the essentiality of the soldier. Key personnel were sometimes operated on overseas, in disregard of ordinarily accepted

criteria, because they were regarded as useful or essential. Nonessential men

were left in their current status or, if surgery was clearly indicated, were

returned to the Zone of Interior for treatment.

FRACTURES OF THE CARPAL SCAPHOID BONE

The results of the methods used in fractures of the carpal scaphoid bone

during the North African campaign were not conclusive, and considerable doubt

was felt as to the soundness of the techniques employed and the criteria of disposition. Circular Letter No. 48, Office of the Surgeon, North African Theater

of Operations, 1943, offered guidance in the management of this injury as

follows:

Greater care must be exercised in making precise and prompt diagnosis

of carpal fractures and dislocations, since early reduction is essential for

satisfactory result. Surgical treatment of an old, unrecognized fracture of the

scaphoid will not rehabilitate soldier. If his disability is complete, he should

be transferred to the Zone of Interior.

The exact method of treatment was left to the decision of the surgeon

who encountered the case, and disposition was according to the judgment of

the disposition board of each hospital.

Survey of cases.—In an effort to determine the effectiveness of the methods employed in the management of fractures of the carpal scaphoid bone,

survey of the cases observed in the theater in 1944 was carried out in 1945

along the general line of the plan described for derangements of the knee joint.
NOXCOMBAT ORTHOPEDIC LESIONS 291

Because of the nature of this injury, the circumstances of this survey

and of the surveys already described were not entirely similar. As in the other investigations, no account was taken of patients not hospitalized for

their injuries, which means that the number of carpal scaphoid fractures analyzed does not nearly indicate the total number of cases observed. This

injury was often treated in outpatient clinics, without hospitalization. At

the 182d General Hospital, for instance, there were no admissions for this

cause during 1944, but 50 carpal scaphoid fractures were treated in the outpatient clinic. Unfortunately, the records for outpatient clinics were generally so fragmentary as to make their use in this investigation worthless.

Patients with fractures of the carpal scaphoid bone, particularly in station

hospitals, were often discharged to duty or to quarters status after the fracture had been reduced and they had adjusted themselves to their casts, the

remainder of their treatment being conducted in outpatient orthopedic clinics.

As result, the figures collected for hospital-stay days do not nearly reflect

the length of time required for return to duty or other disposition. They

merely show the length of time hospital facilities were utilized in the care

of carpal scaphoid fractures and do not indicate the length of time the men

affected were unable to perform useful duties for their organizations.

The information analyzed includes data from the hospitals transferred to

the European theater after the invasion of southern France. These hospitals,

however, were not asked to supply the number of carpal scaphoid fractures in the hospital March 1945, as, obviously, no such patients were from the

Mediterranean theater. On this date, there were 58 patients with carpal

scaphoid fractures in the general and station hospitals in the Mediterranean

theater. Admissions for noncombat injuries during the week ending March

1945 had numbered 3,335. This means that fractures of the carpal scaphoid

bone accounted for 1.73 percent of all such admissions.

During 1944, 16 general and 23 station hospitals in the Mediterranean

theater reported the admission of 291 soldiers with fractures of the carpal

scaphoid bone. The number of cases available for analysis is reduced to 180

by the elimination of 92 duplicate admissions and of 19 other cases in which

the records were too incomplete to be used. Disposition of these patients

was as follows:

Returned to full duty, after average hospitalization periods of 44.89 days,

128 patients (71 percent).

Returned to limited duty, after average hospitalization periods of 79.21

days, 27 patients (15 percent).

Classified to category C, after average hospitalization periods of 49.28

days, 25 patients (14 percent).

Since the average time for the healing of carpal scaphoid fractures is to

months, no clinical significance can be read into the figures for hospitalization. Most of the category and dispositions must have been made with

the hand and forearm still in plaster, the patients being assigned to light

duties with their outfits. Whether the dispositions made when they were
292 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

discharged from the hospital prevailed when the casts were removed it is

not possible to say.

Methods of management.—Although no theaterwide policies of management were established, orthopedic surgeons all tended to use the same general

principles in carpal scaphoid fractures. Both military and civilian experience

indicated that one routine was required for recent or fresh fractures and

another for old fractures. The prognosis of fresh fractures was good if early,

efficient immobilization was instituted and was continued until union had

occurred, assuming, of course, that the fragments were in good position.

The prognosis was less good, and was often poor, if adequate treatment was

not begun within the first few days after the injury or if immobilization was

inadequate or was not continued until healing occurred. If the blood supply

of the fragments, as demonstrated by roentgenograms, remained adequate,

healing could be expected under proper management in to months. If

one or more of the fragments was avascular, healing was likely to be delayed

and was frequently unsatisfactory.

The following principals, based on these concepts, were followed by many

surgeons in the theater. If they had been universally adopted, most of the

poor results observed in these injuries would have been avoided.

All sprains of the wrist were examined roentgenologically, with the idea

of demonstrating or eliminating possible fractures of the carpal scaphoid bone.

This was an essential precaution. In the orthopedic clinic of the 182d General

Hospital, all nine of the old carpal scaphoid fractures which had to be treated

for nonunion had been regarded as sprains when they were sustained and bad

not been correctly immobilized. The situation was entirely different in 41

fresh injuries, which were recognized as soon as they occurred and were

promptly and properly immobilized. Healing was complete in every instance

within 12 weeks, and the fracture line had usually disappeared entirely by this

time. smaller series from the 46th General Hospital also pointed to the role

of the missed fracture in poor results. In this hospital, disposition-board

records showed that or nonunions of carpal scaphoid fractures occurred in

cases in which early care had not been given, while the course of 12 promptly

treated fractures was uncomplicated and satisfactory.

If fracture was not demonstrable in the roentgenograms but it still seemed

likely that the bone had been broken, the wrist and thumb were put up in

plaster cast. The cast was removed cautiously at the end of weeks, and additional roentgenograms were made. new cast was applied if fracture was

visualized on these films.

If fracture was visible in the first roentgenograms, plaster cast was at

once applied. It included the forearm and hand, with the thumb encased to

the distal joint. The wrist was in dorsiflexion and radial deviation, and the

thumb was abducted and in the position of semiapposition. The cast extended

only to the distal palmar crease and allowed free finger motion, which made it

practical for the patient to use his hand for light, simple work. He was told
NONCOMBAT ORTHOPEDIC LESIONS 293

that correct immobilization would determine the end result and was instructed

to report to the clinic as soon as the cast became loose or soft.

The cast was removed between and weeks after it was applied, and additional roentgenograms were made. At this time, it was possible to determine

the vascularity or avascularity of the fragments and to arrive at some decision

as to disposition. If calcification seemed to be proceeding and union to be

occurring, the prognosis was considered good, and the patient was retained in

the theater of operations for further treatment. If the relative density of one

or more fragments indicated avascularity, the prognosis was not considered

good. The healing process in such case was likely to be prolonged, possibly

requiring many months, and unless treatment could be continued in an outpatient dispensary disposition to the Zone of Interior was recommended. Continued use of overseas hospital facilities was not regarded as justified under these

circumstances.

Complete, sound healing of carpal scaphoid fracture could be assumed

only when the fracture line had completely disappeared. Immobilization was

necessary until there was roentgenologic proof that this had occurred.

Old carpal scaphoid fractures, which had been unrecognized or had been

treated improperly, were likely to show nonunion; avascular necrosis; and

traumatic arthritis, with instability of varying degrees. Some soldiers with

lesions of this kind could perform combat duty. Others suffered from so much

pain and weakness that they were more or less disabled and were often unfit

even for limited duties.

The procedures employed to correct the consequences of neglected carpal

scaphoid fractures included drilling, bone grafting, excision of the fragments,

or prolonged immobilization. All gave uncertain results and treatment was

likely to be time consuming. Such methods were therefore not indicated in

theater of operations unless the particular officer or enlisted man was performing

essential duties and the prognosis in the case was particularly favorable.

Careful evaluation and correct disposition of patients provided the answer

to the problem of old carpal scaphoid fractures. period of observation, during

which rest and physical therapy were employed, might promise enough improvement to justify assignment to limited service or even to full duty. If treatment

was likely to be prolonged, however, it was not logical to institute it overseas.

If the soldier’s disability prevented his performing even limited service in the

theater, the better plan was prompt evacuation to the Zone of Interior.

Ninety-five records of old carpal scaphoid fractures ere available for

analysis in the 1944 survey. Less than half of the soldiers (40) could be

returned to full duty, after spending an average of 23.23 days in the hospital

and unknown periods of time in further treatment in outpatient clinics. The

remaining patients were almost equally distributed between categories and

C. The hospital-stay days in the category group averaged 31.54 days and

in the group 19.41 days. There was no economy of military manpower and

medical facilities in these results.
294 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Principles of disposition.—In carpal scaphoid fractures, as in other noncombat injuries in which the symptoms were chiefly subjective, the mental

attitude of the patient was of primary importance in determining his disposition. Exaggeration of minor difficulties was often suspected but was

extremely difficult to prove. The soldier who persisted in his complaints was

usually, therefore, successful, at least eventually, in his attempts to avoid

duty. Frequently he had to be given the benefit of the doubt. The disposition board had the major responsibility of conserving manpower for combat, but

it had an equally important responsibility in limiting the duties of soldiers

to work which they could reasonably be expected to perform successful!} and perform without injury to themselves.
295

CHAPTER XI

Disposition of Patients From Orthopedic Services

of General Hospitals

GENERAL PRINCIPLES OF DISPOSITION

An important phase of the management of wounded in any overseas

hospital was to determine, as promptly as possible, the expected duration of

hospitalization required for each patient before return to duty or some other disposition. Ideally, this determination was made immediately after the

patient’s admission to the hospital, on two military principles, (1) that because

manpower, resources, and other hospital facilities were limited, they must

be conserved and utilized as efficiently as possible; and (2) that soldier who

could not be returned to duty with reasonable degree of promptness should

be evacuated farther to the rear or to the Zone of Interior, in order to leave

empty beds and other hospital facilities for casualties arriving from areas

farther forward.

In forward hospitals in the Mediterranean theater, holding policies varied

with the rate of casualty flow. When casualties were heavy, only those patients

expected to return to duty within 48 hours were held. In very quiet periods,

on the other hand, the holding time might be extended from 10 to 21 days.

The great majority of duty dispositions from forward hospitals, in addition

to those for medical conditions, were for minor sprains, bruises, and superficial wounds. Patients with bone and joint injuries obviously had to be sent

to the rear, for care in fixed hospitals.

The same plan of prompt estimation of hospitalization time was employed

in fixed hospitals, so that soldiers whose military value to the theater was

ended could be sent to the Zone of Interior as soon as was feasible. In the

Mediterranean theater, soldiers whose return to duty could be expected within

90 days or, at other times, within 120 days, were held for treatment in the

theater. All others were evacuated to the Zone of Interior as soon as was

compatible with good surgical practice.

In practice, the determination of transportability was always on an

individual basis. Not only the risk to life but the possible effect of evacuation

on future function and anatomic restoration were considered in the timing.

The general plan was to effect the transfer during some lag period of treatment, when no specific therapeutic procedure was required. It was also

The extensive data onwhich the material in this chapter is based were collected and tabulated by Lt. Col. George

A. Duncan, MC, 45th General Hospital.
296 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

necessary to correlate individual transportability with the availability of

transportation facilities.

Civilian standards for discharge from the hospital or return to work were

not applicable in military dispositions. soldier returned to duty had to be

ready to perform all his assigned tasks in his special branch of the service.

For that reason, hospitalization was necessarily prolonged in comparison

with the period which would be required for comparable condition in civilian

practice.

Dispositions in the Mediterranean theater were as follows:

Category A, to full duty.

Category to replacement depot for weeks. As practical matter,

most patients discharged from fixed hospitals were sent to these depots. Those

who had been classified as category were returned to duty at once. The

others (category underwent reconditioning for weeks. At the end of this

time, each soldier appeared before medical board consisting of surgeon, an

orthopedic surgeon, and an internist, for determination of his final disposition.

As general rule, some 80 percent or more of men classified as category

had their classifications raised to at the end of the reconditioning period.

Replacement centers, like the convalescent centers organized in fixed hospitals,

were operated in the Mediterranean theater by the Combat Conditioning

Command.

Category B, to limited-duty assignment, usually noncombatant.

Category C, to the Zone of Interior.

In the early days of the Mediterranean theater, there was decided

tendency to hold some soldiers with bone and joint injuries in the theater, in

the hope that they could be returned to duty. This tendency was strengthened

by the pressure brought upon the Medical Corps bj' combat commanders to

return as many men as possible to duty. Orthopedic surgeons fully appreciated

the importance of the maintenance of manpower, but many of them felt

and events proved that they were correct—that the pressure exerted in favor

of duty dispositions would result in the return to duty of many soldiers of

questionable fitness, who would be unable to carry out the tasks expected of

them and who would thus be liability to their commands.

As experience increased, the fallacy of the original policy as it applied to

bone and joint injuries became apparent. The very nature of the injuries

which required the admission of the patients to the orthopedic sections of

fixed hospitals automatically established many of them as immediate candidates

for evacuation to the Zone of Interior as soon as their condition permitted.

The best that could be expected for others was disposition to limited assignments, usually noncombatant, within the theater. Only limited number of

casualties with simple fractures and very much smaller number with major

compound fractures or with joint injuries of any severity could be returned to

duty within 120-day holding period, much less 90-day period. Even

wounds of the hands and feet with only moderate bone and joint damage resulted in long periods of disability, and the majority of dispositions in these
DISPOSITION OF PATIENTS 297

groups had to be to category or C. The few patients with injuries of the long

bones who could be returned to full or limited duty had usually sustained

incomplete fractures.

For large part of the war, it was the practice in many forward hospitals

to evacuate to the rear soldiers with chronic, noncombat conditions related

to the bones and joints. This was regrettable expenditure of medical effort

and hospital-bed space. Some of these men, it is true, obviously required

category disposition, and their evacuation to the rear was justified. Many

of them, in fact, should never have been sent to serve in forward combat units.

The others, however, required no additional treatment, and their cases could

have been disposed of immediately in forward hospitals by their prompt return

to duty. The practice, described elsewhere (p. 272), of screening these men

directly behind the battlefront, which was instituted in the late months of the

war, was the solution of this particular problem.

The return to duty of patients with injuries to bones and joints from

general hospitals overseas was considerably less than might have been expected, even in the light of the nature of most injuries of the bones and joints.

large part of the explanation in such cases was the mental attitude of the

soldiers. It was difficult to maintain proper attitude toward return to duty

after long periods of hospitalization, and the experience of the Mediterranean

theater paralleled the experience in other theaters, that the farther from the

firing line soldier was removed, the more difficult it was to get him back to

full duty, even when his condition was such that return to full duty was entirely justified.

SAMPLE HOSPITAL EXPERIENCE

An analysis of the disposition of 4,287 patients with bone and joint injuries and diseases treated on the orthopedic section of the 45th General

Hospital during 1944 bears out what has been said earlier in this chapter.

This hospital had come into the North African theater early in 1943 and by

the beginning of 1944 was thoroughly experienced in the problems of military

orthopedic surgery, including the problem of disposition of patients. Its

experience may be taken as typical of the experiences of many other general

hospitals in the theater.

The 4,287 patients in this series represented approximately 20 percent of

the total (medical and surgical) hospital admissions for 1944. More than 60

percent were battle casualties. The cases further represented 5,203 separate

orthopedic diagnoses and 1,546 diagnoses of additional injuries not connected

with the bones and joints.

Of these 4,287 patients, 24 percent were returned to full duty, either

directly from the 45th General Hospital or after the 6-week period of reconditioning just described. Nineteen percent were returned to limited duty in the

theater. The remaining 57 percent were evacuated to the Zone of Interior.

The predominance of Zone of Interior (category C) dispositions is the more
298 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

impressive when it is recollected that the total figure of 4,287 includes innumerable sprains, many non-combat-connected simple fractures, and many chronic

noncombat orthopedic conditions. The patients in these special groups accounted for large number of the category dispositions to full duty.

Very few patients with compound fractures of the long bones of the

extremity were returned to duty within the theater holding period of 90 or

120 days. Of 374 patients withfractures of the femur of all types, for instance, only 19 were returned to full duty, and 334 were evacuated to the Zone of

Interior. The same proportions held for most patients with fractures of the

bones of the leg and of the arm and forearm. Even fractures of bones of the

hand and foot disqualified large number of patients for further overseas duty.

In 179 compound fractures of the metacarpal bones, for instance, there were

91 dispositions to category and only 49, wellunder third of the total number,

to full duty. In 224 compound fractures of the metatarsal bones, there were

150 dispositions to category and only 43, less than 20 percent of the total

number, to full duty.
299

APPENDIX

Pertinent Circular Letters

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 512

15 May 1943

CIRCULAR LETTER NO. 13

MEMORANDA ON FORWARD SURGERY

1. Surgical Echelons,

a. The welfare of the patient and the tactical necessity for rapid evacuation demand clear understanding of the function or mission of each unit of

the Army Medical Corps. This is best arrived at by dividing the treatment

of casualty into two stages—primary and definitive. Separate groups of

units provide each stage of treatment. In general, the equipment of each

group is designed for that purpose only.

h. Stations of the first and second echelons—Aid Stations, Collecting

Stations and Clearing Stations are equipped and staffed for the primary phase

of treatment. Arrest of hemorrhage, splinting of the injury, resuscitation

measures needed to make the patient transportable and administration of

sulfonamides are the urgent functions of these stations. In addition, the

treatment of minor injuries that allow immediate return to duty is carried out

without evacuation. Clearing Station is not designed to provide definitive

treatment of battle casualties.

c. During combat, especially with long distances in evacuation to the

rear, Surgical Teams are attached to certain Clearing Stations. It is their

function to give emergency surgical treatment to selected cases requiring

immediate operation. This treatment would not otherwise be available in

this echelon. The lack of facilities for pre-operative X-ray examination and

for post-operative care of adequate duration place grave responsibility on the

surgeon in the selection of cases for surgery. These same limitations exist during

quiet times. The length of the evacuation line to the next echelon and changing

tactical conditions require frequent redefinition of the surgery undertaken in

the clearing station.
300 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

d. It must be remembered that the lightly wounded soldier, or casualty

due to accident may regain full combat status within the Theater if proper

surgical treatment is carried out, but the Theater may be deprived of his

service by faulty surgical judgement. Because surgical procedure appears

simple is not sufficient reason for performing it in Clearing Station unless the

man can be returned to immediate duty without evacuation to the rear.

e. Hospitals of the third echelon (Evacuation Hospitals) are designed

to initiate definitive surgical treatment to battle casualties. The more delay

there is before reaching this echelon and the more hands the patient passes

through in reaching it, the poorer will be the final result. The evacuation line

is not an assembly line in which each surgeon does his bit to the patient. It is

conveyance line along the course of which the progress of the patient may be

halted to save life or limb or render him transportable.

/. While Evacuation Hospitals are adequately equipped and staffed to

perform rehabilitation operations, it is not the function for which they were

designed. Even in quiet times these patients are evacuated to the fourth

echelon for operation unless the Commanding Officer assumes full responsibility

based on knowledge of the existing tactical situation as well as the surgical

aspects of the individual case.

2. Surgical Procedures.

a. Dressings: Ideally, the primary phase of treatment is completed in

the first unit reached that is equipped to provide it. The dressing is then left

undisturbed until the patient reaches an Evacuation Hospital for operation.

There are certain safeguards and adjustments that must take place enroute,

but these do not include inspection of the wound by removal of the dressing unless

definite indications are present. compound fracture is halted at the Clearing

Station for more adequate immobilization or resuscitation, but this need not

involve redressing the wound unless there is reason to arrest continuing hemorrhage. wound is not redressed solely for the purpose of reapplying local

sulfonamide. Oral administration is sufficient safeguard.

b. The same principles apply after operation has been completed and

the patient is being evacuated to the rear.

c. Uninformed hands do unnecessary dressings. The best safeguard for

the patient is an adequate and legible record that accompanies him. receiving officer is then in position to refer to the record instead of looking at the

wound. Many wounds after debridement and arrival at the base can be

closed by secondary suture. Infection arising from contamination at the

time dressings are changed makes this impossible.

d. Wound Management: Common mistakes in war surgery are: (1)

Suture of wounds. (2) Tight Plugging by Packs. Hemorrhage is controlled

by stitch ligature if from large vessel. Otherwise, by temporary pack,

elevation and firm pressure. If pack is left in wound make note that it

should be removed at the first opportunity. Vaseline gauze is laid loosely in

wound, not packed in. (3) Failure to Immobilize Site ojInjury. Large wounds
APPENDIX 301

are immobilized even though fracture has not occurred. (4) Overexcision of skin. Circular defects are slow to heal. Very little skin need be excised, and

in some instances none at all. (5) Failure to Open Deep Spaces during definitive

treatment by freely incising fascial planes.

p. Compound Fractures: It is essential to distinguish splinting applied

for limited time as transportation splint from apparatus or splinting designed

for reduction and prolonged or rigid immobilization. An adequate transportation splint prevents additional soft part injury and further deformity. It

cannot in itself cause nerve injury, pressure sores, or jeopardize the circulation

of the extremity. It provides adequate fixation for ambulance transport over

rough roads, but may not secure the fragments in rigid fixation or exert the

traction necessary for further reduction.

q. Plaster Casts: more liberal use of plaster of paris casting is urged.

Plaster casings or slabs applied as temporary transportation splints are padded

and either bivalved or completely split. Encircling bandages and cotton

rolling under the cast are also split as it soon becomes inflexible with dry blood

or serum. Plaster casings applied directly to the skin are rarely found advisable

in forward areas. If skin plaster is applied for definite indication, bony

prominences are padded and the cast is immediately split in its full length.

No encircling bandages or adhesive strips are placed under plaster.

(1) All plaster casts applied in forward areas should he split or bivalved

as soon as sufficiently dry.

r. Skeletal Traction: There is no indication for the use of skeletal traction

or skeletal fixation in conjunction with transportation splinting in the forward

area.

s. Internal Fixation: The use of hone plates or screws is not recommended

in stations forward of an Evacuation Hospital.

t. Humerus: Skin traction, skeletal traction and high abduction spica

plasters or splinting are not only uncomfortable hut dangerous transportation

methods. hanging plaster is unsuitable for transportation purposes.

simple plaster slab running from the affected shoulder over the anterior

aspect of the forearm and upward to the axilla is usually sufficient. The wrist

is supported by bandage sling. Following definitive surgery, the same type

of splinting may be used for further transport, or carefully applied spica with

limited abduction (30°-35°) may be used.

u. Femur: Traction applied by clove hitch, ankle bracelet or through

the boot is not advisable for longer than six hours. This type of traction should

be changed to skin traction at the Clearing Station.

v. Attention is drawn to the Tobruk transportation splint highly recommended by the R. A. M. C. reports from the Middle East. Medical Officers

should be familiar with the design and methods of application of this splint

and more frequent use is suggested.

396961°—57 21
302 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

w. If plaster spica is used the extremity is fixed in slight abduction

and care taken to see that the upper part of the cast does not impinge on the

costal margin. If the other leg is not tied into the spica, and it rarely need be,

the plaster casing is extended well above the costal margin with fenestration

provided for the abdomen.

x. Spica casting for either the upper or lower extremity must be well

applied with adequate padding to avoid discomfort and pressure sores during

transportation. These complications as well as easier application have led to

the development of the Tobruk splint.

y. Amputation: In military surgery an amputation is two-stage operation—the first stage performed in the overseas theater, the final stage, if

necessary, in the Zone of the Interior.

(1) The circular type Guillotine is the amputation of choice. The

indications for primary amputation are control of hemorrhage, destruction of

circulation, removal of irreparably destroyed extremity and as step in the

debridement of traumatic amputation. The site of primary amputation is

the lowest possible level of viable tissues regardless of the eventual utility of

the stump so formed.

(2) Delayed amputation is performed for circulatory insufficiency,

infection, gas gangrene in which more conservative measures have been inadequate or in the judgement of the surgeon will be inadequate, and uncontrollable

secondary hemorrhage. The site of secondary amputation is determined by

the judgement of the surgeon with respect to preservation of maximum bone

length.

(3) Sulfanilamide is dusted on the end of the stump and vaseline

gauze dressing applied. Skin traction is applied on the operating table and

continued until the stump is healed. All lower leg amputations are splinted with

posterior slab to prevent flexion deformity of the knee. The splint extends

below the level of the stump. Transport in ring Thomas splint with support

of the stump and continued skin traction.

(4) Adhesive plaster traction is recommended in the forward areas

where bulky dressing may be desirable. Stockinette applied with skin glue

may be substituted at the base. Adhesive plaster traction strips must extend

to the edge of the incised skin and be anchored by two circular strips. They

should not extend upward beyond the base of the limb.

(5) Secondary closure of amputation stumps is not recommended.

z. Peripheral Vascular Insufficiency: Following wounds that jeopardize

the blood supply of an extremity transport beyond an Evacuation Hospital is

delayed until the collateral circulation has been demonstrated adequate or

until amputation has been performed. Immobilization for transport, or the

additional trauma and shock incident to transport may be determining factor

in producing gangrene.
APPENDIX 303

(1) Principles guiding treatment of limb with defective circulation

are as follows: (1) Immediate restoration of blood volume with plasma supplemented by whole blood transfusion to establish normaloxygen carrying capacity

of the blood. (2) Prevention of loss of body heat by dry woolen coverings for

body and limbs. (3) Do not ligate major artery in continuity. Divide the

vessel between ligatures. (4) Ligate and divide the companion vein. (5) The

extremity supplied by the divided vessel should not be elevated but slightly depressed. Wrap in wool or cotton. Do not directly heat.

(2) To stimulate the development of collateral circulation the following measures are recommended: (1) Heat the body (not the limb) under

cradle. (2) Novocain block of sympathetic chain repeated daily if necessary.

(3) Under special circumstances, sympathectomy, (4) Vasodilating drugs are of

questionable efficacy. (5) Passive vascular exercises. (6) Incision of deep

fascia planes if tense hematoma is present.

(3) Arterial spasm may be encountered when missile passes close to

an artery or there is an adjacent fracture. There is no external bleeding or

hematoma. The limb is cold, numb and muscle action lost. Peripheral pulses

are absent. There is no pain in contrast to occlusion of the artery by an

embolus.

(4) Peripheral pulses return in few days as color and warmth reappear in the limb. Treatment is directed toward warming the body, and the

use of sympathetic novocain block. If the vessel is exposed during debridement direct application of procaine may be tried.

(5) All casualties with defective circulation in an extremity, particularly of the leg should be under close observation for the development of

gas gangrene.

(S) F. A. Blesse

F. A. BLESSE,

Brig. General, AUS,

Surgeon.

DISTRIBUTION:

CG, Fifth Army 500

CG, II Corps 450

CG, NAAF 300

CG, ABS 500

CO, MBS 800

CO, EBS

CO, Hq. Comd., AF 50

SURGEON, NATOUSA 100
304 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

June 1943

CIRCULAR LETTER NO. 16

SUBJECT: MEMORANDA ON FORWARD SURGERY ESPECIALLY

APPLICABLE TO AMPHIBIOUS OPERATIONS

1. General Principles of Wound Management:

a. Surgical operation performed under unfavorable conditions without

facilities for proper after care is often more hazardous than prompt evacuation

if the patient is transportable or can be made so.

b. Wounded evacuated by water should, particularly during early phases

of combat, be so bandaged and splinted that they can swim or at least remain

afloat should emergency require it.

c. Overdosage with morphia produces dangerous coma and respiratory

depression that may delay the administration of an anaesthetic or render

evacuation transport hazardous.

d. All wounds are left open after debridement, frosted with sulfonamide

and loosely filled with vaseline gauze. There are no exceptions. (See below for

specialized regional situations).

e. Only bruised and devitalized skin need be excised, and this with

narrow margin. Avoid circumscision of wounds leaving circular defects by

using linear extensions to gain exposure.

f. During debridement open all deep pockets and transversely divide

fascial planes.

g. Do not pack wounds with gauze or sulfonamide.

h. Immobilize site of extensive injury even if fracture is not present.

i. Continue oral administration of sulfonamide.

j. Make notations on casts and on Field tags and records, (casts are

frequently changed) particularly of what was done at operation. These notes

are not merely for statistical purposes although essential as such. They are

required for the subsequent care oj the patient.

2. Plaster Casts.

a. Split or bivalve all casts as soon as dry. There are no exceptions.

b. Pad all casts and split padding as well as cast. Non-padded plaster

is not suitable for transportation splinting.

c. Apply no circular adhesive or bandage under cast.
APPENDIX 305

d. Maintain foot in neutral position with correction of tendency toward

equinus, valgus or varus.

3. Compound Fractures.

a. Objects to be achieved in initial surgery are control of infection and

safe, comfortable transportation. Reduction and rigid fixation of fracture

can be accomplished at The Base.

b. Careful debridement as priority case. No internal fixation forward of Field or Evacuation Hospitals. Do not pack wound—loosely fill with vaseline gauze. Splint for transportation. Skeletal fixation or traction not recommended for transportation splinting.

c. Femur: Evacuate in Tobruk splint (See Appendix) as early as circumstances permit to reach Base for correction of deformity. fractured

femur should reach General Hospital in the rear within 10 days. Do not

evacuate with clove hitch or boot traction—use skin adhesive.

d. Knee-joint: In debridement minimize incisions that compound

joint. Remove accessible foreign bodies. Irrigate joint with saline. Close

synovial membrane. Loosely fill debrided wound with vaseline gauze.

Evacuate early, immobilized in plaster or preferably Tobruk splint.

e. Leg: Careful debridement all wounds in multiple injuries, as circulation frequently impaired and gas gangrene likely. Penetrating wounds of

calf may require incision for hemostasis as deep hematoma impedes circulation.

Bivalve rather than split casts so inspection dressings may be possible without

losing position in compounded fractures. Hold patient if circulation is questionable, otherwise evacuate as early priority.

f. Humerus: Use modified Velpeau plaster bandage to hold arm to

trunk, or “U” plaster. Skin traction, skeletal fixation, high abduction spica

and hanging cast unsuitable for transportation splinting.

10. Amputations:

a. Circular type guillotine is amputation of choice. In forward surgery

performed for control of hemorrhage, destruction of circulation, removal of

an irreparably destroyed extremity, and as step in the debridement of

traumatic amputation. The site is the lowest possible level of viable tissues

regardless of the eventual utility of the stump.

b. Gas gangrene infection occurs in certain cases with 24 hours delay

in evacuation from the field. Amputate only if more conservative surgery

and full dosage (80,000 to 100,000 units of polyvalent anti-toxin) are judged

inadequate.

c. Apply skin traction on the operating table and maintain during

evacuation.
306 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

d. No sutures. There are no exceptions.

(S) F. A. Blesse

F. A. BLESSE,

Brig. General, AUS,

Surgeon.

Incl: Appendix

DISTRIBUTION:

To all Medical Officers

CG-Fifth Army 900

CG-NAAF 450

CG-ABS 500

CG-MBS 800

CG-EBS 700

CO, PIq. Command AF 50

Surgeon, NATOUSA 250

APPENDIX

Tobruk Transportation Plaster.—Recommended for fractures of the femur,

wounds involving the knee joint and fractures of the leg near the knee.

1. Dress wound and retain dressing with strips of adhesive plaster. No

circular dressing or bandages should ever be put on under plaster case.

2. Support patient with pelvic rest, or bowl under sacrum. One assistant holds the foot by the heel and toes and exerts traction. The foot is kept

at right angles. second assistant supports the fracture and keeps the knee

bent at 10 degrees flexion with the palms of the hands not the fingers.

3. Apply traction strapping as close up to the wound as possible. Fold

distal ends of straps into cords.

4. Pad the heel and malleoli with wool. Turn back the traction straps

from the region of the malleoli while winding the wool round. Pad the knee

prominences similarly. There have been some cases of foot drop from pressure

on the external popliteal nerve. Pad the upper part of the thigh close to the

ring of the splint with layer of wool. Pad the entire extremity with sheet

wadding or stockinette.

5. Lay strip of tin (obtainable from ration boxes etc.) wrapped in paper

over the anterior surface of the length of the limb to beyond the toes.

6. Prepare plaster slab (6 thicknesses)—apply posteriorly as high as

possible and distally over heel and sole offoot to project 3-4" above the toes.

7. Complete plaster cast with circular bandages round the slab enclosing

the whole of the leg and foot except the dorsum of the toes and mould. Do not

cover over traction straps further than just above the malleoli.

8. The traction straps are now emerging from the plaster just above the

malleoli. Turn them back and cut the plaster away from where they emerge,
APPENDIX 307

sufficiently to free the straps from the plaster. This allows the traction to be

on the leg and not on the cast. Trim the plaster over the dorsum of the toes.

See that the little toe is free.

9. Apply Thomas Splint preferably half-ring and fit lower part of ring

against Tuber Ischii and adductor muscles. Hold up ring so as to obtain correct position and insert pads of wool anteriorly and laterally between the ring

and the thigh to maintain the position. Tie traction straps to notch in splint

and insert spreader and Spanish Windlass.

10. Wind plaster bandages round the side bars of the splint, and round the

limb to anchor the splint to the limb.

11. Support distal end of splint with splint bracket.

12. When plaster is moderately firm cut down on thin strip over whole

length plaster and withdraw strip and split the plaster. Cut the underljdng

padding with scissors or knife. It is not necessary to cut stockinette.

13. With indelible pencil draw diagram of fracture and write simple details,

date of wounding, treatment, date of application of plaster, unit, etc.

NOTE. This splint is only intended as transportation splint for the journey

to the base. There is no need to aim at accurate apposition in the Forward

Area. On arrival at the Base Hospital X-ray examination should be made,

position corrected if necessary and routine treatment employed.

This form of fixation will do quite well even for fractures of the upper third

of the femur for transport.

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

26 June 1943

CIRCULAR LETTER NO. 19

Operations on the Knee Joints IV

IV—OPERATIONS ON THE KNEE JOINTS.

1. Careful surgical judgement is to be exercised in the selection of cases for

excision of semilunar cartilages. history of locking is essential. Instability

of the knee joint is contraindication. Post operative care in the form of early

weight bearing without crutches and exercise of the quadriceps muscle groups

instituted early under supervision is essential to recovery.
308 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

2. Operations for major knee disabilities such as repair of collateral or

cruciate ligaments, or removal of both cartilages are to be undertaken only on

recommendation of Disposition Board of General Hospital.

For the SURGEON:

(S) E. Standlee

E. STANDLEE,

Colonel, M. C.,

Deputy Surgeon.

DISTRIBUTION:

CG, Fifth Army 600

CO, ABS 500

CG, MBS 600

CO, MBS Center District 200

CG, EBS 600

CG, NAAF 450

CG, Force 141 300

CO, HQ Comds., AF 50

Surgeon, NATOUSA 150

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

22 June 1943

CIRCULAR LETTER NO. 20

SUBJECT: Tunisian Campaign..Comments by Hospitals of the Zone

of Communications on the Treatment of Battle Casualties in

Forward Areas.

NOTE: At the end of the final phase of the Battle of Tunisia, several

hospitals of the Zone of Communications were asked to submit comments on

the surgical treatment of battle casualties received during the campaign.

Although quotation marks have been eliminated, the following paragraphs are

direct transcriptions of these comments and suggestions. Specific case histories have been assembled in the Appendix with designations as footnotes.

Many of the principles emphasized in these comments have been incorporated

in Circular Letters, and they should be carefully observed by all Surgeons in

the Theater.

Figures in parentheses refer to case histories in the Appendix. Comments

in parentheses were not received from the hospitals.
APPENDIX 309

1. General Considerations.

a. In general, the great majority (90%) of patients received from the

combat zone have been well and adequately treated, and good judgement has

been exercised in selection of cases suitable for evacuation to this general

hospital.

b. In several instances the severity of the injury has not seemed to

warrant evacuation to this point, where, with large proportion of the cases

prospectively to be evacuated to the Zone of the Interior, it is inevitable that

the patients should acquire an exaggerated idea of the severity of their injury,

and reluctance toward return to duty. (1)

c. There are rare instances of patients who were so critically ill on

admission that their evacuation has appeared unwise and unduly hazardous.

d. Many patients might have been returned to full or limited service if

they had not been told that they were to be sent to the Zone of the Interior,

or that they would not regain full function of an injured part.

e. Almost all of our patients have spoken with appreciation of the skilled

and kindly treatment they have received in the most forward areas—litter

bearers, battalion surgeons, and on back. Most of the patients have had

excellent treatment and in particular the work of the Surgical Teams has been

outstanding.

/. number of our patients have received wounds due to shell fragments.

The vast majority of these wounds have been satisfactorily treated by excision

and left open. Most of them have healed kindly and have required only secondary closure or skin grafting for complete healing.

g. Judging from the comparatively small number of war casualties

treated in this hospital it seems evident that delayed primary suture of wounds,

particularly in patients who are to be evacuated is an ill-advised procedure.

(This does not apply to secondary suture in Base Hospital where the patient

can be held until healing is complete.) The suture of wounds using gauze

pack as drain should be avoided. The pack dries and acts as plug rather

than drain.

2. Initial Treatment of Wounds.

a. Adequate debridement of wounds in combination with filling of

vaseline gauze and the use of sulfa drugs and plaster immobilization has produced clean wounds in most instances. The patients have arrived in good

condition, relatively comfortable, and have only rarely show even slight

temperature elevation.

b. The extent of some wounds suggests that skin removal has been too

extensive in many cases.

c. Large numbers of foreign bodies are still present in the wounds in

many cases. The metallic foreign bodies only occasionally are responsible for

persistent draining sinuses. In one case fragments of cloth were found just

beneath the skin, where even casual debridement might have discovered them.

d. Conservation of digits. Numerous fingers with compound injuries

and lacerated tendons have been treated conservatively, often with tendon
310 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

suture and splinting. An over heroic attempt lias been made in the presence of

sepsis to preserve digits devoid of function. The protracted splinting in these

cases results in diffuse stiffness of the hand unrelieved by late amputation of

the useless digits, and necessitating evacuation to the Zone of the Interior.

From the standpoint of military usefulness the results of early amputation in

badly damaged fingers have been more satisfactory.

e. There have been several instances of attempted primary tendon repair

in severe crushing or gunshot wounds of the hand. None of these has been

successful.

/. Packing. The commonest criticism of the packing of wounds is that

excessive amounts of gauze have been used, frequently acting as plug, and

often introduced through small wound of entrance. In several cases through

and through gauze strips have been used to pack perforating wounds of the

extremities. Coarse meshed dry gauze has been used for packing in many

cases, the removal of which is difficult and unnecessarily traumatizing. When

it is necessary to use dry gauze packs to control bleeding, early removal is

urgent and notation that such packing has been employed would ensure an

early change of cast.

g. On many occasions when the casts were removed and the wounds

dressed, tight vaseline packs were found in place and when these were removed

there was gush of dammed back discharge. It seems desirable that the

vaseline gauze strips be laid from the bottom of the debrided wound out over

the skin in an axis at right angles to the wound. Having lain such strips all

about the circumference of the wound the remaining central cavity can be

filled with vaseline gauze folded back and forth. It is worth repeating that the

debridement should be complete, the sulfanilamide sprinkled into all crevices

of the wound and the vaseline packing inserted loosely.

(It is recommended that the term “pack” be dropped from common usage

and reserved specifically for temporary procedure used to control hemorrhage.)

h. Immobilization. Many casts are excessively thick and heavy.

Insufficient padding, or padding carelessly applied, has resulted in pressure

sores in several cases. The use of circular bandages inside casts, or of slings,

mayresult in constriction or pressure sores. Simple linear incision of circular

cast is not sufficient safeguard against swelling and circulatory embarrassment.

In one instance of simple uncomplicated fracture of both bones of the leg,

amputation was barely averted because of circulatory damage which could have been avoided by proper padding or bivalving of the cast.

i. We particularly condemn the use of the skin tight plaster on the acute

injury, even those split up the front. We have had about 20 cases of fracture

of the leg and few of the arm come to us in plasters applied directly to the skin

at the time of debridement in forward hospitals. With very few exceptions the

skin has been blistered when these casts were removed. Sheet cotton, stockinette, cloth of any kind or even newspaper should be used to protect the skin.

j. Insufficient splinting and immobilization has been applied. (2) (3)

Contractures have developed which have been very troublesome and in some
APPENDIX 311

cases have necessitated evacuation to the Zone of the Interior for this reason

alone. Cock-up splints for radial nerve injuries are generally too short.

Patients with peroneal palsy are not protected against foot drop.

k. Hip spicas in the majority of cases are carried unduly high and cause

considerable amount of unnecessary discomfort. In shoulder spicas common

error is to place the arm in too great abduction, and in or behind the frontal

plane of the body rather than forward of it. Patients transported in “hanging

casts” for fracture of the humerus do not travel well. (4)

l. Of the 272 patients treated, 111 were compound fractures, all but four

of whom entered this hospital by air ambulance in excellent condition. The

great majority of these patients had been treated by early debridement, local

application of sulfonamide packing with vaseline gauze and application of

padded plaster cast.

m. Fractures have been well immobilized and the plaster work has been

excellent. In only few instances has it been necessary to remove plaster

because of constriction.

n. In badly comminuted fractures where good position has been obtained

at operation loss of position is to be feared with change of cast. These cases

are problems. While we favor the 10th to 12th day change of plaster we have

allowed them to go several weeks pending soft tissue fixation of the fragments.

It would be helpful if plasters in such cases could be bivalved rather than split

down the center, so the dressing might be done and new cast applied over the

remaining half.

(Bivalving plasters prior to transportation means strengthening the halves

by slabs and secure approximation before evacuation.)

o. Penetrating or perforating injuries of the knee have frequently been

opened surgically in forward hospitals, foreign bodies or bone and cartilage chips

removed, the joint irrigated thoroughly, sulfanilamide inserted into the joint,

the synovial membrane closed and the wound then packed open. All so treated

have done well with minimum of synovial reaction. After the operative procedure all cases should be immobilized in long leg plaster to the groin and the

use of cross stick at the ankle to prevent rotation.

3. Amputations.

a. The small number of amputations seen would have benefited had

they been transported in Thomas splints with skin traction applied to the skin

flaps. The open wounds were clean but the skin had retracted to the point

thatreamputation will probably be necessary to accomplish serviceable stump.

b. In two instances final amputation was done at too high level to

permit use of an artificial limb. Several cases of amputation have arrived with

severe flexion contracture of the knee for lack of posterior splint. Several

cases of severe hip flexion contracture have been received as result of omitting

posterior splints following thigh amputations.

c. Out of twelve cases of anaerobic gas bacillus infection in one hospital,

were in sutured amputation stumps.
312 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

d. In the following case, (5), conservation type of amputation was

performed through level far below the site of vascular occlusion in an infected

leg. think the lesson here is that the line of demarcation in infected extremities with vascular occlusion does not mark the level at which an amputation

stump will be sustained. Circulation just enough to maintain viability of

tissues will not withstand an amputation or cope with an infection. Amputation in such cases must be high, if possible above the level of vascular

occlusion.

(S) F. A. Blesse

F. A. BLESSE,

Brig. General, AUS,

Surgeon.

Incl: Appendix

DISTRIBUTION:

CG, Fifth Army 600

CO, ABS 500

CG, MBS 600

CO, MBS Center District 200

CG, EBS 600

CG, NAAF 450

CG, Force 141 300

CO, HQ. Comd., AF 50

Surgeon, NATOUSA 150

HEADQUARTERS NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

18 November 1943

CIRCULAR LETTER NO. 48

PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED...

PARAGRAPH III, CIRCULAR LETTER NO. 19 IS AMENDED.__ II

USE OF EXTERNAL SKELETAL FIXATION APPARATUS

(ROGER ANDERSON) IN TREATMENT OF FRACTURES

OF THE EXTREMITIES III

DELAYED OPEN REDUCTION AND INTERNAL FIXATION

OF COMPOUND FRACTURES WITH OR WITHOUT SECONDARY SUTURE OF WOUND IV

FRACTURES OF CARPUS

HERNIATED NUCLEUS PULPOSUS VI

“PARRY” OR MONTEGGIA FRACTURE VII
APPENDIX 313

THE TOBRUK SPLINT AND HIP SPICAS VIII TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA IX

I—PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED AS

FOLLOWS:

Operations of the Knee Joint

Follow-up studies on over 200 operations performed in this theater for

removal of dislocated or ruptured semilunar cartilages and other derangements

of the knee joint have been compiled. Appraisal of these results lead to tlie

following recommendations:

1. Operations for the repair or reconstruction of the collateral or cruciate

ligaments of the knee, or for recurrent dislocation of the patella, are not to be

performed in this theater.

2. Careful study and mature surgical judgement will be exercised in the

selection of cases for excision of semilunary cartilage or joint mouse.

a. Elective arthrotomy of the knee will be performed only on the

Orthopedic Service of General Hospital.

b. Initial injuries of the semilunar cartilage without locking and those

that unlock by gentle manipulation, or after to days of skin traction, will

not be subjected to operation. Pressure support, rest, graduated to protected,

then full weight bearing and carefully supervised quadriceps exercise for to

10 weeks, are suggested as method of management. Following symptomatic

relief these soldiers may be returned to duty.

c. Arthrotomy will be limited to:

(1) The persistent locked knee.

(2) The unlocked knee in soldier who cannot perform noncombat duty because of his disability. This will be only the exceptional case.

d. Contraindications to be considered are age, arthritic changes, instability of the joint and, in particular, any but the most favorable mental

attitude of the soldier.

e. Recurrent cases, not locked, and those recurrent cases that unlock

with non-operative therapy, are to be returned to duty unless the total period

of disability in any calendar year exceeds 90 days. Under such circumstances,

they will be transferred to the Zone of the Interior.

f. Operation for the removal of both cartilages from one knee or for

one cartilage from each knee is to be performed only on written recommendation of Disposition Board of General Hospital.

3. General Hospital in which arthrotomy of the knee is performed will

be expected to hold the patient for minimal period of six weeks, so that the

operating surgeon may supervise the regimen of post-operative exercises and

motion essential to good result. Proper post-operative supervision is as

essential to recovery as the operation. If prevailing evacuation policies indicate that the patient cannot be held for at least weeks post-operatively, he

should be transferred farther to the rear for operation.
314 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

4. After weeks in General Hospital, the patient may be transferred to

Convalescent Hospital for further care with full instructions relative to continuation of corrective exercises.

II—PARAGRAPH III, CIRCULAR LETTER NO. 19 IS AMENDED AS

FOLLOWS:

Operations for Recurrent Dislocation of the

Shoulder Joint or Chronic Dislocation of the

Acromio-clavicular Joint

1. The history of patient relative to previous dislocation of the shoulder

is notoriously unreliable. Before making diagnosis of recurrent dislocation,

one or more episodes should be confirmed on Army Medical Records, preferably

with supporting X-Ray evidence.

2. Operations of this type will be performed only with written approval

of the Disposition Board of Geneual Hospital following demonstration that

the disability is of nature that the soldier cannot perform non-combat duty

and when his age and mental attitude give reasonable prospect of military

rehabilitation.

Ill—USE OF EXTERNAL SKELETAL FIXATION APPARATUS

(ROGER ANDERSON) IN TREATMENT OF FRACTURES OF THE EXTREMITIES.

1. This is highly specialized method for the treatment of carefully

selected cases, chosen on the basis of special indications.

2. The use of external skeletal fixation is to be limited to surgeons with

training and experience in the method. If special indication for use of the

method is found in hospital without such surgeon, the patient will be

transferred to hospital with this trained personnel.

3. patient with the apparatus in place is not to be transferred from one

hospital to another within the theater except under emergency conditions.

When transfer is essential, he is to be routed to hospital where there is

surgeon experienced in the method. Patients are not to be evacuated to the

Zone of the Interior with the apparatus in place, but will be held for sufficient

time to permit the removal of pins and the substitution, if indicated, of conventional means of splinting.

4. Clinical records of each patient, on whom the method is utilized, will be forwarded through channels to the Surgeon, NATOUSA, after the treatment is completed. This record will contain essential data for identification

of the case, date of injury, fracture diagnosis, original treatment, character of

the wound if compound, problem involved and indication for use of the method,

length of time required to apply the apparatus and reduce the fracture, number

of X-Ray filmsrequired, date and extent of any observed distraction, incidence

of pin infection and other complications, date of removal of the apparatus and

subsequent treatment, result and disposition.
APPENDIX 315

IV—DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF COMPOUND FRACTURES WITH OR WITHOUT SECONDARY

SUTURE OF WOUND.

1. This procedure is still under trial with reference to indications, hazards, and incidence of serious complications. Its use is restricted to special groups

authorized to assume the responsibility as special study.

V—FRACTURES OF CARPUS.

1. Greater care is to be exerted in making precise and early diagnosis of

carpal fractures and dislocations. Early reduction is essential if satisfactory

result is to be obtained.

2. Operative treatment for old unrecognized fractures of the scaphoid will fail to rehabilitate soldier in this theater. If complete disability is present,

he should be transferred to the Zone of the Interior.

VI—HERNIATED NUCLEUS PULPOSUS.

1. Recommendation Par. II, Circular Letter No. 19, 26 June 1943, is

interpreted to apply to all patients, Army, Navy or Allied Force under treatment for this condition in U. S. hospitals.

VII “PARRY” OR MONTEGGIA FRACTURE.

1. Attention is directed to fracture of the shaft of the ulna with dislocation

of the head of the radius. Uncommon in civilian practice, this fracture due

to direct violence to the forearm (blow with rifle butt or other blunt weapon),

is not infrequent in military experience. It is essential that the dislocation of

the radius be recognized and proper treatment instituted at the time of initial

treatment.

VIII—THE TOBRUK SPLINT AND HIP SPICAS.

1. Experience has shown that the use of Tobruk splint is best limited to

fractures of the lower one-third of the femur, supra-condylar fractures, and

wounds damaging the knee joint. Even in these injuries it has no advantages

over well applied hip spica.

2. The most comfortable and efficient hip spica for immobilization of

fracture of the femur for transportation, following initial surgical treatment,

is short waisted, double spica extending only to the knee on the well leg and

maintaining 20 to 30 degrees of abduction with the knee slightly flexed. The

plaster on the injured leg is carried beyond the toes by plaster slab, leaving

the toes fully exposed anteriorly. Care is taken to avoid equinus and to hold

the foot in neutral position between valgus and varus.

3. High waisted plasters that extend to or above the costal margin cause

discomfort. It is better to tie in the well leg and stop the plaster just above

the iliac crest.
316 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

4. The chief responsibility of the surgeons of the forward area in the

management of all compound fractures is the prevention of infection, rather

than the anatomic correction of deformity. Early evacuation to the Base (a

fractured femur should reach General Hospital within 10 days) will allow

for definitive reduction of the deformity.

IX—TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA.

1. Meticulous nursing care is essential for the prevention of bed sores.

This care is interrupted by rapid evacuation through chain of hospitals.

While it is important to transfer these cases to the Base, when they are transportable, they should not be subjected to long ambulance lifts. On arrival at

an intermediate station, careful nursing care should be provided immediately.

If there are signs of pressure sores, the patient should be held for corrective

measures before further transfer. These patients do not complain of pain

and quite different criteria are required in an estimation of whether they are

to be classified as “transportable” than are found applicable in the management

of other casualties.

For the SURGEON:

(S) E. Standlee

E. STANDLEE,

Colonel, M. C.

Deputy Surgeon.

DISTRIBUTION:

Surgeon, NAAF 400

Surgeon, NAASC 300

Surgeon, EBS 400

Surgeon, MBS 300

Surgeon, ABS 150

Surgeon, IBS 100

Surgeon, PBS 500

Surgeon, AMGOT 25

Surgeon, CD MBS 50

Surgeon, Seventh Army 350

Surgeon, Fifth Army 600

Surgeon, Hq. Command, AF 50

Surgeon, NATOUSA 200
APPENDIX 317

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

19 April 1944

CIRCULAR LETTER NO. 26

SUBJECT: Wound Management.

1. The keystone of successful wound management is the initial surgical

operation. When this is performed correctly the complications of infection are

absent or minimal and secondary suture may be carried out promptly and successfully. To coordinate the initial surgery in the forward area with the definitive surgery at the base observance of the following principles is essential.

2. Initial Wound Surgery.

a. Adequate assistance and instruments, good light and access to the

wound that is unhampered by faulty position of the patient are basic requirements. Ample preparation of wide field by shaving the skin will allow for

extension of the incision or counter incision.

b. Bold incision is the first essential step in an operation on wound.

Adequate exposure is necessary to carry out excision of devitalized tissues. On

the extremity the line of the incision is placed parallel with the long axis of the

limb; elsewhere it follows the natural lines of skin structure. Only the devitalized skin of the margins of the wound is excised in strip rarely wider than

to mm. Circular defects are to be avoided.

c. Incision and excision of the fascial layers is carried out in the same

manner to give free access to devitalized muscle. Unrestricted exposure of successive anatomic layers permits the complete excision of devitalized muscle and

the removal of foreign bodies. The operation on wound is an anatomic dissection and should never be made to resemble digital pelvic examination.

d. The surgeon must be familiar with the blood supply of muscles, particularly large groups like the gastrocnernius-soleus muscles of the calf and respect

these vessels in his dissection. Deep recesses of the wound containing foreign

bodies may be approached by counterincisions planned anatomically rather

than by sacrificing normal muscle structures.

e. Use fine hemostats. Use the finest ligatures compatible with the

procedure. Include the smallest possible amount of tissue in ligating bleeding

point. Do not repeatedly bite the wound with tissue forceps. Sponge gently

with pressure instead of wiping. Remaining devitalized tissue produced by the

missile or by the surgeon must slough before the wound can be closed by secondary

suture.

f. Large wounds in regions of heavy muscles particularly when complicated by comminuted fracture require especial care. The depths of these

306961 —57 22
318 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

wounds must be opened by long incision with counterincision if necessary to

allow free drainage of blood and tissue that may not be identified as dead at the

time of debridement.

g. Only enough vaseline gauze is used to separate the surfaces of the

wound. It should be smoothly laid in the wound—not “packed”.

h. Local application of sulfanilamide is minor adjunct to surgery and

is used as fine frosting of the surfaces. It is not to be “rubbed in”.

i. Ether, white soap, and benzene have slight but definite necrotizing

effects on living muscles. Green soap, hydrogen peroxide and various other

substances used as detergents have greater necrotizing effects. Physiological

saline solution, petrolatum and boric acid ointment are innocuous. If detergent is needed, white soap is the least objectionable.

j. Old wounds (48 hours or longer) are managed in accord with the same

principles except that in selected cases of established pyogenic infection and

anaerobic cellulitis with toxicity the general condition of thepatient towithstand

radical surgery may be improved by immobilization, penicillin and repeated blood

transfusions until an optimum time is selected for intervention. In postponement of surgery the advantage that accrues from the immediate drainage of

septic hematomas, large masses of dead muscle and fascial plane abscesses is

not to be forgotten. Postponement of surgery is not justified if clostridial

myositis (gas gangrene) may be present,

3. Secondary Wound Surgery.

a. On arrival at hospital where bed care can be assured for period

of 15 days the first dressing is removed in the operating room under aseptic

precautions. X-ray films should be at hand. If the primary wound operation

has been complete one, all superficial wounds and many deep wounds may be

closed by secondary suture at this time (4 to 10 days). Foreign bodies in soft

parts adjacent to the wound are removed. Following suture, the part is immobilized preferably by light plaster, or if this is impractical, by bed rest.

b. The presence of residual dead tissue or established infection indicated

by profuse discharge of pus, reddening and edema of the wound margins, persistent fever or toxicity are the common indications for delay in secondary

suture. When these indications are present but minimal, the wound is allowed

to “clean up”. Moist dressings, heat and azochloramine are generally considered to hasten this process. Additional surgical excision of devitalized fragments may speed the process. Secondary suture can then be performed in

few days. If established infection is severe, or if the patient is toxic and anemic

from deep seated sepsis, course of penicillin therapy and blood transfusions

is instituted and followed by radical wound revision.

c. Closure of wounds that compound fractures or joints is only to be

undertaken when the surgeon is completely familiar with the use of penicillin

as an adjunct to surgical wound revision. Penicillin will not “sterilize”

wound that contains devitalized bone, fascia, tendons or foreign bodies. Immediate success may be obtained, but delayed abscess formation, joint infections
APPENDIX 319

and osteoperiostitis are likely to appear as sequelae. The wound revision that is an essential part of “cleaning up” wounds that complicate fractures or joints

for closure, either at the time or subsequently, is not to be taken lightly.

Preparation of the patient by transfusions, diet and accessory surgical procedures is essential.

d. Wounds that have been properly laid open at the initial operation tend to gape widely and give the impression of extensive skin loss. This appearance is actually due to loss of support of the deep fascia. Skin defects are more

apparent than real in the majority of cases and closure of defect is made

from local tissue with suture in straight line when possible. Undermining

with advancement or rotation of flaps provides sufficient skin in nearly all

instances and is preferable to grafting.

e. Technical considerations that are important to the success of secondary wound closure are:

(1) Atraumatic handling of tissue (see par 2, e).

(2) Avoidance of tension sutures.

(3) Accurate approximation of skin margins. The epithelial bridge

is the main support of the wound for considerable period of time.

(4) Obliteration of dead spaces by pressure dressings and immobilization.

(5) Leaving sutures in place for 12 days if stitch infection does

not develop.

(6) Suture in straight lines rather than creation of sharp angles.

(7) Closure by adhesive plaster strips is not as satisfactory as suture.

f. The conditions that most often jeopardize results are:

(1) Suture of wound that is discharging large amount of pus. This

usually means dead tissue in the depths.

(2) Hemolytic streptococcus infection. (3) Diphtheria wound infection.

(4) Too early motion. (Wounds breaking down for this reason should

be immediately resutured.)

(5) Unrecognized foreign bodies adjacent to the wound.

g. Preliminary bacteriologic analysis of the flora of wound does not

provide information pertinent to making the decision to perform secondary

suture or allow the prediction of the result. If the suture is not successful

because of infection, appropriate studies and corrective therapy is instituted

before resuture is attempted. Infection may be considered indicative of the

susceptibility of the individual to the predominate wound organisms.

4. Specialized Problems.

c. Amputations.

Secondary closure of circular guillotine amputation stump is not commonly indicated, as it is impossible to suture the inelastic fascia without wasteful shortening of the bone. Bone length can be saved by continuing the skin
320 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

traction for an additional period of time—4 to weeks. Closure of stumps by

sliding flaps, plastic resection with sacrifice of bone length, or formal reamputation are procedures to be carried out in the Zone of the Interior rather than in

an Overseas Theater. Skin grafting of defects may be performed for temporary

resurfacing of stumps that will later require plastic procedures orreamputation.

It should not be employed when further use of skin traction will promote

healing or covering of the bone end with normal skin. Vertical incisions in the

stump made for infection or as part of the initial debridement should be closed

by secondary suture while skin traction is being maintained to cover the

defect at the end.

e. Closed Plaster Treatment (Truetta).

The regimen of closed plaster management of war wounds has not been

judged applicable to the field conditions of this theater. It is advisable to

remove the initial dressing for inspection of the wound in all cases at least by

the 15th day. Incorporation of pins or other fixation devices in the initial

plaster to maintain the reduction of fractures obtained at the initial operation

has been found impractical as means ol transportation splinting.

While the necessity for the rapid turnover of large numbers of casualties

might justify an adoption of the closed plaster method of management of

compound fractures, high penalty in the form of skeletal deformity would

be the inevitable result. Results obtained by secondary suture do not justify

the use of closed plaster for soft part wounds.

Infrequent change of plaster as practiced in the theater has many advantages, particularly when it is desired to allow granulations to cover exposed

bone in deep irregular wounds (Orr). It is also an accepted method of management for established infection of bone particularly when the wound has caused

an extensive loss of overlying soft parts or there is bone defect. Small surfaces

of bare cortical bone may be removed surgically when this permits closure of

the defect by suture. When resurfacing by skin graft is possible in shallow

wound the bare cortical bone may be left for spontaneous sequestration.

f. Military Aspects. Secondary wound surgery in an Overseas Theater

must be measured against the objectives that are sought. In general, these are:

(1) To return soldier to duty with minimum number of days lost.

(2) To return patients to the Zone of Interior at an earlier date and in better condition.

(3) To reduce ultimate disability and deformity by preventing or

cutting short phase of late wound infection with fibrosis and other harmful

sequelae.

An aggressive attitude is desired in the case of any soldier who may be

returned to duty in this theater. On the other hand, to suture small clean

wound that is compounding fracture of the femur is merely stunt, as the

soft parts will be healed before the bone unites.
APPENDIX 321

It is not desirable to embark on elaborate plastic procedures such as crossed

extremity skin flap grafts or operations undertaken for cosmetic purposes.

For the SURGEON:

(S) E. Standlee

E. STANDLEE

Colonel, M. C., Executive Officer.

DISTRIBUTION:

All Medical Installations

Surgeon, SOS NATOUSA 800

Surgeon, Fifth Army 500

Surgeon, Seventh Army 100

Surgeon, AAFSC/MTO 800

Surgeon, NATOUSA 200

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534 July 1944

CIRCULAR LETTER NO. 36

SUBJECT: Penicillin Therapy in Wound Management, Surgical Disease, Burns, and Anaerobic Infections

1. General.

a. In World War II, two quite different policies have governed the use

of chemotherapeutic agents in the management of wounds. Chemotherapy

has been recommended: (1) as substitute for adequate wound surgery, seeking to delay and minimize operative procedures; (2) as an adjunct to established

and progressive surgical measures designed to achieve better results with an

increased margin of safety. The latter has been and will continue to be the

policy governing the management of the wounded in this theater.

b. The use of penicillin as an adjunct to surgery outlined in this circular

is defined as therapy rather than prophylaxis. Routine immunization of troops

with tetanus toxoid is prophylactic measure. Administration of penicillin

for contaminated wounds and established infection is therapeutic measure. As

with all therapy, if the desired goal is to be achieved, intelligent and precise

professional supervision of every detail is essential.

2. Scope of Penicillin Therapy.

a. Penicillin is accepted as the best available antibacterial agent for

gram-positive bacteria and gram-negative diplococci. It is ineffective for

gram-negative bacilli.
322 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

b. Penicillin does not sterilize dead, devitalized or avascular tissue, nor

does it prevent the septic decomposition of contaminated blood clot. There

is no evidence that it can neutralize preformed bacterial exotoxins or inhibit

the locally necrotizing bacterial enzymes in undrained pus. These limitations

demand that surgical wound management retain the principles of excision of

devitalized tissue, dependent drainage of residual dead space, evacuation of

pus and delayed or staged closure of contaminated wounds (see Circular

Letter Xo. 26, Office of the Surgeon, Hq. NATOUSA).

c. The use of penicillin in an individual patient is based upon the

decision that infection is probable or present.

d. It is recommended that parenteral administration be the basis of

penicillin therapy. The local or topical use of penicillin is supplement to

systemic therapy only in lesions of the central nervous system, serous cavities

and joints. The diffusion of the drug into these areas appears slow and limited.

3. Penicillin Therapy in Relation to Sulfonamide Therapy.

a. Topical and oral administration of sulfonamides as first aid measures

will be continued.

b. Intravenous sulfonamide prior to initial surgery will be replaced by

parenteral administration of penicillin (par. 6, a).

c. At the conclusion of the initial wound operation, the decision will be

made either to institute postoperative course of penicillin therapy or to maintain chemotherapy with sulfonamides. It is recommended that the agents be

used individually and not concomitantly. If course of penicillin is elected,

topical frosting of the wound with sulfonamide is omitted. The following observations will serve as guide in this decision:

(1) Clinical experience with penicillin has been greatest with wounds

of the extremities and the thorax. The drug is recommended for these injuries.

(2) The value of penicillin in craniocerebral wounds is well established,

but an extensive experience has not been accumulated.

(3) Cleanly debrided soft part wounds uncomplicated by fracture,

extensive tissue destruction, or retained missiles are adequately handled by

sulfonamide therapy.

(4) Preliminary evaluation of penicillin therapy for fecal contamination of the peritoneal cavity is encouraging but at the present time is inadequate

for comparison with sulfonamide therapy. In view of the difficulties in maintaining fluid intake adequate to safeguard sulfonamide therapy in this group

of cases, substitution of penicillin may be made at the discretion of the surgeon.

Forcing offluids is not necessary solely because of penicillin therapy and in fact,

reduces the effective concentration of the drug by rapid urinary excretion.

4. Routes of Penicillin Administration.

a. Intramuscular. This is the standard route for administration. The

deltoid, gluteus and thigh muscles are recommended as the sites for injection. The same area may be used repeatedly. Subcutaneous administration is to

be avoided.
APPENDIX 323

b. Intravenous. The intravenous route is reserved for patients with

shock or immediately life endangering infection. single intravenous injection

provides therapeutic concentration of the drug that lasts for two hours. If intravenous therapy is indicated to span longer period, the injection is

repeated or constant drip administration instituted.

5. Dosage.

a. Systemic therapy. Current practice dictates dosage of 200,000 units in 24 hours, given as 25,000 units every three hours by the intramuscular

route. Larger initial dosage or greater 24 hourly dosage have no demonstrable

merit. Maintenance offull dosage schedules throughout the course of therapy is better than graded terminal decrease in dosage.

b. Local therapy. The powdered sodium salt of penicillin is slightly acid

and provokes burning pain and serous discharge ifapplied to an open wound.

solution containing 10,000 units per c. c. is well tolerated as an intramuscular

injection but may produce headache, meningismus and pleocytosis of the

spinal fluid after intrathecal injection. The maximal effective local concentration is 250 to 500 units per c. c. The usual concentration employed clinically

varies between 500 and 5,000 units per c. c. with predominate usage of solution

containing 1,000 units per c. c. The following dosage schedules are recommended for local instillation:

(1) Intrathecal space 7,500 units

(2) Pleural cavity 25,000 units

(3) Peritioneal cavity 50,000 units

(4) Knee joint 10,000 units

Local instillation of penicillin may be repeated at intervals of 12 to 48

hours in accordance with clinical indications. Needle aspiration and injection

is preferable to inlying tubes.

6. Use ofPenicillin in Mobile Hospitals. The following recommendations

are made on the basis of procedures that have been found practical in Evacuation Hospitals:

a. Upon arrival in the shock or preoperative ward, the wounded will

receive 25,000 units of penicillin intramuscularly, unless the wound is certainly

of trivial nature. If shock is present, an additional 25,000 units will be

given intravenously.

b. Preoperative dosage is continued at hourly intervals. It is more

practical to give penicillin to every patient in preoperative ward at the same

time, than to keep each pateint on dosage schedule based on the time of

arrival. There is no objection to time interval of less than hours between

the first two injections.

c. The decision to continue penicillin or to substitute sulfonamide in

the postoperative period is made when the operation is concluded and the

nature and extent of the injury evaluated (see par. c).
324 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

d. No patient will be held in mobile hospital solely for the purpose

of continuing penicillin therapy. The usual criteria based on the conditioe

of the patient will determine the suitability for evacuation. In general, thn

drug is continued for to days beyond the period of clinical recovery from

the hazard or subsidence of infection. course of therapy may be associated

with slight fever which disappears after the drug is stopped. Suitable

periods of therapy are:

(1) Soft part wounds to da}

(2) Compound fractures 10 to 12 days

(3) Thoracic wounds to 10 days

(4) Abdominal wounds to 10 days

(5) Craniocerebral wounds to 10 days

(6) Joint wounds to 14 daj^s

e. Patients evacuated prior to completion of course of therapy will

carry notation “On Penicillin” in the space provided under the designation

“Special attention needed in transit, or other remarks” on the jacket of the

Field Medical Record (Form 52d). This will indicate the need for continuation of therapy in holding stations, hospital ships and fixed hospitals,

7. Use of penicillin in Holding Stations or Hospital Ships.

a. Form 52d will be examined in each case upon admission to identify

those patients receiving penicillin therapy (par. e).

b. 25,000 units of penicillin will be administered intramuscularly every

hours to all such designated patients.

8. Use of Penicillin in Fixed Hospitals.

a. Patients designated as “On Penicillin” (par. e) will have the course

continued on admission to the hospital. Discontinuance of therapy will be

the responsibility of medical officer after he has reviewed the status of the

patient.

b. Secondary suture of cleanly debrided soft part wounds does not

require penicillin therapy. Soft part wounds requiring debridement

or secondary debridement or with established infection may properly receive

penicillin.

c. Reparative surgical procedures on wounds complicated by skeletal,

joint, nerve, tendon or vascular injury require penicillin therapy.

d. Established wound infection is an indication for penicillin therapy.

e. Early secondary reparative operations through recently healed

wounds require penicillin therapy.

9. Surgical Disease.

a. Acute or chronic infections such as furuncles, carbuncles, felons,

desert sores, tenosynovitis, etc. should be treated with penicillin whenever it

is judged that loss of time from duty can be shortened.
APPENDIX 325

10. Burns.

a. The local application of sulfonamide crystals or ointments containing sulfonamides is not recommended. Fine mesh (bandage cloth) vaseline

or boric acid gauze is preferable. Under no circumstances are tannic acid

preparations or other escharotic agents to be used in this theater.

b. Extensive burns or burns that may include areas of full thickness

skin loss will be treated systemically with penicillin or if preferred, sulfadiazine.

c. See Circular Letter No. 26 regarding policy of early skin replacemen t.

11. Anaerobic Infections.

a. Clostridial myositis (gas gangrene). Early and adequate wound surgery remains the most effective preventive measure. Early diagnosis of this

complication when it occurs, is essential to adequate treatment. Treatment

utilizes surgery, penicillin, antitoxin and whole blood transfusion. It is recommended that penicillin be given in the following manner: Initial dosage of

100,000 units intravenously, with 25,000 units intramuscularly at the same

time. course of 25,000 units intramuscularly every hours day and night

is instituted. Larger dosages and other regimens have not afforded any more

satisfactory results. Sulfonamides are discontinued during penicillin administration.

b. Anaerobic cellulitis and other anaerobic infections. Penicillin therapy is used as with clostridial myositis (par. 10a).

c. Amputation for anaerobic infection.

(1) It is of prime importance to differentiate between clostridial

myositis and other anaerobic wound infections to prevent the needless sacrifice

of limbs on the basis of clinical findings of gas and putrid wound exudate.

(2) In the management of clostridial myositis limb need not be

amputated solely as measure designed to arrest the infection. If trauma, vascular occlusion and advancing infection, acting singly or together, have so damaged

the extremity that functional restitution is unlikely, amputation is performed

as ready and effective adjunct to the arrest of infection.

(3) The early diagnosis of clostridial myositis and the employment

of penicillin and other adjuncts to therapy, permit the management of the

infection to be confined to the excision of involved muscles. If the excision

of muscles judged necessary to eradicate the infection must be so extensive

that functional restitution of the extremity is unlikely, amputation should be

performed.

(4) When amputation is performed as part of the surgical treatment

of clostridial myositis, the use of penicillin and other adjuncts to therapy allow

other considerations than the eradication of infection to play part in selecting

the level for amputation. Provided all muscles invaded by the infection and
326 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

remaining in the stump are carefully excised, more distal level of amputation

may be selected if the ultimate function of the extremity is thereby conserved.

For the SURGEON:

(S) E. StaxDLEB

E. STANDEES,

Colonel, M.C.,

Deputy Surgeon.

DISTRIBUTION:

Surgeon, Fifth Army 600

Surgeon, Seventh Army 300

Surgeon, SOS NATOUSA 800

Surgeon, AAFSC/MTO 600

Surgeon, NATOUSA 300

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

29 August 1944

CIRCULAR LETTER NO. 46

SURGICAL MANAGEMENT OF THE WOUNDED III

HI—SURGICAL MANAGEMENT OF THE WOUNDED.

Note: The contents of this circular letter as well as Circular Letter Nos.

26 and 36 are to be brought to the attention of every Medical Officer in the

Theater who is assigned responsibility for the management of the wounded.

7. Reparative Surgery of the Lightly Wounded.

a. It is an eloquent tribute to the high standards that have been attained

in forward surgery that the suture of wounds at the time of the first dressing at the base is established as routine procedure. To maintain this standard requires constant vigilance in techniques as described in Circular Letter

No. 26. The lightly wounded combat soldier is the most valued military asset

entrusted to the care of the Medical Corps. His treatment must be carried

out or closely supervised by surgeons with mature judgement and experience.

There are no “minor” wounds.

b. Forward surgeons will indicate on the record or on the cast the extent

of actual skin loss. At the time secondary suture is performed it is difficult
APPENDIX 327

to distinguish between the gaping of long incision that can be closed by

approximation and the existence of sizeable defect that will require skin

graft.

c. An increased use of splinting of soft part wounds following debridement is advisable. Circular plaster encasement if placed proximally on an

extremity must be immediately bivalved to avoid constriction.

d. In the closure of wounds, particularly those of the extremities, further

refinements are desirable in techniques that have direct effect on restoration

of function and early return to duty.

(1) Transversely divided muscle bundles may be closed by suture, staging the closure of the skin to later date.

(2) Very accurate approximation of the skin as in plastic procedure

is desirable. When drainage is required, this should be through counter

incision.

(3) More use should be made of the principles of plastic surgery, viz.,

the advancement and rotation of skin flaps, zig-zag plastics and other tricks

of closure that minimize scar contracture and limitation of motion.

(4) Trauma to skin margins by rat tooth forceps and rough handling

is productive of necrosis and imperfect healing.

(5) Prolonged hospital neglect of unhealed wounds and skin defects

must be stopped. It is recommended that the chief of surgical service personally review cases of unhealed soft part wounds that remain in hospital

longer than four weeks so that proper treatment can be expedited.

8. Amputations.

a. The most important phase in the management of amputations is the

functional rehabilitation of the patient by the fitting of prosthesis. Amputation centers have been established in the Zone of the Interior for this

purpose. It is the expressed desire of The Surgeon General that the early

management of amputations in overseas theaters conform with policies that

have been set forth in numerous Bulletins and Circular Letters. There will

be no deviation from these policies in this theater.

(1) Forward Area.

(a) Level. Amputations will be performed at the lowest possible

level except that proximal amputation will be done in preference to disarticulation.

(b) Technique. The properly performed flapless guillotine stump

exhibits slightly concave open cross section of the extremity. circular

incision is made through the skin at the lowest level compatible with viable

tissue and the skin allowed to retract; the fascia is then incised at the level to

which the skin has retracted. The superficial layer of muscle is then cut at

the end of the fascia and permitted to retract. At its point of retraction, the

deep layers of muscle are cut through to the bone. After the deep muscles

have retracted the periosteum of the bone is cleanly incised and the bone

sawed through flush with the muscles. No cuff of periosteum is removed

as in closed amputation. Bone denuded of periosteum will sequestrate if
328 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

infection is present and ring sequestrum often results when the periosteum lias

been removed. It is important also that no periosteum be elevated or torn

from the bone in the stump by rough handling.

(c) Dressing and skin traction. The end of the stump is dressed

with fine mesh gauze in such manner that it does not overlap the skin edges.

Skin traction is applied immediately. This may either be by stockinette

cuff attached with ace adherent or by adhesive tape. Traction is obtained

preferably by light plaster cast with wire ladder banjo. The cast always

incorporates the joint above the amputation, e. g., spica for an amputated

thigh. A. Thomas splint may be utilized as an alternative. When this is

done in lower leg amputations, posterior splint from midthigh to beyond

the stump is provided to prevent flexion contracture of the knee. Medical

Supply Item No. 36614—-Cord, Elastic, for Traction—is available and is

preferable to plasma tubing for the elastic traction. Before evacuation, the

traction is examined and if doubt exists as to its effectiveness, it is reapplied.

(2) Base.

(a) All thigh amputations and those of the leg at or near the site

of election will be treated by continuous skin traction. Secondary suture or

skin grafting of the terminal defect with or without revision will not be done.

Removal of the cast or splint and maintenance of to 10 pounds cf traction

over pulley at the foot of the bed is recommended. Traction is continued

for several weeks (at least 6) until all layers of soft tissue have been firmly

fixed by scar formation. Priority air evacuation to the Zone of Interior is

available for amputation cases as soon as they are able to be transported.

Traction during evacuation is provided for by stockinette and banjo plaster.

(b) Amputations in the lower third of the leg and of the upper

extremity may be closed by secondary suture provided the wound is clean and

course of penicillin is instituted. If closure is not feasible, skin traction is

maintained.

(c) Amputations of the thigh or leg performed in fixed hospitals for trauma, vascular insufficiency or infection will be carried out in conformity

with the above principles. In the upper extremity, modifications to secure

primary or early secondary closure are permissible in individual cases.

(d) Patients received with injuries that require amputation will benefit by an explanation of why the amputation is necessary prior to the

operative procedure. About one in five patients will exhibit psychic reactions, often depressive in type, few days after the operation. As soon as the

patient is surgically comfortable and mentally receptive, an interview with

psychiatrist may be extremely helpful. Particular attention should be paid

to what the patient may reasonably expect in the way of aid. The establishment of amputation treatment centers in the ZI may be explained, and assurance given relative to prosthetic appliances, and his potential economic and

social status. Fortification of this type, before patient becomes the target

of sympathetic family and friends, may tip the scales in favor of rehabilitation in contrast to life long disability and resentment.
APPENDIX 329

9. Fractures of the Femur.

The program of reparative surgery in fixed hospitals, improvements in

skeletal traction techniques, and penicillin therapy are expected to result in

improved apposition and alignment of the fractures and improved knee and

muscle function, after the fracture has united. Therefore the following

recommendations are made:

a. Fractures treated by skeletal traction.

(1) Knee flexion produces quadriceps stretch and predisposes to

patellar fixation. As flexion increases quadriceps exercises become more

difficult. While some knee flexion is necessary for comfort and to aid in

reduction of the fracture it should be held to minimum. For lower third

fractures two-wire skeletal traction is recommended. By this method traction

is made by wire (or pin) in the tibial tubercle while second wire through

the lower femoral fragment permits vertical “lift”. Extreme knee flexion is

avoided.

(2) Quadriceps setting exercises and knee motion should be carried

out several times daily as soon as wound management permits. Knee motion

begun early produces less strain on the fracture site than that begun late after

joint “stiffness” has set in.

(3) Duration of traction. Traction in the great majority of cases

must be continued until there is bony fixation clinically and roentgenologically.

This will average about 10 to 12 eeks. Prolonged traction permits an

increasing range of knee motion and will prevent angulation in cast during

evacuation to the of I.

(4) low spica extending to the knee on the well side is the recommended splinting for transportation to the of I. Uncertainty of evacuation

and because spica is preferably applied at least 48 hours prior to transporting, have resulted in many fractures of the femur remaining in plaster for

several weeks or months awaiting and during evacuation, thereby predisposing to restricted knee motion. Collaboration between the surgeon and the

disposition officer permits the application of the spica 48 hours prior to evacuation. Fractured femurs immobilized after traction are excellent priority

cases for air evacuation.

b. Fractures Treated by Internal Fixation.

(1) Wire loop fixation. Alinement should be protected by prolonged

skeletal traction followed by spica (see (3) (4)).

(2) Plating or Multiple Screw Fixation. Postoperative immobilization in Thomas splint with Pierson attachment permits early knee motion.

Following wound healing and period of knee motion and quadriceps exercises,

spica (see (3) (4)) is used for evacuation to the ZI.

IV—DISASTER MANAGEMENT IN FIXED HOSPITALS.

Any hospital in the theater, no matter how far removed from the Combat

Zone suddenly may be called upon at any hour of the day or night to receive

and care for large numbers of wounded or injured. It is essential, therefore,
330 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

that plans for such an emergency be made in advance and be clearly understood by both administrative and professional staffs. The following principles

are important:

1. Early recognition of what may be termed the “pattern of trauma” so

that appropriate treatment may be instituted without delay. This is established by careful examination of representative sample of the injured and

supplemented by inquiry regarding the source and nature of injury, the time

elapsed since injury and the possible number of casualties to be admitted.

Serious secondary effects may be masked by obvious primary manifestations:

thus, the lethal effects of underwater blast may be masked by the effects of

immersion; the inhalation of noxious fumes may pass unrecognized while

superficial flash burns are treated. With explosions of ammunition ships or

dumps in theater of war, consideration must always be given to the possibility

that agents of chemical warfare may have been released.

2. Establishment of wards adjacent to the admitting ward for reception

of patients is essential rather than distribution of the new patients throughout

the hospital.

3. Triage is established at the time of admission to sort three groups of

patients:

a. Those in immediate need of resuscitation, close preoperative supervision and emergency operative procedures.

b. Those that require surgery but will be transportable if and when

it is necessary to reduce the backlog of cases awaiting operation by transfer

to other hospitals for treatment.

c. Lightly injured that will be discharged to duty after short period.

Patients in group a. will be sent to “shock” ward where treatment is

carried out under close supervision. They receive first priority X-ray and

laboratory service.

Group b. require ordinary ward supervision and second priority X-ray

and laboratory service. Clinical records should be maintained and tentative

evacuation list prepared.

Group c. should be fed and made comfortable, but professional attention

postponed during the emergency period unless special indications arise.

4. Surgical Management.

Patients in group a. are assigned to operative teams who direct the preoperative care, request necessary laboratoiy examinations and schedule the

operation. One or more officers are assigned to the Shock Ward and remain

on the ward. It is their duty to be familiar with the progress of each patient;

what treatment has been ordered, and what examinations are in progress or

have been completed. In addition they carry out resuscitation measures

under surgical direction.

After operation, if the patient is in precarious condition he should be

returned to the Shock Ward or to an adjacent Postoperative Ward—but

under no circumstances sent to some remote ward of the hospital.
APPENDIX 331

5. Whole Blood Transfusion.

Plans must include well thought-out method of supplying whole blood

in considerable quantity. Circular Letter No. 30 should be studied. Reliance cannot be based on securing blood from theater transfusion units, as the

function of these installations is to supply blood to armies in combat.

supply of vacuum bottles, transfusion sets, refrigerator space and donor

list from the detachment will enable the laboratory to start banked reserve.

Immediate steps may be taken to supplement the donor list from organizations in the immediate vicinity. Type specific blood should be used as most

economical of donors.

6. Reserve Surgical Supplies.

Sufficient supplies must be kept on hand at all times to meet the demands

of an emergency. Vaseline gauze, fine mesli gauze and other sterile supplies

may be stored in sealed containers and resterilized as often as necessary.

7. X-ray Service.

Request for X-ray examinations should be based on the priority of the

case, and the X-ray Department must not be flooded with examinations that

can be postponed. Patients that may be transferred to another hospital for

surgical operation need not be X-rayed unless necessary to the determination

of transportability or disposition.

system for viewing wet films should be planned, and facilities made

available for the films to accompany the patient to the operating theater.

8. If doubt exists regarding the nature, source of circumstances surrounding the incident, examination of casualties dead on arrival or dying in hospital

may be of importance not only for official record but for treatment of the survivors.

For the SURGEON:

(S) E. Standlee

E. STANDLEE,

Colonel, M. C.,

Deputy Surgeon.

DISTRIBUTION:

Surgeon, Fifth Army 600

Surgeon, Seventh Army 300

Surgeon, SOS NATOUSA 800

Surgeon, AAFSC/MTO 750

Surgeon, Replacement Command 50

Surgeon, NATOUSA 300
332 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

HEADQUARTERS

MEDITERRANEAN THEATER OF OPERATIONS

UNITED STATES ARMY

Office of the Surgeon

APO 512

10 March 1945

CIRCULAR LETTER NO.

SUBJECT: Notes on Care of Battle Casualties.

The contents of several previous circular letters pertaining to the surgical

management of the wounded are consolidated and in certain instances extended

or modified in the following recommendations.

1. The care of the wounded must always be shaped by conditions and

circumstances that govern the tactical situation at the moment. It has been

shown by this Theater that the surgery of war need not be molded by concessions to the need for haste and the confusion of caring for overwhelming numbers

of patients. Military surgery is not crude departure from accepted surgical

standards, but development of the science of surgery to carry out specialized

and highly significant mission. Modern surgical treatment employs many

adjuvants to operative techniques, such as chemotherapy, fluid replacement

therapy, the transfusion of whole blood and fractions of blood employed as

substitutes, potent anesthetic agents and narcotics. These tools are as important to the military surgeon as his scalpel, but are equally dangerous to the

patient if used without expert precision. One of the major responsibilities of

the military surgeon is to make fidl use of these and similar measures and at the

same time to avoid the dangers that mayattend their usage.

The ever-present necessity for evacuation of the wounded to the rear is

in fundamental conflict with idealsurgical management of the individual patient.

To minimize this conflict, close coordination between the functions of administration and professional services is required. It is the responsibility of the

medical officer charged with the surgical management of the patient to place

technical procedures properly, both in time and in space, with due regard to

the tactical situation on the one hand and to the welfare of the patient on the

other. Unless the surgeon visualizes his position and the function of his hospital

in relation to other surgeons and other hospitals, he may become confused in

the mission he is to perform. Although some needed operation may be performed correctly, the military effort may be impeded and unforeseen harm done

to the patient if the operation is done at the wrong time or in the wrong place.

It is the responsibility of administrative officers charged with the establishment of evacuation and hospitalization policies to adapt the schedules of movement of patients to the maintenance of highest standards of surgical treatment.

Priority of movement must be accorded to patients with certain types of injuries

just as the duration of hospitalization in given zone must be differentially

adjusted to the urgent surgical needs of the patients. The term “nontrans-
APPENDIX 333

portable” as relating to the unfitness of battle casualties for interhospital transfer must, when military necessity permits, be extended beyond aetnal danger to

life by consideration of the likelihood of deformity, ultimate disability, and

delay ofrecovery when these hazards exist.

Just as the placement of various types of hospitals and consequently the provision of the facilities for surgery are determined by the geographic deployment of military force, phases of surgical management exist that in general

will conform with military echelons. These phases of surgical management are: first aid measures, initial wound surgery, reparative wound surgery, reconstructive surgery, and rehabilitation measures.

First Aid Measures. Within the divisional area surgical management is

limited to first aid measures and emergency resuscitation. Hemorrhage is

controlled, splints and dressings applied, morphine administered for pain,

plasma infused for resuscitation, booster dose of tetanus toxoid is given, and

chemotherapy initiated.

Initial Surgery. Actual conditions of warfare will determine both the

facilities provided for emergency wound surgery and their location with reference to the combat area. In general, initial surgery is concerned with complete

resuscitation so that surgery may be performed, and with surgical procedures

designed to prevent or eradicate wound infection. Many of the seriously

wounded casualties can be resuscitated only by surgical operation in conjunction with transfusion and plasma therapy. For this reason, it is important

that delays for the purpose ofresuscitation ahead of an installation equipped for

major surgery be kept at minimum. Placement of the advance surgical

hospital in physical proximity to the divisional clearing station accomplishes

this end.

Reparative Surgery. The general hospitals of the communications zone

receive casualties from the hospitals of the forward area for further surgical

management. As the initial wound operation is by definition limited procedure, nearly every case requires further treatment. Soft part wounds,

purposely left unsutured at the initial operation, are closed by suture, usually

at the time of the first dressing on or after the fourth day. Fractures are

accurately reduced and immobilized until bony union takes place.

Designed to prevent or cut short wound infection either before it is established or at the time of its inception, this phase in the surgical care of the

wounded is concerned with shortening the period of wound healing and seeks

as its objectives the early restoration of function and the return of soldier to

duty with minimum number of days lost. In addition, it affords the return

of patients to the United States at an earlier date and in better condition and

minimizes the ultimate disability and deformity in the seriously wounded.

The success of this important phase of surgery depends on the provision

of an adequate period of hospitalization in addition to competent surgical care*,

particularly in specialized fields. It is not to be confused with the reconstructive

phase of surgery, which may be postponed until return to the Zone of the

396961°—57 23
334 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Interior. The ideal time for the procedures of reparative surgery will be

found between the fourth and tenth days after wounding. The patient then

becomes “non-transportable” for period of timewhich, in the case of fractures, may extend to eight or ten weeks. Transfer of patients between fixed hospitals

within the zone of communications must be regulated with these considerations

in mind, otherwise the objectives of this phase of surgical management may be

sacrificed. The establishment of special centers within general hospitals for

certain types of surgery during this phase is highly desirable, as the procedures

are oftentimes of considerable magnitude and call for mature and experienced

professional judgment. Advancement of general hospitals in close support of

Army or utilization of air evacuation from Army to more remote fixed installations are two measures that further the establishment of program of

reparative surgery.

Reconstructive Surgery. Early evacuation to the United States is desirable

for patients whose return to duty cannot be anticipated within the limits of the

hospitalization policy of an overseas theater. The phases of reconstructive

surgery and rehabilitation may then be integrated.

2. Wound Management.

a. Initial Wound Surgery.

(1) X-ray. In the preoperative examination of battle casualty

X-ray examination is essential.

(2) Adequate assistance and instruments, good light, and access to

the wound that is unhampered by faulty position of the patient are basic

requirements. Ample preparation of wide field by shaving the skin will

allow for extension of the incision or counterincision.

(3) Bold incision is the first essential step in an operation on wound.

Adequate exposure is necessary to carry out excision of devitalized tissues.

On the extremity the line of the incision is placed parallel with the long axis ol

the limb; elsewhere it follows the natural lines of skin structure. Only the

devitalized skin of the margins of the wound is excised in strip rarely wider

than to mm. The creation of circular skin defects is avoided.

(4) Incision and excision of the fascial layers is performed in the same

manner to give free access to devitalized muscle. Unrestricted exposure of

successive anatomic layers permits the complete excision of devitalized muscle

and the removal of foreign bodies.

(5) The surgeon must be familiar with the blood supply of muscles,

particularly large groups like the gastrocnemius-soleus muscles of the calf and

respect these vessels in his dissection. Deep recesses of the wound containing

foreign bodies may be approached by counterincisions planned anatomically

rather than by sacrificing normal muscle structures,

(6) Use fine hemostats. Use the finest ligature compatible with the

procedure. Include the smallest possible amount of tissue in ligating bleeding

point. Do not repeatedly bite the wound with tissue forceps. Sponge gently

with pressure instead of wiping. Remaining devitalized tissue produced by
APPENDIX 335

the missile or by the surgeon must slough before the wound can be closed by

secondary suture.

(7) Large wounds in regions of heavy muscles, particularly when

complicated by comminuted fracture, require especial care. The depths of

these wounds must be opened by long incision with counterincision if necessary

to allow free dependent drainage.

(8) Only enough dry, fine, mesh gauze is used to separate the surfaces

of the wound. It should be smoothly laid in the wound—not “packed”.

(9) Ether, white soap, and benzene, have slight but definite necrotizing effects on living muscles. Green soap and various other substances used

as detergents have greater necrotizing effects. Physiological saline solution

is relatively innocuous. In general, progress in wound management points

away from the introduction of any agent into wound, either for its supposed

mechanical or antiseptic effect.

(10) Old wmmds (48 hours or longer) are managed in accord with the

same principles, except that in selected cases of established pyrogenic infection

and anaerobic cellulitis with toxicity the general condition of the patient to

withstand radical surgery may be improved by immobilization, penicillin and

repeated blood transfusions until an optimum time is selected for intervention.

In postponement of surgery the advantage that accrues from the immediate

drainage of septic hematomas, large masses of dead muscle, and fascial plane

abscesses, is not to be forgotten. Postponement of surgery is not justified if

clostridial myositis (gas gangrene) may be present.

(11) Proper transportation splinting is provided for skeletal and

joint injuries. Soft part wounds are supported by firm pressure dressings and

may, if extensive, be advantageously enclosed in light plaster. Care is taken

to avoid any constricting action of pressure dressing placed on an extremity.

Plaster casts must always be padded and split or bivalved before the patient

is returned to the ward.

b. Reparative Wound Surgery.

(1) On arrival at hospital where bed care can be assured for period

of at least fifteen days (soft part w'ounds) the original dressing is removed in

the operating room under aseptic precautions. X-ray films should be at hand.

If the primary wound operation has been complete and has been properly done,

all superficial wounds and many deep wounds may be closed by secondary

suture at this time (4 to 10 day’s). Foreign bodies in soft parts adjacent to

the wound are removed. Following suture, the part is immobilized, preferably

by light plaster, or if this is impractical, by bed rest.

(2) The presence of residual dead tissue or established infection

manifested by profuse discharge of pus, reddening and edema of the wound

margins, persistent fever or toxicity is an indication for delay in secondary

suture. When these manifestations are present but minimal, the wound is

allowed to “clean up”. This process can be hastened by moist dressings or

by additional surgical excision of devitalized fragments. Secondary suture
336 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

can then be performed in few days. If established infection is severe, or if

the patient is toxic and anemic from deep seated sepsis, course of penicillin

therapy and blood transfusions is instituted and followed by radical wound

revision, and staged closure.

(3) Wounds that have been laid open properly at the initial operation

tend to gape widely and give the impression of extensive skin loss. This appearance is actually due to loss of support of the deep fascia. Skin defects

are more apparent than real in the majority of cases and closure of defect is

made from local tissue with suture in straight line when possible. Undermining with advancement or rotation of flaps provides sufficient skin in nearly

all instances and is preferable to grafting.

(4) Technical considerations that are important to the success of

secondary wound closures are:

(a) Atraumatic handling of tissue.

(b) Avoidance of tension sutures.

(c) Accurate approximation of skin margins. The epithelial

bridge is the main support of the wound for considerable period of time.

(d) Obliteration of dead spaces by pressure dressings and immobilization. Stab wound drainage may be instituted when desired and is

preferable to drainage through the suture line.

(e) Leaving sutures in place for twelve days if stitch infection

does not develop.

(f) Suture in straight lines rather than the creation of sharp angles.

(5) Preliminary bacteriologic analysis of the flora of wound does

not provide information pertinent to making the decision to perform secondary

suture or allow the prediction of the result. If the suture is not successful

because of infection, appropriate studies and corrective therapy is instituted

before resuture is attempted.

(6) The conditions that most often jeopardize results are:

(a) Suture of wound that is discharging pus. This usually

means dead tissue in the depths.

(b) Too early motion. (Wounds breaking down for this reason

should be immediately resutured.)

(c) Unrecognized foreign bodies adjacent to the wound,

c. Closed Plaster Treatment.

(1) The regimen of closed plaster management of war wounds is

not considered as satisfactory as the method described above when field conditions permit the use of the latter.

(2) While the necessity for the rapid turnover of large numbers of

casualties might justify an adoption of the closed plaster method of management of compound fractures, high penalty in the form of skeletal deformity

would be the inevitable result. Results obtained by secondary suture do not

justify the use of closed plaster for soft part wounds.

(3) When it is desired to allow granulations to cover exposed bone

in deep irregular wounds, the wound may be encased in plaster subject to in-
APPENDIX 337

frequent changes. This is also an accepted method of management for established infection of bone, particularly when the wound has caused an extensive

loss of overlying soft parts or there is large bone defect. Before application

of the plaster, all devitalized tissue and loose bone fragments are excised.

There should be no pocketing or pooling of pus in the fracture site or adjacent

fascial compartments. Small surfaces of bare cortical bone may be removed

surgically when this permits closure of the defect by suture or skin graft.

h. Amputations.

(1) The most important phase in the management of amputations is

the functional rehabilitation of the patient by the fitting of prosthesis. Amputation centers have been established in the Zone of the Interior for this

purpose. It is the expressed desire of The Surgeon General that the early

management of amputations in overseas theaters conform with policies that

have been set forth in numerous Bulletins and Circular Letters and which are

summarized below.

(2) In the forward area, amputations will be performed at the lowest

possible level except that proximal amputation will be done in preference

to disarticulation. The technique for the performance of amputations is

as follows: circular incision is made through the skin at the lowest level compatible with viable tissue and the skin allowed to retract; the fascia is then

incised at the level to which the skin has retracted. The superficial layer of

muscle is then cut at the end of the fascia and permitted to retract. At its

point of retraction, the deep layers of muscle are cut through to the bone.

After the deep muscles have retracted, the periosteum of the bone is cleanly

incised and the bone sawed through flush with the muscles. No cuff of periosteum is removed as in closed amputation. Bone denuded of periosteum

will sequestrate if infection is present and ring sequestrum often results

when the periosteum has been removed. It is important also that no periosteum be elevated or torn from the bone in the stump by rough handling.

The properly performed Hapless guillotine stump exhibits slightly concave

open cross section of the extremity. (3) The proper dressing of the stump is important. The end of the

stump is dressed with fine mesh gauze in such manner that it does not overlap

the skin edges. Skin traction is applied immediately. This may either be

by stockinette cuff attached with ace adherent or by adhesive tape. Traction

is obtained preferably by light plaster cast with wire ladder banjo. The

cast always incorporates the joint above the amputation, e. g., spica for an

amputated thigh. The Army Hinged Half-Ring splint may be utilized as an

alternative. Medical Supply Item No. 36614, Cord, Elastic, for Traction,

is available and is preferable to plasma tubing for the elastic traction. Before

evacuation, the traction is examined and if doubt exists as to its effectiveness, it is reapplied.

(4) At the base areas, secondary closure of circular guillotine amputation stump is not indicated, as it is impossible to suture the inelastic fascia
338 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

without wasteful shortening of the bone. Bone length can be saved by continuing the skin traction for an additional period of time—4 to weeks. Closure

of stumps by sliding flaps, plastic resection with sacrifice of bone length, or

formal reamputation are procedures to be carried out in the Zone of the Interior rather than in an overseas theater. Skin grafting is not indicated.

Vertical incisions in the stump made for control of infection or as part of the

initial debridement should be closed by secondary suture while skin traction

is being maintained to cover the defect at the end.

(5) In the Communications Zone continuous skin traction is maintained in all cases. After removal of the cast or splint, maintenance of to

pounds in below-knee and to pounds in thigh stumps of traction over

pulley at the foot of the bed is indicated. Traction is continued until the

wound is healed. Priority air evacuation to the Zone of Interior should be

available for amputation cases as soon as they are able to be transported.

Traction during evacuation is provided for by stockinette and banjo plaster,

i. Fractures.

(1) The management of compound fracture is divided into the

following phases: first aid splinting in the field; debridement and the application of transportation splinting in mobile hospital; final correction of the

deformity and attainment of wound healing and bony union at fixed hospital

(reparative phase); reconstructive or corrective surgery (bone grafting, osteotomy, sequestrectomy, etc.) in the Zone of the Interior. In every phase

attention is directed to the ultimate Junction of the extremity which is dependent

on muscles, nerves, blood vessels and joints as well as on skeletal integrity.

(2) Transportation Splinting applied subsequent to initial wound

surgery for evacuation from mobile to fixed hospitals is not designed to provide anatomic reduction or prolonged fixation in suitable reduction. Except

in rare instances it is by plaster of Paris. Plaster bandages are adequately

padded and bivalved or split through all layers to the skin. Skeletal fixation

by the incorporation of pins or wires into the plaster is not recommended.

The only indication for the use of internal fixation in the forward area is to

preserve the vascular integrity of the extremity.

Methods of transportation splinting that have proved safe and comfortable are:

Femur: low waisted “one and one half” plaster spica with the knee

slightly flexed and minimal abduction.

The Tobruk plaster and the Army leg splint with skin traction do not

provide as adequate immobilization and should only be used as emergency

measures when large numbers of casualties or multiple wounds in single

casualty demand concessions to operating time or for special indications such

as the presence of colostomy or suprapubic cystostomy. When restricted

to lower third femoral fractures and knee joint injuries the Tobruk splint

provides adequate immobilization.

Humerus: thoracobrachial plaster with the arm forward in internal

rotation.
APPENDIX 339

plaster Velpeau bandage binding the arm to the trunk with the forearm

flexed at right angle and placed across the chest. The Army humerus splint designed for field (first aid) use is not suitable for postoperative transportation splinting.

hanging cast is both uncomfortable and ineffective as method of

transportation splinting.

Forearm:

circular plaster bandage that extends to the midbrachial region with

flexion of the elbow and extending only to the proximal palmar crease.

Plaster slabs in the form of “sugar-tongs.”

Tibia and Fibula:

circular plaster bandage from toes to groin. The knee is slightly (15

degrees) flexed and the foot held in neutral position at 90 degrees to the axis

of the limb. plantar slab may extend beyond the toes to afford protection,

but hyperextension is to be avoided.

(3) Reparative Surgery of Compound Fractures. (See Wound Management, par. on Closed Plaster Treatment.)

Reparative surgery in compound fractures is made necessary by leaving unsutured the large incisions made for debridement and the recognized fact

that splinting suitable for transportation is inadequate for complete reduction

and fixation of the fracture. The goal is functional restoration of the extremity and demands treatment of muscle and nerve injury as well as skeletal

damage. Observance of certain basic principles are important to the success

of this phase of management.

Preoperative correction of anemia by whole blood transfusion. Despite

whole blood transfusion for resuscitation in the forward area, high percentage

of compound fracture cases will arrive at fixed hospital in the Communications Zone with low red cell volume (hematocrit) and hemoglobin. An approximate estimate of the quantity of whole blood needed to restore red cell

volume may be deduced from the rough rule of 500 cc blood for each points

of the hematocrit or 0.9 grams of hemoglobin. In the use of whole blood

transfusion for correction of secondary anemia or hypoproteinema the total

volume administered in 24 hour period should not exceed 1000 cc except

to replace blood lost at operative procedures. This is in contrast with the

larger volumes that are administered for resuscitation when the total circulating blood volume may be greatly reduced. No correlation exists between

the hematocrit or hemoglobin levels and circulating blood volume and care

must be taken not to precipitate pulmonary edema by overtransfusion of

patient in whom the blood volume has been restored by dilution but who still

shows greatly reduced cell volume (hematocrit) and hemoglobin.

The surgical elimination of residual necrotic tissue. No available chemotherapeutic agent can “sterilize” an open wound containing devitalized tissue

or blood clot. properly managed clean wound requires no local antiseptic.

The control of invasive infection by systemic chemotherapy. Systemic penicillin therapy in dosage of 25,000 units every three hours is recommended
340 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

as routine adjuvant for secondary operations on compound fractures. Treatment is continued post operatively until the likelihood of invasive infection

is passed.

Reduction or closure of soft tissue dejects. Exposed cortex of bone, nerves

and tendons are vulnerable to the necrotizing effect of wound suppuration and

are protected by the apposition of adjacent soft parts. Transversely divided

important muscle groups are united by suture. Fascial compartments are restored to minimize scarring and improve muscle function. Certain of these

procedures may be staged operations. Emphasis should not be placed on early

or complete skin closure, as in most cases any remaining cutaneous defect will

heal before bony union occurs.

Provision of drainage for residual exudate. Severely comminuted fractures

may require dependent drainage in association with the apposition of soft parts

over exposed bone. Exteriorizing fascial plane incisions have proven superior

to stab wounds or rubber drains. Upper extremity fractures rarely present

drainage problem. The thigh may be drained by posterolateral incision between the vastus lateralis and the biceps. An adequate posterior drainage

route for the shaft of the tibia does not exist and such an injury may necessitate period of “on the face” nursing.

Internal fixation of battle fractures is not feasible commonly because of extensive comminution. Further, the method demands further periosteal stripping and surgical trauma to the wound. Limitation of the use of this method

to cases carefully selected by specialists fully experienced in the techniques and

hazards of its usage is strongly advised. An example of sound usage is the

employment of screws for restoration of the articular surface of major joint.

Reduction of the fracture is the goal of reparative surgery—not the use of

internal fixation.

Use of suspension traction. The application of suspension traction in the

treatment of fractures, particularly those of the femur, is the safest and most

satisfactory method of management. In fixed hospitals fractures of the femur

should be treated by skeletal traction for ten to twelve weeks until enough

union has been obtained to permit safe transportation to the Zone of the Interior in plaster spica. The use of suspension traction promotes the maintenance of joint and muscle function and prevents angulation or over-riding

deformity.

Overpull and resulting distraction must be avoided at all times, particularly in cases associated with injury or division of the thigh muscles. Certain

cases of this type require very expert attention and delay in the application of

traction until firm fibrous union of muscles has been attained b} suture,

j. Joints.

Early complete debridement is the keystone of success in the management

of wounds that compound joint. The wound of the soft part is excised and

the bone and cartilage damage assessed through incisions that provide complete

exposure. Comminuted fragments of bone and cartilage are removed from the

joint and careful search made for foreign material. Badly comminuted frac-
APPENDIX 341

tures of the patella are excised completely as step in the debridement of

knee joint wound.

Every effort is made, after cleansing the joint cavity, to close the capsule.

The skin is left unsutured. Closure of the joint is especially difficult in the

face of extensive loss of soft parts. When it is impossible to close joint by

suture of synovia or capsule, an occlusive dressing is applied. On arrival at

fixed hospital, effort is directed toward closing the defect by advancement of

skin flap or other plastic procedure.

Adequate exposure of the hip joint is specialized procedure that requires

precise anatomical orientation. The same principle of management must be

applied to improve the results of this particular lesion.

Penicillin is inserted into joint at the end of the operation. In joints

that are accessible to needle aspiration, accumulating exudate may be withdrawn and penicillin injected during the postoperative period.

Wounds of the ankle joint with comminution of the os calcis or astragalus

are peculiarly liable to sepsis. Initial debridement of comminuted bone fragments must be minimal if function is to be preserved and early efforts are made

in the reparative surgical phase to reduce or close the skin defect with split

thickness graft when necessary. When sepsis is established, subperiosteal excision of necrotic bone fragments followed by wound closure by graft or suture

should not be delayed.

For the SURGEON:

(S) E. Standlee

E. STANDLEE. Colonel, M. C., Deputy Surgeon.

DISTRIBUTION:

Surgeon, PENBASE 300

Surgeon, NORBS 20

Hq. A/GofS 10

Surgeon, Adriatic Base Command 100

Surgeon, Fifth Army 600

Surgeon, AAFSC/MTO 700

Surgeon, Replacement Command 50

Surgeon, Rome Area Command 25

Surgeon, Hq. Command, AF 30

Surgeon, MTOUSA 300

343

MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the history of the Medical Department of the

United States Army in World War II are divided into two series: (1) The

administrative and operational series, which constitutes part of the general

series of the history of the United States Army in World War IT, prepared by

The Surgeon General and published under the direction of the Chief ofMilitary

History; and (2) the professional, or clinical and technical, series, prepared by

and published under the direction of The Surgeon General, This is one of

the volumes published in the latter series.

345

INDEX

Abduction of thumb

in splinting for carpal scaphoid fractures,

292

in splinting for radial-nerve paralysis, 47

in testing for radial-nerve injury, 72

Abscess formation in fractures of bones of

leg, 163

Abscesses;

about fracture site, 93

about lower femoral pin in external skeletal

fixation, 205

drainage of, 63, 72 of fascial plane, 72, 139

Accidents. See Noncombat orthopedic lesions.

Acetabulum, damage to articulating surfaces

of, 237

Adjutant General’s Office, MTOUSA, 280

283

Agents of wounding. See Wounding agents.

Aidmen, medical, 32-33

Air evacuation of amputees, 253, 257

Alinement of fractures by—-

external skeletal fixation, 208

internal fixation, 134, 198, 199-200, 202

plaster immobilization, 40-41, 125, 165,

182

skeletal traction, 139, 149, 182

Ambulation, after menisectomy, 286

American Red Cross, 31

Amputation, 245-270

avoidance of, 130

directives on, 7, 245, 247-249, 251-254,

257, 259

in fractures of

bones of foot, 183

bones of leg, 166, 175-176

femur, 139, 158

in reparative-surgery program, 107, 197

in wounds of knee joint, 216, 231, 235

indication (s) for, 245, 246-247, 266-269

disease as 247, 262-264

infection as, 247, 249

trauma as, 246, 264- 265

trenchfoot as, 262

vascular insufficiency as, 246, 249

Amputation—Continued

level of, 247-249

multiple, 262, 270

of arm, 261

of leg, 253, 254

of lower extremity, 261, 262, 269

of thigh, 253, 254

of upper extremity, 247-249, 254

psychological considerations in, 245

recommendations on, by consultant in

orthopedic surgery, 7-8

reparative surgery after, 253-257

site of, 262

statistics on, 260-270

technique of, 251-253

through long bones, 249

timing of, 269

traction after, 253, 256, 257

traumatic, 246, 249, 262, 264, 265

Amputation centers, in Zone of Interior, 245,

253

Amputation stump, 251-260

closure of, 253-257

healing of, 256-257

revision of, 259-260

Amputees:

air evacuation of, 253, 257

deaths of, 260

Anatomic restoration, as factor in disposition

of patients, 295

Anemia, secondary, before reparative surgery, 82-83

Anesthesia for reparative surgery, 83

Angulation of fractures of

bones of foot, 182

bones of leg, 167

femur, 154-155

humerus, 34, 125

Ankle:

disarticulations at, 261

emergency splinting of, 35-39

transportation splinting of, 51

Ankle joint:

arthrotomy of, 286-287

involvement of, in fractures of bones of

leg, 175

Unlessit is otherwise specified,ail references in this indexare to (1) orthopedicsurgery, (2) battle-incurred compound

fractures, and (3) the Mediterranean (formerly North African) Theater of Operations. “Disposition of patients”refers

to disposition from general hospitals of base sections.
346 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Ankle joint—Continued

loose bodies in, 286-287

position of, in immobilization of fractures

of bones of leg, 164

resection of, 243-244

use of external skeletal fixation after, 210

wounds of:

management of, 243-244

suppurative arthritis in, 244

Ankylosis, in wounds of hip joint, 214, 237,

242

Anomalies, congenital, disposition of patients

with, 274

Antibiotic therapy, 64, 72, 83. See also

Penicillin.

Anzio, 43, 63, 81, 138, 139, 186, 217

Appliances, manuals on, 31-32

Arch supports, use of, in management of

painful feet, 275

Arm. See Humerus.

Army Air Forces:

disposition of patients in, 276-277

elective surgery policy in, 277

hospitals supporting, 276, 280, 282

Army half-ring leg splint. See Hinged halfring leg splint.

Arthritis:

as factor in management of noncombat

lesions, 274, 279

suppurative:

of hip joint, 237, 242, 243

of knee joint, 214, 215, 217-219, 227, 236

of smaller joints, 244

traumatic, 293

Arthrotomy of

ankle joint, 286-287

elbow joint, 286-287

knee joint, 231, 235-236

contraindication for, 283-284

disposition of patients after, 277-278,

281, 282-283, 284, 286-287

incision for, 223

prognosis after, 284-285

statistics on, 277, 280, 282, 286

theater policy on, 279

Articular cartilage:

damage to

in fractures of humerus, 123

in ounds of hip joint, 241

in wmunds of knee joint, 219

necrosis of, in wounds of knee joint, 221

removal of, 223, 243, 279, 286

See also Semilunar cartilage.

Articular surfaces:

anatomic replacement of, 187

damage to, in wounds of hip joint, 237

damage to, in wounds of knee joint, 217

defect in, as factor in diagnosis of joint

mice, 286

Aspiration-instillation regimen, in wounds of

knee joint, 219-221, 231

at initial surgery, 227

at reparative surgery, 227, 235

Astragalus, fractures of, 183

Atrophy of muscles, as factor in diagnosis,

283, 289

Autofrance, Maj. Otto E., 160n

Axillary contents, risk of injury to, in use of

hinged full-ring arm splint, 34

Axillary nerve, damage to, in fractures of

humerus, 122

Backs, painful, 271-275

diagnosis of, 272-274

disposition of patients with, 274-275

management of, 274-275

Bacterial count in wound closure, in World

War I, 58-60

Bacterial flora in war wounds, 59

Bagnoli, 20

Balanced-suspension skeletal traction—-

in fractures of femur, 139, 142-143, 149-

155, 156, 159

in wounds of knee joint, 227

Bandages:

Carlisle, 32, 34

figure-of-eight plaster, 51

manuals on, 31-32

muslin, 40

roller, 32, 34-35, 41

triangular, 32, 34-35

Banjo traction;

after amputation, 251, 253, 257

in fractures of bones of foot, 182

Basswood splints, use of, in emergency splinting, 32, 34

Battalion aid stations, 33, 34

first aid in, 66-67

Battlefield, first aid on, 66-67

Bed rest

after fractures of bones of foot, 183

as treatment for noncombat orthopedic

lesions, 274, 275, 279, 288, 293

Bed space, 271-272

as consideration in elective surgery,

waste of, caring for patients with chronic

orthopedic, non combat lesions, 297

Belgium, 212
INDEX 347

Belts, for painful backs, 275

Biceps femoris muscle, 148

BIP (bismuth subnitrate, iodoform, and

paraffin), use of, in World War I, 53

Bizerte, 4, 20

Bladder, urinary, 237

Blister formation in closed plaster method of

fracture management, 55

Blood, availability of, 63, 67

Blood pressure in shock, 68, 70

Blood replacement

in management of fractures

after initial surgery, 80

after reparative surgery, 82-83

before initial surgery, 68-70

before reparative surgery, 82-83

of bones of leg, 162-163

of femur, 80, 138

of upper extremity, 116-117

in management of wounds of knee joint,

219

in reparative-surgery program, 63, 64

Blood supply of bone fragments, 292, 293

Blood transfusions. See Blood replacement.

Blood vessels, 246

injuries to, associated with wounds of hip

joint, 237

ligation of, at initial surgery, 74

protection of, in fractures of upper extremity, 117

Body warmth, conservation of, before initial

surgery, 67

Bone and nerve surgery in fractures of—-

bones of leg, 161

humerus, 128-129, 132

upper extremity, 116

Bone cortex:

coverage of, at reparative surgery, 93-103

excision of fragments of, at initial surgery,

79

exposure of, in fractures of bones of leg,

160, 161

fragmentation of, in fractures of tibia, 79

Bone coverage, in fractures, 186

after internal fixation, 87

of bones of foot, 181

of bones of leg, 163

of humerus, 129

of upper extremity, 116, 117

Bone fragments:

blood supply of, 292, 293

displaced, 182

distraction of, 201

Bone fragments—Continued

excision of, in carpal scaphoid fractures, 293

management of, in fractures, 198, 207

at initial surgery, 78-79

at reparative surgery, 84, 86, 87

by delayed internal fixation, 134, 146,

187, 199, 201, 207

of bones of foot, 182

of bones of forearm, 41, 134

of bones of leg, 163, 165, 170

of femur, 142, 149, 154

of humerus, 128

of upper extremity, 117

policy on, 78-79

role of, as bone grafts, 79

Bone grafting—-

after fractures, 196, 199, 200, 201

as factor in reparative surgery, 134, 165,

166, 173, 207

after wounds of knee joint, 237

Bone injuries;

data on, methods of accumulation of, 28

disposition of patients with, 295-298

initial surgery for, 64-81

management of;

administrative considerations, 3-28

objectives of,

personnel required for, in general hospitals, 26-27

responsibility for, 25

reparative surgery for, 81-114, 139-186

See also specific bones, techniques, injuries.

Bone loss, 87, 107, 185, 187, 199, 201

after massive sequestration, 196, 199

as indication for application of hip spica,

156

as indication for external skeletal fixation,

207

avoidance of, 79

In fractures of

bones of forearm, 134-135, 202

bones of leg, 160, 161, 165, 170, 173, 201

femur, 144

humerus, 116, 126-127, 201

lower extremity, 245

upper extremity, 116

Bone-nerve injuries, in fractures of bones of

forearm, 134-135

Bone shortening, 187

in fractures of—-

bones of forearm, 135

bones of leg, 165, 201

humerus, 126-127, 128
348 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Bone shortening—Continued

in wounds of knee joint, 231, 236

indications for, 87

Bone tumors, disposition of patients with,

274

Boot plaster cast, 182, 183, 275

Bou Hanifia, 19

Boxing-glove type of plaster cast,

Bracemakers, assignment and utilization of,

15-20, 27

Braces, for painful backs, 275

Braceshops, 275

equipment for, 15, 20

Brachial artery, risk of damage to, in splinting, 34

Brott, Capt. C. R., 245n

Bruises, disposition of patients with, 295

Burns associated with fractures, 209

Butterworth, Maj. R. D., 168n

Buxton, St. J. D., 250

Cahen, Maj. Irvin, 137, 146, 149, 152

Calcification, in carpal scaphoid fractures,

293

Calf, wounds of, 73

Callus formation, after fractures, 81

of metatarsal bones, 182

Capillary attraction, drainage of wound

exudate by, 78

Capsule of hip joint, closure of, 241

Capsule of knee joint. See Synovial membrane.

Carlisle bandages, 32, 34

Carpal scaphoid fractures, 271

diagnosis of, 292

disposition of patients after, 291, 293-294

surveys on management of, 276, 290-294

theater policy on mangement of, 290, 292

union of, 293

Carrel-Dakin method, 53, 211

Cartilages, articular:

damage to

in fractures of humerus, 123

in wounds of hip joint, 241

in wounds of knee joint, 219

necrosis of, in wounds of knee joint, 221

removal of, 223, 243, 279, 286

See also Semilunar cartilages.

Casablanca,

Caserta, 63

Cassino, 4, 43, 62, 139, 186

Casts, plaster:

banjo, 182, 251, 253, 257

boot, 182, 183, 275

boxing-glove type, 8,

Casts, plaster—Continued

hanging, 41, 27-31, 33, 117, 12:1-126, 127

hip spica, 8, 48-49, 139, 154

long arm, 41

long leg, 49, 61, 170, 173, 216

shoulder spica, 41, 43, 123, 125, 127

type, 43

Velpeau, 41, 43

See also Plaster immobilization, Plaster

casts.

Casualties. See Patients.

Cellulitis, 72

Certificate of Disability discharge, 237

Chain of evacuation, 14

role of, in reparative-surgery program, 62

Chemotherapy, 57

institution of, as first-aid measure, 67

See also Sulfonamide therapy.

Chiefs of orthopedic sections:

classifications of, 26

duties of, 26, 27

role of, in accumulation of data, 28

Chiefs of surgical services, responsibility of,

Chip fractures of knee, 283

Churchill, Col. Edward D. See Consultant in surgery.

Circular amputations. See Open circular

amputations.

Circular letters:

No. 13, Office of the Surgeon, NATOUSA,

15 May 43—47n

No. 16, Office of the Surgeon, NATOUSA,

June 43—47n

No. 36, Office of the Surgeon, NATOUSA,

July 44—-10

No. 46, Office of the Surgeon, NATOUSA.

29 Aug 44—7, 8, 9, 245, 247-249, 251-

254

No. 48, Office of the Surgeon, NATOUSA,

18 Nov 43—185, 203-204, 278-279.

287, 289, 290

No. 91, Office of the Surgeon General, 26

Apr 43—247n

Circular wounds, 74

Circulatory status of extremities, determination of, after initial surgery, 80

Civilian orthopedic practice, 273

knee disabilities in, 284-285

wounds of joints in, 212-213

Clary, Capt. Beverly B., 160n

Clearing stations:

first aid in, 66-67

responsibility of, 14

Cleveland, Col. Mather,
INDEX 349

Closed plaster method of fracture management, 53-58

clinical observations on, 57

discontinuance of use of, 58

in fractures of bones of leg, 63, 178

modification of, 56

objectives of, 53

results of, 53, 55-56

Clostridial myositis—-

after amputation, 249, 256

as indication for amputation. 247, 249, 267,

269, 270

in fractures of bones of leg, 178

in fractures of femur, 139, 140

Closure of amputation stump, 253, 254-257

Closure of capsule of hip joint, 241

Closure of knee joint, 216, 219

Closure of synovial membrane in wounds of

knee joint, 216, 217, 219, 221, 223

smaller joints, 243

Closure of wounds. See Wound closure.

Collecting stations, first aid in, 66-67

Collom, Maj. Spencer A., Jr., 21 In, 137n

Colostomy, 47

Comminuted fractures, 87, 129, 134, 146, 159.

165-170, 173, 175, 178-179, 186, 201, 207,

208-209, 219, 223

Comminution

as contraindication to internal fixation, 86,

87, 122-123, 128, 186

as indication for external skeletal fixation,

207, 208-209

Committee on Surgery, Division of Medical

Sciences, National Research Council, 31

Subcommittee on Orthopedic Surgery, 213

Como,

Condylar fractures, 198

of femur, 87, 146

of humerus, 87, 129

Conference, Interallied Surgical, 1917, 211

Congenital anomalies, disposition of patients

with, 274

Consultant(s):

in neuropsychiatry, Fifth U. S. Army, 272-

273

in orthopedic surgery, 1, 4, 5, 63, 188, 189,

238, 242, 277

activities of, 7, 12. 238, 277

mission of, 4, 6-7

to field armies, advantages of appointment of, 5. 13, 237

to Fifth U. S. Army,

Consultant(s) —Continued

in surgery, 1, 4, 58, 65

function of, 6,

to Fifth U. S. Army, 5, 7, 8, 10

to Seventh U. S. Army, 4, 5, 12, 51

role of, in training of medical officers, 65

Consultant system, evolution of, 3-5

Continental Advance Base Section, 10-12

Contraindications to

delayedprimary wound closure, 59, 91, 103,

163

external skeletal fixation, 207

internal fixation, 86, 186

periosteal stripping, 86

surgery for knee disabilities, 279, 283-284

Trendelenburg position, in shock, 68

Convalescent hospitals, 66, 279

Copper sulfate hematocrit and serum protein

determination, 82

Counterincisions, utilization of, for

elimination of dead space, 77

removal of foreign bodies, 73

wound drainage, 74, 93, 103

Cox, Col. Francis J., 137n, 148

Crider, Capt. Russell J., 137n, 152, 155

Crouch, Capt. Francis R., 115n, 160n

Dead space, 57, 59, 93, 163-164, 166

as surgical limitation to wound closure,

59, 103

drainage of, 186

obliteration of, 77, 117, 142

Deaths

after delayed internal fixation, 197

in fractures of femur, 137, 139, 140, 158

in reparative-surgery program, 107

of amputees, in fixed hospitals, 260

Debridement:

at reparative surgery, 59

in closed plaster method of fracture management, 54, 55

in wounds of—-

hip joint, 242

knee joint, 216, 217, 219, 223-227, 235

smaller joints, 243-244

objectives of, 71

See also Initial surgery

Delayed internal fixation of fractures, 91, 146, 155, 185-202

about joints, 185, 187

advantages of, 197

comminution, as contraindication to, 186

disadvantages of, 187

hazards of, 195-196, 198-199

indications for, 190-191, 197

399661°—57 24
350 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Delayed internal fixation of fractures—Con.

of bones of forearm, 185

of bones of leg, 185, 199

of femur, 197, 199

of long bones, 187

of upper extremity, 199

results of, 186, 188-202

techniques of, 187

theater policy on, 185

with segmental bone defects, 185, 187

with soft-tissue loss, 185

with unhealed wounds, 185, 186

See also Screw fixation, Plating, and other

specific techniques.

Delayed primary suture of amputation

stump, 256

Delayedprimary wound closure. See Wound

closure, delayed primary.

Delayed union in fractures, prevention of,

198

Delta Base Section, 11, 12

Deltoid muscle, 122

Dependent drainage, 77, 142, 143, 148, 161,

163

Devitalized tissue, 57

drainage of products of, 91, 143, 148, 186

excision of, 188

as criterion for wound closure, 59

at initial surgery, 73

at reparative surgery, 84

in closed plaster method of fracture

management, 57

in fractures, 63, 117, 142, 179-180, 181

in wounds of joints, 219, 241

effect of, on wound closure, 60, 149

effect of, on wound healing, 112

in fractures of femur, 142, 149

inadequate excision of, 56

sequestration of, 81, 107

Diagnosis of noncombat orthopedic lesions,

272-274

in civilian orthopedic practice, 272

of back, 274

of carpal scaphoid fractures, 290, 292

of knee, 283

of shoulder, 287

Dirty wounds:

after incomplete initial surgery, 117

extensive wound revision for, 103

necessity of drainage in, 149

reparative surgery in management of, 107

restriction or avoidance of periosteal stripping in, 87

Disarticulation, 261

theater policy on, 247-249

Disease, as indication for amputations, 247, 262-264

Dislocation (s) of

hip, in management of wounds of hip joint, 243

humerus, 122

patella, 278

shoulder, 271-274, 276, 287-290

Disposition boards in hospitals, 276, 279,

287, 290, 294

Disposition of patients. See Patients, disposition of.

Drainage

in fractures, 83

after reparative surgery, 63, 91-103,

107, 186, 188

at initial surgery, 72, 74, 78

in closed plaster method of fracture

management, 53-58

in external skeletal fixation, 204

of bones of foot, 182

of bones of leg, 161, 163-164, 175-178

of femur, 142, 148-149, 201

of upper extremity, 117

in wounds of

hip joint, 237, 242

knee joint, 216, 217, 219, 231, 235

smaller joints, 244

Drains:

gauze used as, 103, 163

rubber tissue, 77, 103, 163

Drayer, Lt. Col. Calvin S., 272-273

Dressing of stump, after amputation, 251

Dressing of wounds:

after initial surgery, 74, 77-78

after reparative surgery, 103, 182

Drilling, in carpal scaphoid fractures, 293

Duncan, Lt. Col. George A., 115n, 137n,

160n, 21 In, 295n Edema;

in closed plaster method of fracture

management, 55

control of, 103, 183

Elastic cord, use of, after amputations, 8,

11, 253

Elbow:

arthrotomy of, 286-287

disarticulations at, 261

extension of, in hinged full-ring arm

splint, 34
INDEX 351

Elbow—Continued

fractures about, 122, 129-130

delayed internal fixation of, 198

emergency splinting for, 34

transportation splinting for, 41, 43-44

loose bodies in, 286-287

protection of function of, in fractures of

radius, 134

resection of, 54

wounds of, management of, 243-244

Elective surgery:

general discouragement of,

in Army Air Forces, 277

policy on, 278-279

Elephant-tusk splint, 43

Emergency splinting. See Splinting, emergency.

England,

Equipment:

for braceshops, 15, 19-20

for emergency splinting, 32, 34, 35, 37, 39

for transportation splinting, 39, 41

in communication zone, 14, 15

in forward area, 14

Evacuation:

after amputation, traction during, 257

after initial surgery of fractures, 80

air, of amputees, 253, 257

chain of, 14

role of, in reparative-surgery program,

62

effect of, on patient, as consideration in

disposition, 295

Evacuation hospitals. See Hospitals, evacuation.

Evacuation policies;

as factor in management of noncombat

orthopedic lesions, 279

general principles of disposition and,

295-298

military considerations in, 64

Ewino, Maj. William M., 137n

Exercises, quadriceps, 150, 154, 279, 284, 286

External skeletal fixation, 80, 156, 165, 170,

203-210

in closed plaster method of fracture management, 53-58

Extremities:

circulatory status of, determination of,

after initial surgery, 80

nerve function in, determination of, at

initial surgery, 72

See also Lower extremity, Upper extremity.

Facilities in hospitals, 7, 271, 272, 295, 297

in communications zone, 14-15, 19-20

in forward areas, 14

See also Equipment, Personnel.

Falling-drop technique. See Copper sulfate

hematocrit and serum protein determination

Fascia:

coverage of, at reparative surgery, 93

excision of, at initial surgery, 76

incision of, at initial surgerv, 73

sloughing of, in fractures, 91

Fascia flaps, use of in wounds of knee joint,

223

Fascia lata, 76, 141-142

Fascial plane;

abscesses of, 72, 139

drainage through, in fractures of femur,

143,148

Fat pad, excision of, in menisectomy, 285

Feet:

amputation of, 183, 262

fractures of bones of, 180-183

banjo traction in, 182

disposition of patients with, 181, 296,

298

emergency splinting for, 35

initial surgery of, 181

manipulation in, 182

plaster immobilization of, 182

reparative surgery of, 181-183

transportation splinting for, 40-41, 51

painful, 271-272, 274

diagnosis of, 272-274

disposition of patients with, 275

management of, 275

See also Lower extremity.

Femur:

articulating surfaces of, damage to, 237

fractures of, 137-159

about joints, 221

amputations in, 139, 158

associated with wounds of thigh, 84

balanced-suspension skeletal traction

after, 139, 142-143, 149-155, 156, 159

blood replacement in management of,

68, 70, 80, 82, 138

complications in, 140

deaths in, 137, 139, 158

disposition of patients with, 298

drainage in, 148-149, 159

duration of traction after, policy on,

emergency splinting for, 39
352 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

emur—Continued

fractures of—Continued

external skeletal fixation of, 156, 207,

209

hip spica in, 139, 156

infection in, 139, 140, 156, 159

internal fixation of, 87, 143-148, 155-

156, 199, 201

Kirschner wire in, 142

knee motion after, 140, 153, 154, 197

management of, 138-140

nerve injuries associated with, 141

operating time for initial surgery of, 138

periosteal stripping in, 146

quadriceps muscle tone after, 140

reduction of, 139-140, 143-148, 150-

157, 159

reparative surgery of. 141-159

operative position for, 142

results of, 157-159

scar formation in, 139, 140

sequestration in, 159

shock associated with, 138

sinus formation in, 140, 158-159

statistics on, 137-141, 158

transportation splinting for, 47-48

two-wire skeletal traction after, 149

union of, 154-155

wound healing in, 139, 140, 155, 159

wound management in, 148-149

Ferguson, Maj. William R., 115n, 137n,

155, 160n

Fibula, fractures of, 160-180

blood replacement in management of, 68,

162-163

bone loss in, 160, 165-170

closed plaster technique in management

of, 163

disposition of patients with, 164-165, 173

drainage in, 161, 163-164

external skeletal fixation of, 208, 209

infection in, 160

internal fixation of, 170-173, 199, 201

manipulation in, 160

nerve and bone surgery in, 161

nerve injuries in, 162

nonunion of, 161

plaster immobilization of, 164, 165,166-

170, 173

reduction of, 57, 160, 161

reparative surgery of, 162-180

scar formation in, 160

sequestration of, 160

skeletal traction in, 160, 166-170

Fibula, fractures of—Continued

statistics on, 162, 175-178

tissue loss in, 161

transportation splinting for, 40-41, 51

union of, 160-161

wound closure in, 161, 163-164

wound healing in, 160, 163

wound management in, 162-164, 175-179

Field hospitals. See Hospitals, field.

Field manuals. See Manuals.

Fifth U. S. Army, 4, 49, 51, 138, 261

consultants to, 4, 7, 272-273

Figure-of-eight plaster bandage, 51

Fingers:

determination of circulatory status of, 80

motion of, in fractures of upper extremity,

117

motion of, in splinting for carpal scaphoid

fractures, 292

transportation splinting of, for radialnerve paralysis, 43, 47

First aid for fractures, 65-67

First-aid splinting. See Splinting, emergency.

Fixed Hospitals. See Hospitals, fixed.

Flat feet, disposition of patients with, 275

Flexion contracture of knee after amputation, prevention of, 253

Flexion of

elbow, in emergency splinting, 34

hip joint—-

in hinged half-ring leg splint, 39

in hip spica, 49

knee

in balanced-suspension skeletal

traction, 150, 152

in emergency splinting, 39

in transportation splinting, 40, 41, 49,

52

in immobilization after wounds of knee

joint, 227

thumb, in testing for ulnar-nerve injury, 72

toes, in fractures of bones of leg, 164

Flynn, Capt. James H., 115n

Forearm. See Radius, Ulna.

Foreign bodies:

removal of, 63, 73, 84, 181, 223, 241

retained, 68

Forward hospitals. See Hospitals, forward.

Fracture frames, 14, 15

Fracture table, portable, 14, 39

Fractures:

about joints, 87, 185, 187, 221

amputation after, 139, 158, 249
INDEX 353

ractures—Continued

avoidance of amputation in, 130

blood replacement in management of, 68,

70, 82-83, 116-117, 162-163

bone fragments in, 78-79, 128, 134, 163

bone loss in, 87, 126-127, 160, 165, 185, 187

characteristics of, 65-66, 138

closed plaster techniquein management of,

53-58, 163

complications in, 140

deaths in, 137, 139, 158

delayed internal fixation of, 91, 146, 155,

185-202

displacement of, in plaster casts, 56

disposition of patients with, 164-165, 173,

181, 296, 298

drainage in, 54, 91-103, 148-149, 161,

163-164

emergency splinting for, 31-39

external skeletal fixation of, 128-129, 156,

165, 203-210

first aid for, 66-67

functional restoration of extremity after,

87, 129

granulation in, 130, 132

infection in, 57, 63, 123, 132, 134, 139-140,

156, 158, 159, 160, 199, 236

initial surgery of, 64-81

internal fixation of, 86-91, 126-127, 129,

130, 134, 143-148, 165, 170-173

malposition of, prevention of, 159

management of. See Management of

fractures,

manipulation in, 160, 182

motion after, 153, 154

nerve injuries in, 50, 116, 127-129, 130,

132, 134-135, 141, 161, 162

nonclosure of wounds in management of,

74, 77

nonhealing of wounds in, 192-202

nonunion of, 192-202

of ankle, 35, 51

of astragalus, 183

of bones of

forearm, 34, 41, 43, 47, 57, 68, 87, 115-

117, 133-137, 185, 202, 207, 208, 209, 298

foot, 35, 51, 180-183, 298

leg, 35, 37-39, 40-41, 51, 57, 68, 79,

160-180, 199, 200, 201, 207, 209, 298

of condyles of

femur, 87, 146

humerus, 87, 129, 298

ractures —Continued

of femur, 9, 39, 47-49, 68, 80, 82, 84, 137-

159, 197, 199, 201, 207, 209, 221, 298

of humerus, 34, 41, 43, 68, 87, 115-133, 201

of long bones, 187

of lower extremity, 245

of olecranon process, 87, 134

of patella, 219, 221, 223

of upper extremity, 115-117, 199

operating time for initial surgery of, 138

operative position for reparative surgery

of, 142

osteomyelitis in, 132

plaster immobilization of, 103, 122-127,

133, 139, 156, 164, 165, 166-170, 173,

182

protection of function in, 134

range of motion following internal fixation

of, 197

reduction of, 55, 56, 57, 63, 80, 86-91, 107,

122, 123, 126, 129, 130, 133-134, 135,

139-140, 142-148, 149-157, 159, 160

reparative surgery of, 81-114, 122-133,

162-173

golden period for, 81, 141

objectives of, 8, 137

results of, 130-133, 135-137, 141-159,

173-180

scar formation in, 139, 140, 160

sequestration in, 132, 159, 166

shock in, 138

sinus formation in, 132, 140, 158, 159

skeletal traction in, 134, 139, 142-143,

149-155, 156, 160, 166-170, 182

soft-tissue loss in, 87, 130, 161, 197, 199

splinting after reparative surgery for, 4,

117, 150

stabilization of, 64

statistics on, 115, 137-138, 139-141, 161,

162, 175-180

tendon injuries in, 116

transportation splinting for, 39-52

union of, 79, 83, 126, 130, 132, 154-155

after delayed internal fixation, 186,

192-202

unreduced, internal fixation of, 186

vascular damage in, 80

without bone loss, 123-126

wound closure in, 74, 91-103, 123, 129,

133, 161, 163-164

wound healing in, 55, 57, 79, 116, 130,

132-133, 134, 135, 139, 155-166, 163

after delayed internal fixation, 92-202,

186
354 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Fractures—Continued

wound management in. See Management of wounds.

Fractures, comminuted, 87, 129, 134, 146,

159, 165-170, 173, 175, 178-179, 186, 201,

207, 208-209, 219, 223

Fractures, simple, 207, 271, 276, 290-294,

296, 298

France, 4, 9, 31, 51, 161, 204, 280, 291

Frankatj, C. F. S., 215

Full-ring hinged splint. See Hinged fullring arm splint.

Fusion of Joints, 215, 237, 244

Gangrene, as indication for amputation, 246,

268, 269

Gas-bacillus infection, identification of, after

initial surgery, 80

Gastric lavage, before initial surgery, 68

Gastrocnemius muscle, 52, 73

General hospitals. See Hospitals, general.

German prisoners of war, analysis of amputations on, 261-270

Glenoid process, 122

Gluteus maximus muscle, 148

Godfrey, Maj. Joseph D., 137n, 142, 152

Golden period for reparative surgery, 81,

141. See also Reparative surgery, timing

of.

Gottschalk, Capt. Robert B., 115n, 160n

Grafting. See Bone grafting.

Grafts. See Skin grafts.

Granulation, wound healing by, in fractures,

58, 59, 64, 91-103

in closed plaster method of management,

55, 57

of bones of foot, 181

of bones of leg, 160, 163, 175

of femur, 139, 159

of humerus, 130, 132

Gross normal alinement of injured extremity,

maintenance of, by splinting, 40

Guillotine amputations. See Open circular

amputations.

Half-ring leg splint. See Hinged half-ring

leg splint.

Hallux valgus, disposition of patients with,

275

Hammertoes, disposition of patients with,

275

Hampton, Col. Oscar P., Jr. See Consultant in orthopedic surgery.

Hamstring muscle, 148

Hand:

emergency splinting of, 34

importance of function of, in management

of fractures of upper extremity, 115

Hand injuries:

disposition of patients with, 296, 298

management of, 8, 9, 74

Hanging plaster cast, use of, in fractures of

humerus, 117, 127

advantages of, after reparative surgery,

123-126

inadequacy of, for transportationsplinting,

41

Harris, Maj. Herbert W., 148, 203n, 211n

Heel bone, fractures of, 181, 183, 245

Hematocrit, copper sulfate determination of,

82

Hematocrit level, before reparative surgery—-

in fractures, 82

of bones of leg, 162-163

of femur, 138

of upper extremity, 116-117

in wounds of knee Joint, 219

See also blood replacement.

Hematomas, in fractures, 93

elimination of, as criterion for wound

closure, 59

purulent decomposition of, 57

septic, drainage of, 72

Hemoglobin level, 82

Hemorrhage, 82

control of, at first aid, 66

control of, before initial surgery, 67

detection of, after initial surgery, 80

Hemostats, use of

in first aid, 66

in initial surgery, 73

Hinged full-ring arm splint, use of—-

in amputation, 257

in emergency splinting, 32, 34

in transportation splinting, 41

Hinged half-ring leg splint, use of

in amputation, 253, 257

in balanced-suspension skeletal traction,

150, 151, 152, 227

in emergency splinting, 32, 35-39, 67

in transportation splinting, 47, 51

Hip Joint;

capsule of, closure of, 241

emergency splinting of, 35, 37, 39

flexion of, 49

transportationsplinting of, 47-49

wounds of, 237-243

ankylosis in, 237
INDEX 355

Hip joint—Continued

wounds of—Continued

infection in, 237, 238-241, 242

management of, 237, 242-243

suppurative arthritis in, 237, 242

wound healing in, 241

Hip spica, use of

after thigh amputation, 253

in fractures of femur, 139, 154, 156

in transportation splinting, 48-49

in wounds of hip joint, 242

in wounds of knee joint, 8, 227

Holding periods in hospitals;

after elective arthrotomy, 279

for accomplishment of reparative surgery,

63, 65, 83

for fractures of femur,

for wounds of hip joint, 242

in forward areas, 295

theater policy on, as factor in disposition

of patients with noncombat orthopedic

lesions, 276

Hopkins, Maj. George S., 245n

Hospital(s):

captured German military, 261

convalescent, 279

mission of, 66

evacuation:

8th—7

9th—236

16th—68, 138

38th—7

94th—7

See also Hospitals, forward,

field:

33d—7

See also Hospitals, forward,

fixed:

amputation at, 246, 260-261

disposition of patients, 295-298

management of

amputation stump at, 246, 253-256

fractures at, 55-57, 138, 139-140, 187-

188, 203-210

noncombat lesions at, 272-294

wounds of joints, 216-221, 227, 231,

235-236, 242, 243, 244

mission of, 63

reparative surgery at, 81-114

segregation of bone and joint injuries

at, 25

See also Hospitals, general; Hospitals,

station.

Hospital(s) —Continued

forward:

amputations at, 246

assignment of general surgeons to, 12, 13

assignment of orthopedic surgeons to,

5, 12-13

disposition of patients from, 295, 297

facilities at, 14

holding period at, 242, 295

initial surgery at, 14, 67-81

management of

fractures at, 55, 138, 163

wounds of joints at, 231, 242 243

mission of, 63

screening of patients at, 272-273

transportation splinting at, 39-52

See also Hospitals, evacuation; Hospitals, field,

general:

disposition boards at, 276, 279, 287

disposition of patients from, 295-298

facilities at, 14-15, 19-20

numbered;

3d—11

6th—9, 101-108

12th—9, 148, 286-287

17th—148, 219, 235

2lst—10, 19, 82, 115, 121-138, 141-

183, 186, 197, 219, 244

23d—81, 82, 138, 142, 152, 186, 219

24th—20, 140-183

26th—280, 282-283

33d—8, 9, 121-133, 140-183, 286 287

36th—10, 11, 12

43d—11

45th—115, 133-137, 161-181, 215, 219, 286-287, 297-298

46th—10, 12, 19, 292

64th—8, 140-183

70th—236

182d—291, 292

300th—121-138, 141-183, 186

outpatient dispensaries in, 27

personnel required in, 26-27

See also Hospitals, fixed,

station:

disposition boards at, 276

numbered:

35th—11

70th—11

73d—9

78th—11

80 th—11

180th—10
356 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Hospital(s) —Continued

station—Continued outpatients clinics in, 27

See also Hospitals, fixed,

supporting the Army Air Forces, 276, 280, 282

Zone of Interior, mission of, 64, 116

Hospital administration, 25-27

Hospital center for prisoners of war, 261

Hospital disposition boards, 276, 279, 287,

290, 294

Hospital facilities, 7, 271, 272, 295, 297

Hospitalization period:

after arthrotomy of knee joint, 277-278, 279, 281, 282

after carpal scaphoid fractures, 291-292,293

after disabilities of knee, 280-281, 282

after reparative surgery of fractures, 65

of bones of foot, 183

of femur, 157

after shoulder dislocations, recurrent, 288

Hospitalization policies, military considerations in, 64, 65

Humerus:

amputations of, 261

dislocations of, 122

fractures of, 115-133

about elbow joint, 129-130

about shoulder joint, 122, 126

blood replacement in management of, 68

disposition of patients with, 298

emergency splinting for, 34

granulation in, 130, 132

infection in, 123, 129-130, 132

internal fixation of, 87, 126-129, 201

management of, 115

nerve and bone surgery in, 128-129

nerve injuries associated with, 116, 122,

127-129, 130, 132, 134

osteomyelitis in, 132

plaster immobilization of, 123-127

reduction of, 122-130

reparative surgery of, 122-133

sequestration in, 132

sinus formation in, 132

soft—tissue damage in, 130

tendon injuries associated with, 116

transportation splinting for, 41-46

union of, 132

with bone loss, 116, 126-127, 201

without bone loss, 123-126

wound closure in, 123, 129

wound healing in, 130, 132-133

wound management in, 122-124

Improvised sacral rests, 39

Improvised splinting. See Splinting, emergency, improvised.

Incidence. See Statistics.

Incisions:

enlargement of, at reparative surgery, 84

for amputations, 251

for initial surgery

of fractures, 72, 73, 74—76, 163

of wounds of knee joint, 223

for menisecotomy, 285

relaxing, for wound closure, 163

Indications for

amputation, 245, 246-247, 266-269, 270

arthrotomy, 277

changes of cast in closed plaster method of

fracture management, 54

external skeletal fixation, 207-210

hip spica, in fractures of femur, 156

internal fixation of fractures, 87, 128, 134, 173, 197

elective, 191, 200, 201, 202

obligate, 190-191, 200, 201, 202

resection of knee joint, 231, 236

Infection:

after amputation, 256

as indication for—-

amputation, 247, 266, 269, 270

reamputation, 270

in fractures, 66, 80, 81, 84, 103, 107

after external skeletal fixation, 204

after internal fixation, 186, 188

control of, 72, 199

in closed plaster method of fracture

management, 55-57

in World War I, 53

of bones of foot, 183

of bones of leg, 160, 175, 178

of femur, 87, 139, 140, 142, 146, 148, 149, 154, 156, 158, 159, 201

of humerus, 123, 129, 132

of radius, prevention of, 134

of upper extremity, 116

in wounds of—-

hip joint, 237, 238-241, 242-243

knee joint, 49, 216, 217-221, 227, 231,

235-237

smaller joints, 244

prevention of, 57, 103, 183, 186

by initial surgery, 71, 73

by utilization of reparative-surgery

program, 64

See also Sepsis.
INDEX 357

Initial surgery, 14

amputations at, 246

in wounds of

hip joint, 237, 241, 242

knee joint, 223-227, 235-236

smaller joints, 243-244

of fractures, 64—81

appraisal of wound at, 71-72

blood replacement in, 138

evacuation following, 80

first aid preceding, 66-67

fracture management at, 80

general principles and practices of, 72-

74

management of bone fragments at 78-

79

objectives of, 71

of bones of foot, 181

of femur, 138

postoperative regimen after, 80

preoperative preparation for, 67-71

technical considerations in, 74—78

timing of, 64-66, 72

role of, in prevention of amputation, 268

See also Debridement, Staged management.

Injuries. See Fractures, Wounds, and special

wounds.

Interallied Surgical Conference, 1917—211

Internal fixation of fractures, 86-91, 107, 187,

188

advantages of, 86, 87

contraindictations to, 86, 128

disadvantages of, 87

indications for, 87, 126

of bones of forearm, 134

of bones of leg, 165, 170-173, 178

of femur, 142-148, 153, 155-156

of humerus, 126-129

See also Delayed internal fixation, Plating,

Screw fixation, and other specific techniques.

Intestines, involvement of, in wounds of hip

joint, 241

Intra-abdominal wounds, associated with

wounds of hip joint, 237

Inverted-cone stumps in amputation, 251

Irrigation in wounds of joints, 216, 223, 227,

243

Italy, 3, 4, 8, 13, 19, 20, 26, 121, 133, 139, 140,

236, 243, 261

Jergesen, Maj. Floyd H.,

Joint(s):

fractures about, 57, 87, 185, 187

loose bodies in. See Joint mice,

wounds of, 211-244

data on, methods of accumulation on, 28

disposition of patients with, 295-298

in civilian orthopedic practice, 212-213

in Spanish Civil War, 213

in World War I, 211-212

initial surgery for, 64-81

management of:

administrative considerations in, 3-28

evolution of, 3, 63, 214-231, 242-243

objectives of,

personnel required for, in general

hospitals, 26-27

resection in, 213

responsibility for, 25

See also specific joints.

Joint mice:

disposition of patients with, 286

survey on management of, 276, 286-287

theater policy on management of, 278

Joldersma technique of balanced-suspension

skeletal traction, 151-152

Jolly, D. W., 213

Kirschner wire, 142, 149, 182

Knee:

arthrotomy of, 277-278, 281, 286-287

disabilities of, 271-272

diagnosis of, 272-274, 283, 284

disposition of patients with, 277-278,

279, 280-281, 282-284, 286-287

management of, 276-286

disarticulations at, 261

flexion contracture of, after amputation of

lower leg, 253

position of, in—-

emergency splinting, 35, 37, 39

skeletal traction, 150, 152

splinting after reparative surgery, 164

transportation splinting, 40, 41, 49-52,

227

resection of, 210, 216, 221, 231, 235-237

suppurativearthritis of, 215, 217-219, 227,

236

wounds of, management of, 8, 214-237

Knee motion afterfractures of femur, 140, 142, 150. 151, 154,

159, 197

wounds of knee joint, 216, 221, 227

LaPanne, 212
358 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Leg;

amputation of, 253, 254, 262

wound closure after, 253

emergency splinting of, 35, 37-39

fractures of bones of, 160-180

associated with bone loss, 245

blood replacement in management of, 68

disposition of patients with, 298

external skeletal fixation of, 207

inadequate reduction of, 185

transportation splinting of, 51-52

See also Tibia, Fibula.

Leghorn,

Ligaments of knee, injuries to, policy on

management of, 278, 281

Ligation of blood vessels, at initial surgery, 74

Linch, Maj. Albert O., 151

Litter, use of, as operating table, 71

Long arm plaster cast, 41

Long bones:

amputations through, 249

fractures of, 87, 187

disposition of patients with, 297, 298

external skeletal fixation of, 207

hematocrit values in, 82

internal fixation of, survey on, 188-202

Long leg plaster cast, 49, 51, 170, 173

in wounds of knee joint, 216

Loose bodies in joints:

disposition of patients with, 286

survey on management of, 276, 286-287

theater policy on management of, 278

Lower extremity:

amputations of, 261, 262, 269, 270

emergency splinting of, 35, 37-39

transportation splinting of, 47-52

See also Femur, Tibia, Fibula.

Lymphangitis, 72

Lyons, Maj. Champ, 63, 83

Malalinement in fractures, persistent, 207

Malingerers, 283, 289

Malposition in fractures, 80, 159

Malunion of fractures, 57, 198

Management of fractures, 53-114

at initial surgery, 80

atreparative surgery, 86-103

by delayed internal fixation, 185-202

by external skeletal fixation, 203-210

by internal fixation, 86-90

closed plaster method in, 53-58

concept of, 58, 114

functions of fixed hospitals in, 63

functions of forward hospitals in, 63

in World War I, 53

Management of fractures—Continued

of bones of foot, 182-183

of femur, 141-159

favorable factors in, 141-142

results of, 139-140

unfavorable factors in, 142

of fibula, 160-180

results of, 173-180

unfavorable factors in, 160-161

of humerus, 122-130

results of, 130-133

of radius, 133-134

results of, 135-137

of tibia, 160-180, 188-189

results of, 173-180

unfavorable factors in, 160-161

of ulna, 133-134

results of, 135-137

of upper extremity:

favorable factors in, 116

objective of, 115

principles of, 116-117

problems of, 115-116

Management of noncombat orthopedic lesions, 271-294

diagnosis in, 272-274, 283

surveys on, 272-294

Management of wounds;

associated with fractures

at initial surgery, 71-78

at reparative surgery, 84

of bones of foot, 181-182

of bones of forearm, 133

of bones of leg, 162-164, 175-179

of femur, 148-149

of humerus, 122-123

of upper extremity, 117

closed plaster method in, 53-58

concepts of, 58, 113-114

of joints, 211-244

evolution of 3, 63, 214-231, 242-243

in civilian orthopedic practice, 212-213

in Spanish Civil War, 213

in World War I, 211-212

of ankle, 243-244

of elbow, 243-244

of hip, 242-243

results of, 237-241

of knee, 215-231

in fixed hospitals, 216-221, 227

in World War I, 223

results of, 231-236

of shoulder, 243-244

of wrist, 243-244
INDEX 359

Manipulation, in management of

fractures, 81, 91, 185, 199, 271

in closed plaster method, 56, 57 of bones of foot, 182

of bones of leg, 160, 165

knee with injuries of semilunar cartilage,

279, 283-284

Manpower:

as factor in disposition of patients, 295, 296

loss of, from noncombat orthopedic lesions,

271, 274

Manual (s):

Bandaging and Splinting, FM 8-50,

1944—32

First Aid for Soldiers, FM 21-11, 1943—32

Guides to Therapy for Medical Officers,

TM-8-210, 1942—213

Military Medical Manual, 31

Orthopedic Subjects (Military Surgical

Manual), 1942—31, 213

Soldiers Handbook, FM 21-100, 1941—32

Splints and Appliances, 1917—31, 39

Splints, Appliances and Bandages, FM

8-50, 1940—31, 32

March fractures, management of, 275

Mead, Maj. Newton C., 148, 151, 271n, 280

Mechanic’s waste, use of in hand injury, 8,

Median nerve, 117, 127-128, 134

Medical aidmen, 32, 33

Mediterranean Base Section, 19, 277

Medullary canal, cortical fragments in, 79

Menisci, injuries of, 280, 281, 283

disposition of patients with, 280-282

management of, 221, 223, 276, 279

Menisectomy, 284-285

postoperative management after, 285-286

Merano, 261

Metacarpals:

fractures of, disposition of patients with,

298

position of, in transportation splinting, 47

Metatarsals, fractures of, 181-182

disposition of patients with, 298

Meyerding sacral rests, 39

Modlin, Capt. John., 137, 146, 149, 151,

152, 153, 155

Mollin, Capt. Edwin L., 203, 211

Morphine, administration of, as first-aid

measure, 66-67

Muscle tension in fracture of femur, 207

Muscles;

atrophy of, 283, 289

damage to, as consideration in amputation, 249

Muscles-—Continued deficits of, 87, 187

excision of, 73, 76-77

methods for determining viability of, 77

See also specific muscles.

Naples, 4, 20, 63, 132, 139, 153, 158, 217, 219, 238

National Research Council, Division of

Medical Sciences, Committee on Surgery,

31

Subcommittee on Orthopedic Surgery, 213

Navy technique of balanced-suspension

skeletal traction, 151-152

Necrosis, 57

as factor in determining level of amputation, 249

avascular, 293

in fractures of bones of forearm, 133

in fractures of humerus, 123

of articular cartilage, in wounds of knee

joint, 221

of tissue, in fractures, 91, 93, 107

pressure, protection from, in emergency

splinting, 39

Nerve and bone surgery in fractures of

bones of leg, 161

humerus, 128-129, 132

upper extremity, 116

Nerves;

injuries of, 72, 87, 116, 127-129, 130, 132,

134-135, 141, 187, 196

protection of, in splinting, 34, 117

See also specific nerves.

Neuropsyclnatric-orthopedic consultation, in

management of noncombat orthopedic

lesions, 272-273

90-90-90 technique of balanced-suspension

skeletal traction, 142, 152

Nodules, avascular, 286

Nonclosure of wounds

after initial surgery, 74, 77

after reparative surgery, 91-103, 122, 123,

148, 163-164, 175, 231

Noncombat orthopedic lesions, 162, 181, 215,

271-294

diagnosis of, 272-274, 283

disposition of patients with, 274 275, 277-

284, 286-290, 297, 298

hospitalization period after, 277-278, 2S0-

282

surveys on management of, 276-294

theater policy on management of, 278-279
360 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Xonhealing of wounds, in fractures

after internal fixation, 192-202

of bones of leg, 79, 178

Nonunion of fractures, 57, 107, 292, 293

after internal fixation, 192-202

of bones of leg, 161

prevention of, 87, 198

Obletz, Maj. Benjamin E., 137n, 142, 152

Olecranon process, fractures of, 87, 134

Open circular amputation, 247-270

directives on, 245, 247-249, 251-254, 257

level of, 227-250

reparative surgery after, 253-257

technique of, 251

traction after, 253, 256, 257

statistics on, 260-270

Open reduction of fractures, 86, 91, 122, 155,

185. See also Internal fixation.

Operating room, in general hospitals, 14

Operating table, litter used as, 71

Oran, 4, 19

Orr, H. Winnett, 53

Orthopedic sections, chief of;

Classification of, 26

duties of, 26, 27

role of, in accumulation of data, 28

Os calcis, 181, 183, 245.

Osteoarthritis, as contraindication to arthrotomy, 284

Osteochondritis dissecans, 276, 277-278, 283, 286-287

Osteomyelitis, 185

following external skeletal fixation, 204

in fractures of humerus, 132

Oxygen, administration of, before initial

surgery, 68

Pain;

after fractures of bones of foot, 182

in backs, 271-275

in feet, 271-274, 275

in old carpal scaphoid fractures, 293

in wounds of knee joint, 231

relief of, 32, 34, 66

Parker, Maj. Joseph M., 115n, 137n, 160

Patella:

fractures of, 219, 221, 223

defects of, disposition of patients with, 286

dislocations of, policy on management of,

278

Patients:

chain of evacuation for, 14

disposition of, 272-273, 295-298

after arthrotomy of joints, 278, 281,

282-284

Patients —Continued

disposition of—Continued as consideration in elective surgery,

as factor in assignment of orthopedic

personnel, 12

categories of, 276, 296

Army Air Forces, 276-277

considerations in, 66, 272-274

with carpal scaphoid fractures, 290, 293-291

with fractures, 296, 298

of bones of foot, 181, 183

of bones of forearm, 137, 298

of bones of leg, 164-165, 173, 298

with joint mice, 286-287

with knee disabilities, 278-279,280-283, 284

with painful backs, 274-275

with painful feet, 275

with shoulder dislocations, recurrent,

288-290

Penicillin, use of

in amputation, 253, 268

in wounds of hip joint, 243

in wounds of knee joint, 8, 217-221, 223,

227, 231, 235

role of, in reparative-surgery program, 63

theater policy on, 10

See also Antibiotic therapy.

Periosteal stripping, in internal fixation of

fractures, 86, 87, 91, 187, 195, 198

of bones of leg, 170, 188, 199

of femur, 146, 199

of humerus, 126, 127, 129

Peroneal nerve, damage to, 141, 162

Personnel:

assignment and utilization of, 5, 12-13, 15

problems of, in management of bone and

joint injuries, 4, 5, 6, 65

use of

for initial surgery, 73

for transportation splinting, 39, 40, 41

in general hospitals, 26-27

See also Surgeons, orthopedic.

Petrolatum-impregnated gauze, 9, 55, 56, 78, 182

Physical therapy, as treatment for noncombat orthopedic lesions, 273, 274, 275, 288, 293

Physiologic salt solution, in testing for nerve

damage in fractures, 128

Pierson attachment to hinged half-ring leg

splint, 150-152, 227
INDEX 361

Plasma transfusion:

as first-aid measure, 67

before initial surgery, 68, 70

Plaster casts, 253, 293

bivalving of, 49

policy on, 40

changing of, 55

indications for, 54-55

timing of, 54-56

molding of, around arch of foot, 51, 164

records of wound data on, 40

splitting of, 49

policy on, 40

windows in, 43, 103, 227

Plaster immobilization:

after open circular amputation, 253

after reparative surgery, 117

in carpal scaphoid fractures, 292-293

in closed plaster method of fracture management, 53-58

in fractures, 185, 271, 275

of bones of foot, 182-183

of bones of forearm, 133

of bones of leg, 164-170, 173, 178

of femur, 139, 156

of humerus, 123, 126

use of, with external skeletal fixation,

207-208, 210

in transportation splinting, 39-52, 242

in wounds of hip joint, 242

in wounds of knee joint, 216-217, 221, 227

in wounds of smaller joints, 244

Plaster room, equipment for, in general

hospital, 15

Plaster spica, 210. See also Hip spica,

Shoulder spica.

Plaster Velpeau, use of, in transportation

splinting, 41, 43

Plating of fractures, 87, 187, 198, 199

advantages of, 86

of bones of forearm, 134, 135, 202

of bones of leg, 170-173, 188, 197, 199, 202

of femur, 146, 199, 201

of humerus, 126-128, 201

results of, 192-196

Pool, Eugene H., 211-212, 223

Popliteal artery, protection of, in fractures

of femur, 39

Popliteal space, protection of, in splinting,

49

Position, Trendelenburg, in shock, 68

Postoperative management

after initial surgery of fractures, 80

after menisectomy, 285-286

Postoperative management—Continued

after reparative surgery of fractures, 103

of bones of foot, 183

of femur, 129-157

of upper extremity, 117

for wounds of knee joints, 231

Preoperative preparation—-

for initial wound surgery, 67-71

for reparative surgery, 82-83, 116-117,187

Pressure dressings, 9, 66, 285

Pressure sores, in closed plaster method of

fracture management, 55

Primary suture, delayed. See Wound

closure, delayed primary.

Prisoners of war, analysis of amputations on,

261-270

Psychological considerations in—-

amputation, 245

disposition of patients, 297

management of noncombat orthopedic

lesions, 272-273, 279, 285, 287, 290.

294

Quadriceps exercises:

after fractures of femur, 150, 153, 154

after knee disabilities, 279, 284, 286

Radial deviation of wrist, in splinting for

carpal scaphoid fractures, 292

Radial-nerve injuries, associated with fractures:

of bones of forearm, 134

of humerus, 130

splinting for, 117

statistics on, 127-128

testing for, at initial surgery, 72

Radial-nerve paralysis, transportationsplinting for, 43, 47

Radius:

fractures of, 87, 115-117, 133-137

blood replacement in management of, 68

disposition of patients with, 137, 298

emergency splinting for, 34

external skeletal fixation of, 207-209

infection in, 134

internal fixation of, 134, 202

management of bone fragments in, 134

nerve injuries in, 116, 134-137

plaster immobilization of, 133

protection of function in, 134

reconstructive surgery of, 134, 135

reduction of, 57, 133-135

reparative surgery of, 133-137

skeletal traction in, 134

tendon injuries in, 116

transportation splinting for, 41, 43, 47
362 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Radius —Continued

fractures of—Continued

wound healing in, 134, 135

wound management in, 117, 133

involvement of, in fractures of humerus,

129

Rawles, Maj. Benjamin W., 160n, 21 In,

245n

Reconstructive surgery of fractures, 64, 134,

137, 175

considerations of, at reparative surgery,

165, 166

Rectum, wounds of, associated with wounds

of hip joint, 237

Rectus femoris muscle, 73

Red Cross, 31

Redebridement, in wounds of hip joint, 243

Reduction of fractures, 57. 63. 64, 80, 107,

271

by delayed fixation, 185-202

by external skeletal fixation, 203-210

by internal fixation, 86-90

by manipulation, 81, 91, 199

by skeletal traction, 91, 139, 142-143,

149-156, 159

in closed plaster method of fracture

management, 55-56

of bones of foot, 182-183

of bones of forearm, 133-134, 135

of bones of leg, 160, 161, 165-173, 175, 179

of femur, 139-140, 142-148, 149-157

of humerus, 122, 123, 126, 129, 130

Rehabilitation of patients with noncombat

orthopedic lesions, 273, 277, 284, 287, 290

Reparative surgery:

after open circular amputation, 253-257

appraisal of wound at, 84

concept of, 81

delayed internal fixation at, 185-202

drainage at, 91-103

golden period for, 81, 141

holding period after 9, 63, 65, 83

internal fixation at, 86-91, 107, 187, 188

nerve and bone surgery as part of, 128-129

nerve repair in, 116

objectives of, 137, 186

of fractures, 59, 81-114

of bones of foot, 182, 183

of bones of forearm, 133-135

of bones of leg, 162-173

of femur, 141-159

of humerus, 122-130

of soft-tissue wounds, 58-60, 61

of wounds of knee joint, 227, 231-237

Reparative surgery—Continued

postoperative management after, 103, 117

preoperative preparation for, 82-83, 116-

117, 187

revision of wound at, 84

splinting after, 117 technical considerations in, 83-103

timing of, 65, 81, 116-117, 141, 162, 163,

227, 236, 241

wound closure in, 91-103

See also Staged management.

Reparative-surgery program: application of, to fractures, 61-64

application of, to soft-tissue wounds, 58

application of, to wounds of joints, 63, 223

development of, 58-60

holding period required for, 9, 63, 65, 83

objectives of, 64

survey of, by consultant in orthopedic

surgery 7-12

Resection of joints, 213, 243, 244

of ankle, external skeletal fixation after,

210

of hip, 243

of knee, 216, 221, 231, 235-237

external skeletal fixation after, 210

indications for, 231, 237

Resuscitation;

in preparation for initial surgery, 68-71

emergency splitting as part of, 32

in fractures of femur, 138

Roentgenologic examination, 68, 72, 73, 82, 86, 122, 153, 274, 279, 283-284, 287, 289,

291-292, 293

Roller bandage, 32, 34, 35, 41

Rome, 8, 158

Rovane, Capt. John W., 115n

Rubber-tissue drains, 77, 103

Russell traction, 152-153

Sacral rests, 39

Salerno,

Scar formation

after amputation, 253

in closed plaster method of fracture management, 57

in fractures, 64, 188

of bones of leg, 160

of femur, 139, 140, 159

Sciatic-nerve injuries, statistics on, 141

Screw fixation of fractures, 87, 187, 198

advantages of, 86

of bones of forearm, 134

of bones of leg, 170-173, 178, 199

of femur, 146, 197, 199
INDEX 363

Screw fixation of fractures—Continued

of humerus, 122, 127, 129

results of, 192-196

2d Auxiliary Surgical Group, 249

II Corps,

Secondary surgery, in closed plaster method

of fracture management, 56

Secondary suture of amputation stump, 253

Sedatives, use of, as first-aid measure, 67

Semilunar cartilage, injuries of:

disposition of patients with, 277-278, 282-

283

management of, 276, 278-279, 282

See also Articular cartilage.

Sepsis:

after inadequate debridement, 73

consideration of, in delayedprimary wound

closure, 59

in fractures of femur, 153, 159

in wounds of knee joint, 216, 221

See also Infection.

Sequestration in fractures, 91, 93, 107

after delayed internal fixation, 195-196,

198-201

after periosteal stripping, 86

of femur, 159

of fibula, 160

of humerus, 132

of tibia, 160, 175, 188

Serum protein, copper sulfate determination of, 82

Seventh U. S. Army, 4-5, 12, 51

Shock:

in fractures of femur, 138

prevention of, by emergency splinting, 32

recurrence of, 71

resuscitation in, 68-71

Shorbe, Maj. Howard B., 21 In

Shortening of bone

in fractures, 187

indications for, 87

of bones of forearm, 135

of bones of leg, 165

of femur, 135

of humerus, 126-127, 128-129

in wounds of knee joint, 231, 236

Shoulder:

disarticulations at, 261

dislocations of, 271-272

diagnosis of, 272-274, 287, 289-290

disposition of patients with, 288-290

management of, 287-290

immobilization of, in fractures of humerus,

122-123

Shoulder joint:

emergency splinting of, 34

involvement of, with fractures of humerus, 122-126

transportation splinting of, 41-46

wounds of, management of, 243-244

Shoulder spica, use of—-

in fractures of humerus, 123-127

in transportation splinting, 41-46

Sicily, 4, 13, 26, 47

Simple fractures, 207, 271, 276, 290 294,

296, 298

Sinus formation in fractures, 93, 107

of bones of leg, 175, 179

of femur, 140, 158, 159

of humerus, 132

Sixth Army Group, 12

Skeletal traction, use of:

in closed plaster method of fracture management, 56, 57

in fractures, 9, 91, 185, 199

of bones of forearm, 134

of bones of leg, 166-170, 178

of humerus, 123

in wounds of hip joint, 242

See also specific types.

Skin;

devitalized, excision of, at initial surgery,

73, 76

excoriations of, in closed plaster method

of fracture management, 55

preparation of, at initial surgery, 73

Skin defects:

avoidance of, 73

in fractures of bones of leg, 164

management of, at reparative surgery, 107

Skin deficits, management of, at reparative

surgery, 59

Skin flaps, use of, 59, 93

in fractures of

bones of forearm, 133

bones of leg, 163, 164

humerus, 129

in wounds of hand, 74

in wounds of knee joint, 223

Skin grafts, 84

after amputation, 253, 255

split-thickness, 59, 133, 164

Skin traction

after amputation, 251-253, 255, 256, 257

by use of elastic cord, recommendation

on, 8, 11

in management of knee disabilities, 279

in wounds of hip joint, 242
364 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Skintight plaster casts, 40

Sling(s), 32, 33, 34, 35, 47

Snyder, Col. Howard E. See Consultant

in surgery, Fifth U. S. Army.

Soft tissue:

damage to, in fractures of

bones of foot, 181

bones of leg, 165

humerus, 123, 130

loss of, in fractures, 87, 103, 185, 197, 199

loss of, in wounds of knee joint, 223

role of, in determination of level of amputation, 247-249

wounds of, management of, 103

closure in, 58-60

recommendations on, by consultant in

orthopedic surgery,

Soleus muscle, 73

Spanish Civil War, 39, 53, 125, 164, 213

Spica, plaster, 210. See also Hip spica,

Shoulder spica.

Splint(s);

basswood, 32, 34

elephant tusk, 43

hinged full-ring arm, 32, 34, 41, 257

hinged half-ring leg, 15, 32, 35, 37, 39, 47, 51, 67, 253, 257

with Pierson attachment, 150, 151, 152,

227

improvised, 32, 33

plaster of pans, 253

removal of, after amputation, 253

requirement for, in forward areas, 14

Tobruk, 8, 47, 49-51, 221, 227

wire ladder, 32, 34, 251

Splinting:

after reparative surgery of fractures:

of bones of foot, 183

of bones of leg, 164

of femur, 154

of upper extremity, 114

classification of, 29

in World War I, 31

manuals on, 31-32

objectivesof, 29

Splinting, emergency, 31-39

equipment for, 32, 33

inspection of, before initial surgery, 67

objectives of, 32

regional, 34-39

timing of, 33

training in, 31-32

Splinting, transportation, 39-52

equipment for, 39, 41

objectives of, 40

personnel required for, 40, 41

regional, 41-52

use of plaster in, 39-52

Split-thickness skin grafts, 59, 133, 164

Spondylolisthesis, disposition of patients

with, 274

Sprains:

disposition of patients with, 295, 298

in diagnosis of carpal scaphoid fractures,

292

Staged management, 63

concept of, 84

evolution of program of, 3, 53-64

See also Initial surgery, Reparative surgery.

Statistics;

amputations, 254-257, 259, 260-270

balanced-suspension skeletal traction, 152-

153, 155

blood replacement at initial surgery, 68

carpal scaphoid fractures, 291-294

delayed primary wound closure, 60

fractures of—■

bones of foot, 180-181

bones of leg, 162, 173, 175-178

femur, 139-141, 158, 159

humerus, 122, 130

upper extremity, 115

external skeletal fixation, 204-206

hematocrit levels before reparative sur- gery, 82

internal fixation, 146, 165, 192

joint mice, 286-287

knee disabilities, 276-284

nerve injuries, 127-128, 134, 141, 162, 196

nonbattle injuries, 162

refractures, 197

shoulder dislocations, 287-290

wounding agents, 141, 162

wounds of hip joint, 241

wounds of knee joint, 215, 231-236

Steinmann pin, 202

Stockinet, use of, after amputation, 251, 253,

257

Strains of back, disposition of patients with,

275

Streptococcus infection, 57

Stump, amputation, 253-260

Subcommittee on Orthopedic Surgery, Committee on Surgery, Division of Medical

Sciences, National Research Council, 213
INDEX 365

Sulfonamide therapy:

in closed plaster method of fracture management, 57

in wounds of knee joint, 216, 285

See also Chemotherapy.

Suppurative arthritis

of hip joint, 237, 242, 243

of knee joint, 214, 215, 217-219, 227-231,

236

of smaller joints, 244

Surgeon (s):

general, 12, 13, 25, 26

of Delta Base Section, 11

of Fifth U. S. Army, 261

of NATOUSA (MTOUSA), 189, 204,

238, 280

orthopedic, 4, 5, 6-7, 12-13, 25, 26, 28, 40,

79, 173, 204, 245, 253-254, 257, 268,

286, 296

See also Personnel.

Surgeon General, The, 253-254

Surgical Consultants Division, Office of the

Surgeon General, 189

Sutures:

for initial surgery, 74

for reparative surgery, 9, 93, 117

Synovial membrane, closure of—-

in wounds of knee joint, 216, 217, 219,

221, 223

in wounds of smaller joints, 243.

Synovitis, as factor in disposition of patients

with knee disabilities, 282

T-fractures of humerus, 129

Tarsus, fractures of, 181-183

Technicians, orthopedic, 20, 27

Ten don(s);

coverage of, at reparative surgery, 93

coverage of, in fractures of bones of

foot, 281

injuries of, in fractures of upper extremity,

116

sloughing of, in fractures, 91

Tendonitis, in shoulder dislocations, 290

Tetanus toxoid, 67

Thigh;

amputation in, 245, 253, 254

emergency splinting of, 35, 37, 39

transportation splinting of, 47-49

wmiinds of, 73, 84

Thomas splint, 51. See also Hinged halfring leg splint.

Thoracentesis, 43

Thrombophlebitis in fractures of femur, 140

Thrombosis, as indication for amputation,

247

Through-and-through wounds, 77

Thumb, position of:

in splinting, 43, 47, 292

in testing for nerve injuries, 72

Tibia, fractures of, 160-180

blood replacement in management of, 68,

162-163

bone fragments in, 163

bone loss in, 160, 165-170

bone shortening in, 165

closed plaster technique in management

of, 163

disposition of patients with, 173

drainage in, 161, 163-164

external skeletal fixation of, 165, 208, 209

exposure of bone cortex in, 160, 161

infection in, 160

internal fixation of, 91, 165, 170-173, 188-

189, 199, 201

loss of tissue in, 161

manipulation in, 160

nerve and bone surgery in, 161

nerve injuries in, 162

nonunion of, 161

plaster immobilization of, 164-170, 173

reduction of, 57, 160, 161

reparative surgery of, 162-180

scar formation in, 160

sequestration of, 160

skeletal traction in, 160, 166-170

statistics on, 161-162, 175-178

transportation splinting for, 40, 41, 51

union of, 160-161

wound closure in, 161, 163-164

wound healing in, 79, 160, 163

wound management in, 162-164, 175-179

Tibial nerve, 141, 162

Timelag, from

initial surgery to reparative surgery, 65,

81, 116

institution of first-aid measures to initial

surgery, 65

wounding to

initial surgery, 72, 217, 241

institution of first-aid measures, 65

reparative surgery, 81, 117, 141, 162,

163, 227, 236, 241

Tobruk splint;

precaution in use of, 51

use of, in transportation splinting, 47, 49,

51

use of, in wounds of knee joint, 8, 221, 227

396961°—57 25
366 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Toes:

avoidance of hyperextension of, 51

circulatory status of, determination of, at

initial surgery, 80

flexion of, in fractures of bones of leg, 164

fractures of bones of, 181-182

Tourniquet, use of

after menisectomy, 285

at initial surgery, 67, 223

during first aid, 66

Toxemia, associated with wounds of

hip joint, 237

knee joint, 216

Traction:

in transportation splinting, 39

with Tobruk splint, 51

See also specific types.

Traction hitch, 34, 67

Traction ward, in general hospital, 14

raining—-

in emergency splinting, 31, 32

in military management of bone and joint

injuries, 5, 6,

Transfixion pins, use of, in closed plaster

method of fracture management, 55

Transfusion. See Blood replacement.

Transportability of patients:

after initial surgery, 81

as factor in disposition, 295

as factor in early reparative surgery, 65

military considerations in, 64

Transportation splinting. See Splinting,

transportation.

Trauma:

as indication for amputation, 246, 249,

264-266, 269-270

operative;

at initial surgery, 74

at wound closure, 163

from internal fixation, 86, 87, 143-146, 187

in menisectomy, 285

Traumatic arthritis, in carpal scaphoid

fractures, 293

Trenchfoot, as indication for amputation,

247, 262, 269

Trendelenburg position, in shock, 68

Triangular bandages, 32, 34

Trueta, J., 53, 54, 213

Tuberculosis, as indication for amputation,

247

umors;

bone, disposition of patients with, 274

malignant, as indication for amputation,

247

Two-pin plaster technique, in management

of fractures, 165, 170

Two-wire method of balanced-suspension

skeletal traction, 149-151

U-type plaster cast, 43

Ulna;

fractures of, 115-117, 133-137

blood replacement in management of,

68

bone fragments in, 134

disposition of patients with, 137, 298

emergency splinting for, 34

external skeletal fixation of, 207, 208

internal fixation in, 133-135, 202

management of, 15, 17, 133-134

nerve injuries in, 116, 134-137

plaster immobilization in, 133

reconstructive surgery of, 135, 137

reduction of, 57, 133-137, 185

reparative surgery of, 133-137

skeletal traction in, 134

statistics on, 115

tendon injuries in, 116

transportation splinting for, 41, 43, 47

wound management in, 117, 133

wound healing in, 133, 185

involvement of, in fractures of humerus,

129

Ulnar-nerve injuries

in fractures of bones of forearm, 134

statistics on, 127-128

testing for, 72

Ulnar-nerve palsy, 117

in fractures of humerus, 130

Union of fractures, 87, 292-293

after internal fixation, 186, 192-202

concept of, 79

in closed plaster method of management, 55

of bones of leg, 160-161

of femur, 154-155

of humerus, 132

Upper extremity:

amputation of, wound closure after, 253, 254

emergency splinting of, 34

fractures of bones of, 115-137

blood replacement in management of,

116-117

external skeletal fixation of, 207
INDEX 367

Upper extremity—Continued

fractures of bones of—Continued

internal fixation of, 199

management of, 115-117

nerve injuries in, 116

splinting after reparative surgery of, 117

tendon injuries in, 116

wound healing in, 116

wound management in, 117 See also Humerus, Radius, Ulna,

transportation splinting of, 41, 43, 47

Urinary bladder, wounds of, associated with

wounds of hip joint, 237

Vascular impairment, determination of, after

initial surgery, 80

Vascular insufficiency, as indication for amputation, 246, 249, 266-269, 270

Vascular status, appraisal of, at initial

surgery, 72

Vaseline gauze. See Petrolatum-impregnated gauze.

Vastus lateralis muscle, 148

Velpeau plaster cast, use of, in transportation splinting, 41, 43

War of the Rebellion, 212

Ward officers, 26-27

Wards, orthopedic:

management of, in general hospital, 14

traction, desirability of, in general hospital,

14

Webbing strap, 37

Weight bearing—-

after disabilities of knee, 279

after march fractures, 275

after menisectomy, 286

Willems method, 212, 216, 244

Window edema, prevention of, 103

Wire ladder splints, use of—-

after amputation, 251

in emergency splinting, 32, 34, 35

Wire-suture fixation of fractures, 87, 187,

198, 199

of bones of forearm, 134, 202

of bones of leg, 170-173, 178, 199

of femur, 146, 156, 199, 201

of humerus, 122, 126, 127, 129, 201

results of, 192-196

World War I:

management of bone and joint injuries in,

53, 211-212, 223

delayed primary wound closure in, 58

responsibility for, 25

splinting in, 31, 39

statistics on fractures of femur in, 137-138

Wound(s):

access to, 182, 209, 210

appraisal of:

at initial surgery, 71-72

at reparative surgery, 59, 84

before initial surgery, 67-68

circular, 74

closure of. See Wound closure,

dressing of, after initial surgery, 77-78

nonclosure of. See Nonclosure of wounds,

of calf, 73

of hands, 8, 9, 74, 296, 298

of joints, 211-244

of rectum, 237

of thigh, 73, 84, 151, 152

of urinary bladder, 237

revision of, at reparative surgery, 84, 103,

107

saucerization of, at initial surgery, 77

through-and-through, 77

unhealed, delayed internal fixation of fractures with, 185, 186

See also specific regions and wounds.

Wound closure:

delayed primary, 9, 58-60, 63, 91-103

by approximation of soft parts, 117

by skin flaps, 59, 74, 129, 133

by skin graft, 175

by split-thickness skin grafts, 59, 133

concept of, 58-59

criteria for, 59

effect of excisional surgery on, 84

effect of holding period on, 83

in fractures, 117, 123, 133, 149, 161,

163-164, 175, 181, 186, 188

in World War I, 58

in wounds of hip joint, 242

in wounds of knee joint, 221, 227, 231, 235

in wounds of smaller joints, 244

objectives of, 93, 148

partial, 163, 175

results of, 103-114

statistics on, 60

primary, 58

timing of, 65, 81

Wound healing:

after delayed primary wound closure, 59, 60

after external skeletal fixation, 205-210

after internal fixation, 91, 186, 192-202

by granulation, 55, 57, 59, 64, 91, 103, 139,

159, 163, 175, 181

concept of, 79
368 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER

Wound healing—Continued

effect of excisional surgery on, 84

effect of holding period on, 83

in carpal scaphoid fractures, 293

in closed plaster method of fracture management, 57

in fractures, 79, 91, 116, 126, 130, 132-133, 134, 140, 142, 155-156, 159, 160, 166, 171, 173, 175, 178, 179-180, 186

promotion of, 83, 183

in reparative-surgery program, 64, 103-114

in wounds of hip joint, 241

in wounds of knee joint, 216, 221, 231

in wounds of soft tissues, 58, 59-60

of amputation stump, 255-257

Wounding agents:

determination of sites of entry and exit

of, 71-72

in amputations, 261-266, 270

in fractures, 65-66, 73, 141, 162, 181

in wounds of knee joint, 215

Wrist:

disarticulations at, 261

position of;

in splinting for carpal scaphoid fractures, 292

in transportation splinting, 41, 47

sprains of, as factor in diagnosis of carpal

scaphoid fractures, 292

wounds of, management of, 243-244

X-ray. See Roentgenologic examination.

Z-shaped incision, use of, at initial surgery,

76, 163

Zone of Interior, 4, 9, 20, 29, 63, 126, 127, 129, 130, 132, 156, 158, 159, 165, 166,

170, 173, 181, 183, 221, 236, 242, 254,

257, 259, 271, 272, 274, 275, 276, 278,

279, 280, 281, 282, 283, 286, 290, 293, 295, 296, 297, 298

amputation centers in, 245, 253

followup study on delayed internal fixation in, 185-202

hospitals in, function of, 64, 115, 175

U. S. GOVERNMENT PRINTING OFFICE: 1957

For sale by the Superintendent of Documents, U. S. GovernmentPrinting Office, Washington 25, D. C. Price $4 (Buckram)