MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II

MEDICAL DEPARTMENT, UNITED STATES ARMY

Surgery in World War II

ORTHOPEDIC SURGERY

in the

EUROPEAN 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., 1956
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

Hazel 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. I). 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

EUROPEAN THEATER OF OPERATIONS

VII

Foreword

As medical officer who served in Europe during World War II, can

speak with first-hand knowledge of the role of orthopedic surgery in large

and continuously active theater of operations. In terms of combat personnel

and medical facilities, the European theater was the largest single theater of

World War II. It was the scene of continuous and intensive combat; the

fighting might vary in intensity from area to area, but there was never

general period of inactivity.

Casualties were very heavy, and, as in all theaters, battle injuries of the

extremities, including bones and joints, comprised the largest single group,

approximately two-thirds of the 381,350 wounded and injured in action in

Europe.

The orthopedic care of this enormous number of wounded was task of

the first magnitude. It was accomplished brilliantly. It could not have been

accomplished at all without thoughtful and detailed planning, which included:

1. The careful assignment of the relatively small number of qualified

orthopedic surgeons in the theater to positions in which their professional

qualifications could be employed with maximum benefit.

2. The training, overseas, in the fundamentals of military orthopedic surgery, of large number of medical officers and enlisted technicians who were

without previous training in this field.

3. The prompt publication and distribution of uniform combat-tested

principles and practices of military orthopedic surgery, which in many respects

were dissimilar to the principles and practices then current in civilian orthopedic

surgery.

4. The continuous supervision of personnel caring for orthopedic casualties, and the consistent execution of the principles and practices mentioned

above.

The result of this carefully planned program was superior performance,

from care rendered by medical aid men in the frontlines of the army area to

definitive surgery in fixed hospitals far to the rear in the communications

zone.

large part of the credit for this accomplishment must be attributed to

the tireless efforts of the senior consultants in orthopedic surgery, Col. Mather

Cleveland, Medical Corps, and Col. Rex L. Diveley, Medical Corps, who preceded

him in that assignment. There are few phases of the care of bone and joint

casualties in the European Theater of Operations which do not reflect their

administrative ability and clinical competence.

Colonel Cleveland has added to his wartime service by his continued

interest in the recording of the orthopedic experience in this theater in World

War II. This volume is the result of those endeavors.
VIII

It is essential that this experience be recorded. This volume is record

of errors as well as of successes. Both have been related with equal frankness

and without reservation.

The lesson of history, as the saying goes, is that the lesson of history is

never learned. If this volume is used as it should be, there is hope, in the

unhappy event of another war, that these particular lessons will not have to

be relearned, as they have had to be in previous wars, at great price. They

are plainly set forth, and, if they are properly applied, they should save both

life and limb in any future war.

S. B. Hays,

Major General, United States Army,

The Surgeon General.
IX

Preface

In the spring of 1945, while serving as senior consultant in orthopedic

surgery in the European Theater of Operations, received letter from Brig.

Gen. Fred W. Rankin, chief consultant in surgery, Office of The Surgeon

General, asking me to serve as editor of the volumes on orthopedic surgery in

the history of the United States Army Medical Department in World War II.

To carry out that objective, all junior consultants in orthopedic surgery in the

European theater, as well as many chiefs of section, were requested to supply

information concerning their experiences in the care of wounds and injuries

involving the bones and joints. Some 25 of these officers furnished reports and

clinical studies, and these data, together with my own observations and comments as senior consultant in orthopedic surgery, made up the report from

which the story of orthopedic surgery in the European Theater of Operations

has been written. This theater had the largest number of troops deployed of

any of the theaters of operations and also had the largest number of hospitals

and the greatest number of medical personnel.

Although these reports were written early in 1946, various delays in publication occurred. In November 1953, an advisory editorial board for the

history of surgery, World War II, Medical Department, United States Army,

was constituted. Dr. Alfred Shands (formerly colonel, MC, assigned to the

Army Air Force) and were asked to survey the orthopedic material available.

We read, and wrote critiques upon, more than hundred manuscripts, chiefly

from the Zone of Interior. These manuscripts have been utilized to prepare

the story of orthopedic surgery in the Zone of Interior and to supplement the

history of this specialty in the European theater and the Pacific theaters.

Perhaps we should not be unduly discouraged by the length of time it has

taken to prepare this history. The last of the volumes which make up the

Medical and Surgical History of the War of the Rebellion did not appear until

1888, 23 years after General Lee’s surrender at Appomattox Courthouse.

Similarly, some of the volumes of the Medical Department of the United States Army in the World War did not appear until 1928, 10 years after the

so-called armistice of 1918.

special debt of gratitude is owed to Miss Elizabeth M. McFetridge for

her patient and untiring efforts throughout these years in correlating the material and providing the authors with invaluable assistance and encouragement.

would also like to express appreciation to Mr. Herman Van Cott, chief,

Medical Illustration Service, Armed Forces Institute of Pathology, and to his

staff for their valuable contribution in preparing for publication all illustrations

in this volume.

We who were privileged to serve as medical and surgical consultants in the

European theater owe great deal to our Chief Surgeon, Maj. Gen. Paul R.

Hawley, MC, United States Army.
We also owe great deal to the late Dr. Elliott C. Cutler, onetime colonel, then brigadier general, Medical Corps, Army of the United States, chief

surgical consultant in the European theater. In 1946, Dr. Cutler read the report from the European theater from which this history of orthopedic surgery in the theater has been prepared and wrote foreword for it, as follows:

This volume contains material which will be of value and interest not only to the

military surgeon but to those interested in bone and joint surgery in civil life. All

surgeons know that wars have given great impetus to their art, and that many of the

forward steps in our work have been the result of battlefield experiences. The recent

war is no exception to preceding history. The matter of the proper handling of the

combined major nerve injury and the compound fracture was varied and unsatisfactory

until the experience of the recent war. Now, as can be learned by those who turn the

pages of this volume, this difficult problem is settled and can be taught to the growing

generation of doctors as final, useful part of their education. Similarly, there are

many other problems of equal importance which this war, with the benefits permitted

by modern antibiotics, has given to our profession. That the orthopedic surgeon was

sufficiently wide awake, well educated and alert to utilize all of the data available to

him, and make such great strides forward, is tribute to his education and the great

experience afforded him by the war.

Having seen at first hand much that is written of in this volume, can recommend

it to all surgeons as compendium of military experience now ready for use in the

broad field of surgery and particularly in the surgery of bones and joints, as an excellent summary of where we stand today in this important field. The former senior

consultant in orthopedic surgery for the European Theater of Operations writes with

the voice of authority. Of the 16,000 civilian doctors serving as medical officers in

the Army of the United States in the European Theater of War, those working in the

field of orthopedic surgery shared mightily in the occasion, for injury to bone was

most frequent happening and the direct responsibility for the guiding of these orthopedic surgeons was that of the senior consultant. His directives, when sent out after

careful evaluation, brought standard form of surgery to those in his special field.

This experience is now available to all.

These remarks, prepared by Dr. Cutler in 1946, are still valid almost 10

years later. They summarize excellently the orthopedic experience in World

War II and the lessons to be learned from that experience, not only for future

war but for orthopedic surgery in world at peace.

Mather Cleveland, M. D.,

Colonel, MC, AUS,

Formerly Senior Consultant in Orthopedic Surgery,

European Theater oj Operations.
Acknowledgments

Grateful acknowledgment is hereby made to the following medical officers

and enlisted men who served in the European Theater of Operations in World

War II and whose reports, data, and clinical observations have made this

volume possible:

Col. Charles B. Odom, MC, Headquarters, Third United States Army

Lt. Col. George T. Aitken, MC, Headquarters, Fifteenth United States Army

Lt. Col. Roderick E. Begg, MC, 46th General Hospital

Lt. Col. Sante D. Caniparoli, MC, 46th General Hospital

Lt. Col. William H. Cassebaum, MC, 9th Evacuation Hospital

Lt. Col. Philip S. Foisie, MC, 129th General Hospital

Lt. Col. Louis A. Goldstein, MC, 19th General Hospital

Lt. Col. Nathaniel Gould, MC, 168th Station Hospital

Lt. Col. John A. Grove, MC, 15th Hospital Center

Lt. Col. George Hammond, MC, 298th General Hospital; 818th Hospital Center

Lt. Col. G. Baker Hubbard, MC, 216th General Hospital; 803d Hospital Center

Lt. Col. Julian E. Jacobs, MC, 65th General Hospital; 805th Hospital Center

Lt. Col. Darrell G. Leavitt, MC, 50th General Hospital; 819th Hospital Center

Lt. Col. John G. Manning, MC, Headquarters, Ninth United States Army

Lt. Col. Thomas B. Quigley, MC, 22d General Hospital

Lt. Col. Dudley W. Smith, MC, 4th Auxiliary Surgical Group

Lt. Col. Marcus J. Stewart, MC, 2d General Hospital; 307th Station Hospital; and

827th Convalescent Center

Lt. Col. William J. Stewart, MC, 102d Evacuation Hospital

Lt. Col. James E. Thompson, MC, 9th Evacuation Hospital

Lt. Col. John Pettit West, Jr., MC, 2d Evacuation Hospital

Lt. Col. Malvin White, MC, 129th General Hospital

Maj. William H. Blodgett, MC, 217th General Hospital; 815th Hospital Center

Maj. Arthur D. Ecker, MC, 117th General Hospital

Maj. Irvine M. Flinn, Jr., MC, 67th General Hospital; 801st Hospital Center

Maj. Floyd H. Jergesen, MC, 2d Auxiliary Surgical Group

Maj. Harold B. Kernodle, MC, 65th General Hospital

Maj. Charles F. Kincheloe, MC, 68th General Hospital; 804th Hospital Center

Maj. William K. Massie, Jr., MC, 117th General Hospital

Maj. Marshall R. Urist, MC, 22d General Hospital; 802d Hospital Center

Capt. Edmund A. Maxwell, MC, 22d General Hospital

Capt. Lincoln Ries, MC, 22d General Hospital

Capt. Charles F. Stewart, MC, 9th Evacuation Hospital

M. Sgt. Robert Ferguson, Ordnance

Sgt. William Pitney, 129th General Hospital

Contents

Page

FOREWORD YII

By Maj. Gen. S. B. Hays

PREFACE IX

By Mather Cleveland, M. D.

ACKNOWLEDGMENTS XI

INTRODUCTION

By Mather Cleveland, M. D.

Part

Administrative and Related Considerations

By Mather Cleveland, M. D.

Chapter

THE CONSULTANT SYSTEM

Functions of the Senior Consultant

Junior-Consultant System

Consultants in Army Areas 10

Evaluation and Assignment of Personnel 11

II TOURS OF HOSPITALS 19

Tour of Hospitals in the United Kingdom Base, November 1944 20

Tour of Hospitals on the Continent, 23 November-3 December 1944_ 29

III TRAINING OF PERSONNEL 35

General Considerations 35

Methods of Training 36

Professional Conferences 39

IV HOSPITAL FACILITIES AND ORTHOPEDIC EQUIPMENT 41

Hospital Facilities 41

Equipment and Supplies 42

MASS MANAGEMENT OF CASUALTIES WITH BONE AND JOINT INJURIES 55

Transit Hospitals 55

General Hospitals 58

VI MANAGEMENT OF BONE AND JOINT INJURIES IN PRISONERS OF

WAR 63

VII REPRESENTATIVE HOSPITAL EXPERIENCES 67

298th General Hospital 67

50th General Hospital 69

217th General Hospital 69

Fifteenth United States Army Hospitals 70
Part 11

Clinical Policies and Practices

By Mather Cleveland, M. D.

Chapter Page

VIII GENERAL CLINICAL POLICIES 73

Evolution of Clinical Policies 73

Establishment and Dissemination of Policies 74

General Medical Policies 77

Evacuation Policies 78

IX THE MANAGEMENT OF COMPOUND FRACTURES INITIAL AND REPARATIVE WOUND SURGERY 81

Development of Policies 81

Debridement 83

Delayed Wound Closure 87

Management of Fractures 89

Results of Delayed Primary Wound Closure in Compound Fractures. 91

Combined Nerve-Bone Injuries 104

Combined Vascular-Bone Injuries 106

THE MANAGEMENT OF COMPOUND FRACTURES—TECHNIQUES OF

FRACTURE MANAGEMENT 109

Plaster of Paris 109

Tobruk Splint 110

Skeletal Traction 113

External Fixation 116

Internal Fixation 116

XI REGIONAL INJURIES H9

Forearm 119

Clavicle 143

Humerus 144

Pelvis 146

Spine 147

Femur 147

Tibia and Fibula 151

Ankle 151

Foot 153

XII AMPUTATIONS 155

Incidence and Case Fatality Rates 157

Evolution of Techniques 158

Special Considerations of Traction 165

Amputations Caused by Special Types of Missiles 166

XIII ADJUNCT THERAPY 167

Resuscitative Measures 167

Supplemental Therapy 167

Chemotherapy and Antibiotic Therapy 168

Psychotherapy 170

XIV POSTOPERATIVE COMPLICATIONS 173

Wound Infections 173

Osteomyelitis 174

Secondary Hemorrhage 174

Decubitus Ulcers 175
Chapter Page

XV REHABILITATION 177

Rehabilitation Hospitals 177

Physical Therapy Programs 178

Replacement Centers 179

XVI NONCOMBAT LESIONS 185

General Considerations 185

Elective Surgery 185

Disabilities of the Feet 186

Part III

Special Types of Bone and Joint Injuries

By Marshall R. Urist, M. D. and Mather Cleveland, M. D.

XVII COMPLETE DISLOCATIONS OF THE ACROMIOCLAVICULAR JOINT 191

Anatomic Considerations 195

Mechanism of Injury and Nature of Lesion 197

Pathologic Process 199

Diagnosis 202

Management 202

Associated Fractures 215

Complications and Sequelae 216

XVIII BATTLE-INCURRED COMPOUND FRACTURES ABOUT THE HIP JOINT. 221

Emergency Measures 223

Initial Wound Surgery 224

Surgical Approach to the Hip Joint 232

Management of Retained Foreign Bodies 233

Wound Closure 234

Adjunct Fracture Management 234

Adjunct Therapy 237

Complications of Hip Injuries 238

Early Reconstructive Surgery 247

An Ideal Plan of Management 249

XIX JEEP INJURIES OF THE HIP JOINT 25

Basic Information 251

Anatomic Considerations 254

Dislocations 254

Fractures of the Acetabulum Without Dislocation 262

Fracture-Dislocations 269

Followup Studies 296

XX INJURIES OF THE KNEE JOINT 305

Nature of the Injury 305

Diagnosis 306

Initial Wound Surgery 307

Treatment in the General Hospital 310

Suppurative Arthritis 310

Analysis of Cases 312

APPENDIXES

Pertinent Directives 319

Proposed Revision of Manual of Therapy (Orthopedic Section) 335

INDEX 357

372572°—56

Introduction

Mather Cleveland M. D.*

In all of the major wars in which the United States has been engaged,

battle casualties caused by injuries involving the bones and joints have presented formidable problem to the Army Medical Department. This has

been true from the standpoint of their frequency as well as their incapacitating

effects. In the Civil War, in World War I, and in World War II, more than

70 percent of the wounded who survived to reach hospitals have had wounds

or injuries involving the upper or lower extremities. In the Korean conflict,

about two-thirds of the wounded or injured in action had injuries of these sites.

Compound (or open) fractures make up an appreciable part of these wounds

or injuries of the extremities; for the period of the Korean conflict, about onefourth. The mere citation of these figures indicates the magnitude of the task

which confronts the military orthopedic surgeon.

The full significance of the proportions just mentioned cannot be appreciated without knowledge of the numbers of troops under arms in the various

theaters of operations. In May 1945, at the close of hostilities in theEuropean

and Mediterranean theaters, United States Army troops (including the United

States Army Air Force) were deployed as follows:

1. In the European theater, the total strength was 3,065,505 men. These

troops were served by total of 290 hospitals, including 63 evacuation hospitals,

34 field hospitals, 146 general hospitals, and 47 station hospitals.

2. In the Mediterranean theater the total strength was 493,876 men.

These troops were served by total of 47 hospitals, including evacuation

hospitals, field hospitals, 11 general hospitals, and 21 station hospitals. It

should be remembered that the troop strength in the Mediterranean theater

was correspondingly diminished when the United States Seventh Army invaded

southern France, taking with it troops and hospitals from Italy to augment the

strength of the European theater.

At the close of hostilities in the Pacific theaters, in August 1945, total

strength of 1,389,010 United States Army troops were deployed. This number

was somewhat larger than the troop strength of 1,257,098 deployed in May

1945, when hostilities ceased in the European and Mediterranean theaters.

These troops were served by total of 146 hospitals, including 15 evacuation

hospitals, 24 field hospitals, 46 general hospitals, and 61 station hospitals.

The enormous number of men under arms in the various theaters and the

frequency of bone and joint injuries indicate the actual and potential responsi-

*Consulting orthopedic surgeon, St. Luke’s Hospital, New York, N. Y.; member, special medical advisory group,

Veterans’ Administration; consultant in orthopedic surgery for The Surgeon General. Formerly colonel, MC, AU8.
ORTHOPEDIC SURGERY IN EUROPEAN THEATER

bilities carried by orthopedic surgeons in theaters of operations in World War

II.

In spite of the brief duration of the independent participation of United

States Army Medical Department personnel in World War I, the total orthopedic experience, combined with the far longer British experience, resulted in the evolution of method of management of injuries of the bones and joints.

In summary, this experience was as follows:

1. In the British Army, the treatment of wounds by free excision (debridement) was generally adopted after 1918. The earlier the treatment was

carried out and the more thorough was the removal of all damaged muscle and

foreign bodies, the better were the results. Free incisions were necessary to

provide access to the deeper parts, but unnecessary excision of the skin militated against satisfactory wound closure.

2. In the early days of the war, wounds were treated by suture, but healing

was generally unsatisfactory and the practice was completely abandoned. In

1917, when wound closure was revived, it was found that if aseptic conditions

could be obtained and if damaged tissues were thoroughly excised and all

foreign bodies were removed, healing was generally satisfactory.

3. In 1918, Col. Joseph A. Blake, MC, United States Army, described the

management of gunshot fractures of the extremities by wide incision of the

overlying wounds; adequate debridement of all devitalized tissue; and closure

by primary, delayed primary, or secondary suture. Bone fragments were left

in situ in the absence of contraindications, the objective being to preserve the

continuity of the shaft of long bones as far as this was possible.

4. The following year, Col. Eugene H. Pool, MC, United States Army,

also stated that delayed primary suture coidd be carried out in most compound

fractures of the long bones, with little risk and few failures. Like Blake, he

emphasized that the temptation toward free removal of bony fragments should

be resisted.

5. In this same publication, Pool advocated the management of wounds

of the knee joint by ample debridement, immediate closure of the joint capsule,

and delayed primary closure of the overlying tissues.

Blake’s and Pool’s observations were based on sizable series of casualties

treated by adequate debridement of devitalized muscle and other damaged

soft tissue, removal of foreign bodies, and competent management of compound

fractures. Without the benefit of either chemotherapeutic or antibiotic

agents, which did not then exist, satisfactory results were achieved by these

techniques in more than 80 percent of the wounds in which they were employed.

These methods, however, were never in general use in the First World

War. For one thing, as already noted, the independent American orthopedic

experience was relatively brief. For another, the use of these methods was

limited to relatively small number of highly competent, top-ranking American officers. The information was not relayed to the outlying and forward

hospitals in which the majority of orthopedic casualties were treated. The

war was over, in fact, before the information appeared in the medical literature.
INTRODUCTION

This priceless information was incorporated in both the British and

American official histories of the medical experience in World War I. It

would have proved extremely valuable had it been put to immediate use in

World War II. It was not. Almost no use was made of these techniques in the interim between the wars. They were not utilized when World War II

broke out, either in the training of medical officers after it had become evident

that United States participation in the war was inevitable, or later, when this

country entered the war.

Practically none of the experience of World War was incorporated in

the military manual entitled “Orthopedic Subjects,” which was published in

1942 under the auspices of the Committee on Surgery of the Division of Medical Sciences of the National Research Council. The book was prepared and

edited by the subcommittee on orthopedic surgery and contained forewords

by the Surgeons General of the Army and the Navy.

This well-written text, designed to furnish “essential up-to-date and reliable information regarding military surgery,” was prepared, for the most

part, by medical officers who had served in World War and who were outstanding orthopedic surgeons. It did not, however, meet the needs of the

military situation. With few exceptions, the book is simply compendium of

reconstructive procedures on the bones and joints, all of them suitable for

performance only in fixed hospitals in the Zone of Interior. The text is almost devoid of specific directions for the care of these injuries in active

theaters of operations. Debridement is excellently described, and the importance of splinting compound fractures is emphasized. On the other hand,

the observation, “Splints can be improvised at the scene of the accident if

they are needed,” is completely unrealistic. It fails to take cognizance of the

fact that in military surgery there may be need, at any given point, for the

simultaneous treatment of hundreds, and sometimes of thousands, of severely

injured men. Wounds of the joints, which are frequent and serious wartime

injury, are dismissed in half page; the discussion is totally inadequate. Acute

and chronic hematogenous osteomyelitis, which was practically nonexistent in

World War II, occupies almost third of the 290 pages of the text. Skeletal

traction in the management of compound fractures, delayed primary closure

of wounds over compound fractures, and similar subjects are not mentioned.

The whole text, in short, although it purported to furnish the information

necessary for orthopedic surgeons as they entered military service from civilian

life, was chiefly written from the standpoint of civilian practice. The material that would have been of value to these new medical officers, and that

would have avoided the trial-and-error method by which the management of

bone and joint injuries was finally evolved in World War II, remained buried

and forgotten in the British and American official histories of the war. As

result, American orthopedic surgeons and other physicians who found them- selves obliged, by the exigency of the wartime situation, to handle casualties

with bone and joint injuries, entered upon their World War II experience with
ORTHOPEDIC SURGERY IN EUROPEAN THEATER

no clear-cut concepts of the optimum procedures for the management of these

casualties.

If the medical histories of World War II incorporate the clinical experiences of that war and if what is printed will be read in the future—as it has

not always been read in the past—military surgeons will not, in the future,

repeat the mistakes of the past, as they did in World War II.

The account of the orthopedic surgical experience in the various overseas

theaters and in the Zone of Interior is an endeavor to relate the errors as well

as the successes associated with the management of bone and joint injuries in

World War II. To deny that mistakes were made or to fail to describe them

in detail would lessen the usefulness of this account for future military

surgeons.

“They who forget the past are condemned to repeat it.”
PART

ADMINISTRATIVE AND RELATED

CONSIDERATIONS

Mather Cleveland M. D.

CHAPTER

The Consultant System

The first formal step in the establishment of orthopedic surgery as

recognized specialty in the European Theater of Operations was the appointment

of Col. Rex L. Diveley, MC, as senior consultant in orthopedic surgery in July

1942. The Professional Services Division, Office of the Theater Chief Surgeon,

to which he was appointed, had been set up about month earlier.

Colonel Diveley held this appointment until May 1944, when he was

relieved to devote his full time to the Division of Rehabilitation. He was

succeeded on D-day minus 20 by Col. Mather Cleveland, MC, who served until

the end of the fighting in Europe.

Throughout the war, both senior consultants in orthopedic surgery had

ready and satisfactory access to higher medical authority as well as to other

consultants in the various branches of medicine and surgery. This access

had much to do with the success of the planned program in orthopedic surgery

and with the competent treatment of casualties with bone and joint injuries.

Functions of the Senior Consultant

The principal duties of the senior consultant in orthopedic surgery,

European Theater of Operations, were as follows:

1. To investigate the training, qualifications, and competence of orthopedic surgeons and other medical officers doing orthopedic surgery and to

recommend adjustments of personnel to provide for full orthopedic coverage

in all hospitals;

2. To visit medical installations in the theater as often as possible, in

order to aid in the processing and treatment of casualties with bone and joint

injuries by advice, suggestion, correction of errors, and general direction;

3. To provide special supervision for hospitals in which there were no

trained orthopedic surgeons or in which medical officers doing orthopedic work

were inexperienced and likely to require special advice and direction;

4. To formulate policies of treatment of the wounded by writing circular

letters and directives to be issued with the approval of the Chief Surgeon,

European Theater of Operations;

5. To disseminate, and to interpret by word of mouth, Army and theater

directives pertaining to the professional care of casualties with bone and joint

injuries and to carry, from hospital to hospital, policies and practices devised

in the various installations, when they had been found to be useful and efficient;

6. To organize such professional training programs as the exigencies of

wartime service permitted;

7. To supervise and encourage such clinical investigation as wartime

exigencies permitted;
ORTHOPEDIC SURGERY IN EUROPEAN THEATER

8. To assemble, collect, and preserve data on the management of battle

casualties and the results of various methods of treatment of bone and joint

injuries; and

9. To function in liaison capacity between the theater and army surgeons

and personnel in lower echelons.

Hospital visits.—Visits of the consultant to the hospitals in the theater

were of considerable practical value, especially when the units were isolated.

Information as to specified techniques of management was disseminated more

readily than through channels, and information as to methods devised in the

various hospitals was thus transmitted to other hospitals. Techniques of

management were surveyed, with the idea of keeping them as uniform as

possible. Errors in management were also promptly detected, usually during

the extensive ward rounds which were part of every visit. All incorrectly

treated cases were fully discussed during these rounds, and, as far as was

practical, personal conferences were held with the officers responsible for the

errors.

Evacuation practices were also investigated and corrected as necessary.

In some hospitals there was tendency to hold patients too long, while in

others evacuation was too rapid.

The consultant was often called upon for advice on both general problems

and specific cases. One hospital, for instance, in the 802d Hospital Center, which had previously served as transit hospital, was suddenly given the

responsibility for definitive orthopedic surgery. No surgeon in the hospital

had the necessary qualifications for its performance. The junior consultant

in orthopedic surgery visited the hospital, reviewed the situation, and arranged

for team of qualified orthopedic surgeons to be placed on temporary duty

in it. Before these surgeons left, they had been able to instruct the surgical

personnel in the proper use of skeletal traction, in the technique of handling

amputees, and in other orthopedic problems in which they previously had had

practically no experience.

It was unfortunate that the senior consultant in orthopedic surgery could

not visit the hospitals on the Continent more frequently. Some were visited

only twice—once while they were still on the beachhead and once when the

battlefront had moved farther inland. This was unavoidable, because of the

increase in the number of hospitals and the increasingly great distances to be

covered to reach them. Under these circumstances, the work of the junior

consultants in orthopedic surgery was particularly useful.

Junior-Consultant System

The junior-consultant system was devised as the solution for two problems. The first, as just mentioned, was the inability of the senior consultant in ortho- pedic surgery to make frequent, regular visits to all hospitals. The second was

the unavoidably uneven distribution of trained orthopedic personnel throughout the theater (p. 14). Junior consultants were appointed to serve in various
THE CONSULTANT SYSTEM

base sections and hospital centers in the United Kingdom and on the Continent. They assumed these duties in addition to theirregular duties as chiefs

of orthopedic sections in their own hospitals. All of them served with distinction.

In all, orthopedic surgeons served as junior consultants in the United

Kingdom, and were later appointed to similar positions on the Continent. The

situation on the Continent, however, never in the course of the active fightingpresented the stability that was obtained in the United Kingdom, and frequent

changes of consultant personnel were necessary as hospitals were moved from

base to base and center to center. It was Y-E Day, in fact, before anything

approaching stability was accomplished on the Continent, and for this reason

most of the junior consultants who served there were not appointed until near

the end of, or after, the war. The interpretation of policies would have been

greatly facilitated by their earlier appointment, whether they had served full

time or part time.

The junior-consultant system filled serious need and was regarded as

extremely successful. The chief defect of the system was that the consultants

did not have sufficient direct and personal contact with the senior consultant in

orthopedic surgery. Provision for such contacts should be made in the event

of future emergency.

Some junior consultants rendered monthly reports to the senior consultant

in orthopedic surgery. Others reported to him only after tours of duty. Some

of the junior consultants also made complete reports at the conclusion of hostilities.

One such report, from the orthopedic section of the 802d Hospital Center,

January-June 1945, is summarized statistically as typical of the work covered

by junior consultant in orthopedic surgery who, in addition to his consultant

duties, supervised the work in this center, conducted superior orthopedic

service in his own hospital (the 22d General Hospital), and also found time to

collect certain data of unusual interest, some of which will be commented on

elsewhere. Other junior consultants had equally meritorious achievements

to their credit. Cases Number

Total admissions 42, 372

Orthopedic admissions 10, 647

Consultations (hospital and clinic) 6, 790

Fractures of

Humerus 1, 182

Radius, ulna, both 2, 117

Femur 1, 202

Tibia, fibula, both 1, 307

Injuries of and about hip 161

Infected compound fractures 988

Plaster-of-paris splints 10, 448

Skeletal traction 2, 134

Open reductions 202

Amputations 215
10 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Total admissions—Continued Cases Number

Delayed primary closure of compound fractures 1, 880

Successful 1, 514

Partly successful 283

Failures 83

No closures, or failures due to sepsis 312

The 802d Hospital Center consisted of 19 hospitals (13 general and

station hospitals) with 18,636 beds. The largest block of beds, 7,500, approximately 40 percent, was assigned to orthopedic surgery. The number of medical

officers assigned to the orthopedic section averaged 64.

summarized report from the orthopedic section of the 22d General

Hospital, 10 June 1944 to June 1945, is also included as typical of the work

of well-conducted orthopedic section in general hospital.

Cases Number

Orthopedic admissions 2, 460

Fractures of

Humerus 203

Radius, ulna, both 301

Femur 301

Tibia, fibula, both 567

Injuries of and about hip 154

Open reductions 90

Amputations 32

Consultants in Army Areas

It would have been highly desirable if each field army could have had

its own consultant in orthopedic surgery in the army surgeon’s office, though

he would have been useful only if he had had ready access to all hospitals in

the area and complete freedom, within the limits of security, to move about

the area and to visit these units frequently. The logic of such an appointment

is obvious, namely, the uniformly large proportions of wounds of the extremities

in all battle-incurred injuries.

During World War II, only of the armies which functioned in combat

in the European theater had their own consultants in orthopedic surgery.

One of these armies, the Fifteenth, became operational so late that it handled

few battle casualties. In the Ninth United States Army, however, the value

of the policy was clearly evident. The consultant in orthopedic surgery for

this army concentrated his attention and efforts on evacuation hospitals,

where casualties with bone and joint injuries were constantly received in large

numbers. This left the consultant in surgery free to devote himself to field

hospitals, where surgery of the chest and abdomen and other urgent operations

were performed. The two officers worked in close liaison with each other.

The direct supervision of work in the evacuation hospitals by the Ninth

Army consultant in orthopedic surgery was soon reflected in the status of the

patients received in the general and station hospitals to the rear. They arrived

in better condition. There was striking improvement in the selection and
THE CONSULTANT SYSTEM 11

application of plaster casts. There were also notably fewer errors in evacuation

practices.

Evaluation and Assignment of Personnel

Evaluation.—A complete, up-to-date file of orthopedic personnel was

maintained in the office of the senior consultant in orthopedic surgery, with all

the information which could be secured about the officers assigned to this

branch. The original material was secured on special form (fig. 1). This

permitted an immediate tentative evaluation of the officer, on the basis of

data which he himself supplied, and served until additional and more authoritative information about him could be secured.

The Military Occupational Specialty (MOS) rating for orthopedic surgery

was 3153:

An officer with the rating of A-3153 was professor of orthopedic surgery

at class medical school, or nationally or internationally recognized leader

in the profession, or an officer who had made definite contribution to advancement of the knowledge of this specialty.

An officer with the rating of B-3153 was diplomate of the American

Board of Orthopaedic Surgery or fully trained medical officer who had not

yet been able to take his examination for certification. This group also included an occasional American Board of Surgery diplomate with qualifications

in traumatic surgery.

An officer with the rating of C-3153 had almost completed his civilian

training in orthopedic or traumatic surgery and had augmented his experience

in these fields during Army service.

An officer with the rating of D-3153 had had little or no basic surgical training in civilian practice and varying amount of experience during his

Army service.

In 1944, when the invasion of the Continent occurred and mass management of battle casualties was necessary for the first time, there were 820 living

diplomates of the American Board of Orthopaedic Surgery. Sixty-three of

these were then serving among the approximately sixteen thousand medical

officers assigned to the European theater.

Three of the sixty-three diplomates were serving as consultants in orthopedic surgery, and three were assigned to therehabilitation service. The other

diplomates in the European theater were assigned to general, station, and

evacuation hospitals or headed orthopedic surgical teams in auxiliary smgical

groups.

The 63 certified orthopedic surgeons in the European theater were supplemented by 95 other medical officers who had some training in orthopedic surgery. At minimum, each of them had had years of surgical training, including

year or more of training as resident in orthopedic surgery. There were also

85 other surgeons who had completed residencies in general surgery or who had

served as surgical residents for varying periods of time. These categories
12 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Last Name First MI Rank Branch Component ASN Date Interview

DATE BIRTH ENTERED ACTIVE DUTY

UNIT T/0 VACANCY

MEDICAL SCHOOL DEGREES

INTERNSHIPS

RESIDENCIES

FELLOWSHIPS BOARD CERTIFICATIONS

OTHER TRAINING OR POSITIONS

PRIVATE PRACTICE

ARMY ASSIGNMENTS. SPECIAL COURSES

CIVILIAN GRADING MILITARY GRADING: PAST PRESENT

(include dates in filling out questionnaire)

REMARKS.:

Figure 1. Special form used for securing information about officers assigned to the ortho'

pedic surgery branch.
THE CONSULTANT SYSTEM 13

Table 1.—Assignment of medical officers with MOS 3153, Orthopedic Surgeon, June 1944-

provided more or less solidly trained nucleus of 243 medical officers, who

carried most of the orthopedic responsibility in the theater. (See table 1.)

In the early spring of 1945, there were in the European theater 146 general

hospitals, 47 station hospitals, and 63 evacuation hospitals whose tables of

organization called for one or more specialists in orthopedic surgery. If these

requirements had been fulfilled, the theater would have utilized the services of

446 specialists in this field, for each general hospital, each 750-bed station hospital, each 500-bed station hospital, and each 750-bed evacuation hospital, and

for each 400-bed evacuation hospital and each 250-bed station hospital.

To fill existing vacancies in these various hospitals, it was necessary to

utilize the services of 174 medical officers who had had no basic civilian training

that qualified them as surgeons. Some were very recent graduates. Some were

older practitioners. Some had specialized in other fields of medicine. For the

most part, these officers received their training for orthopedic work on the orthopedic sections of Army general hospitals in the theater, under more experienced

orthopedic surgeons. Their instructors were well qualified, and most of the

untrained officers were willing pupils. It was therefore perfectly possible to

teach them quickly the relatively simple surgical techniques of military

traumatic surgery of the extremities.

It should be noted, however, that there were two reasons why this system

succeeded so admirably: (1) Definite regimens of management were set up and

followed precisely; and (2) there was careful supervision in all echelons. To

fulfill the technical minimum requirements in orthopedic surgery in the European theater, it would have been necessary to use several times the number of

qualified surgeons who were available for service. By adherence to the criteria

just stated, it was possible to maintain high standards of professional care in

the absence of full complement ot professionally trainedorthopedic surgeons.

The 243 fully or partially trained orthopedic surgeons and the other officers

trained in the theater to do orthopedic work provided service in this specialty for maximum troop strength in May 1945 of 3,065,505 men. Between

Strengthreports of the Army, prepared by office of Chief of Staff.

Rating

Hospital Auxiliary surgical group Other Total

General Station Evacuation

Number Percent Number Percent Number Percent Number Percent Number Percent

0. 72 0. 24 0. 72

36 8. 63 0. 96 2. 16 0. 96 1. 20 58

87 20. 86 19 4. 56 27 6. 47 14 3. 36 1. 44 153

91 21. 83 22 5. 27 34 8. 15 1. 20 47 11. 27 199

Total. 217 52. 04 45 10. 79 71 17. 02 23 5. 52 61 14. 63 417

See p. 11 forrequirements foreach rating.
14 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

February 1942 and May 1945, 381,193 casualties with battle-incurred injuries and 278,500 admissions with nonbattle injuries were treated in the

medical installations in the European theater. Between 35 and 40 percent of

battle casualties and some 36 percent of nonbattle injury admissions had involvement of the bones and joints. This small number of orthopedic surgeons

(243) was called upon to treat between 220,000 and 250,000 hospitalized patients, aside from wounded prisoners of war and the patients managed in outpatient clinics.

Assignment.—The personnel problem in the European theater was matter

of assignment as well as of number of trained orthopedic surgeons. shortage of adequately trained orthopedic personnel will undoubtedly occur in any war, because so much of the patient load consists of injuries to the bones and joints.

The solution of the shortage in World War II was twofold: The effective distribution of such qualified personnel as were available and the performance of

forward surgery by surgeons without specialized orthopedic training.

Orthopedic responsibilities began with the arrival of the first United States

troops in the United Kingdom early in 1942. The orthopedic sections of the

general and station hospitals which had reached the European theater by

the end of that year were all occupied with the treatment of civilian-type accidents and the various injuries which always occur in mass training for combat.

The 2d Evacuation Hospital, at Diddington, Hunts, was kept busy with Air Force casualties.

At first, there was no shortage of orthopedic personnel in the theater, and

assignment presented no difficulties. Even as late as the fall of 1943, some hospitals were arriving in the theater with two or more qualified orthopedic surgeons among their personnel. These were usually affiliated hospitals. As

time passed, the situation became very different. From 1943 until the end of

the war, some hospitals arrived in the United Kingdom with only partly trained

orthopedic surgeons on their staffs, while other hospitals had none at all. It

was always nonaffiliated general hospitals which came into the theater without

orthopedic personnel. Furthermore, the medical officers in many hospitals of

this kind had been engaged in administrative problems and had been without

professional contacts for so long that they were inadequately prepared for the

clinical problems presented by hundreds and thousands of soldiers with battleincurred injuries of the bones and joints.

The problem of supplying qualified personnel to staff the orthopedic sections of the hospitals in the European theater therefore became acute long

before the invasion of the Continent. As D-day approached and the military

ArmyBattle Casualties and Nonbattle Deaths in World War II, Final Report. Note: Personnel killed in action

and battle-wound or injury cases carded for record only (CRO admissions) are excluded from the figure cited.

This figureincluded CRO admissions. Data for 1942-44 were obtained from tabulations of individual medical records; data for January-8 May 1945 are estimated. Theestimate was based on sample tabulations of individual medical

records and data compiled from summaries of the Statistical Health Report (WD AGO Form 8-122). Provisional tabulations such as these will be supplemented in time by final tabulations.

These battle-casualty estimates represent the general opinion of the medical staff, based upon personal experience.

The nonbattle estimate isprovisional, awaiting publication of final tabulations.

Semiannual Report, Professional Service Division, Orthopedic Surgery, Office of the Chief Surgeon, European

Theater of Operations, January-30 June 1945.
THE CONSULTANT SYSTEM 15

exigencies became keener, it was necessary that hospitals with an oversupply

of qualified personnel be plundered to supply the needs of hospitals which had

arrived without orthopedic surgeons on their staffs. The objective was to supply all general hospitals, as well as all station hospitals in the United Kingdom, with orthopedic surgeons. Later, as the need increased with the increase in

combat casualties, station hospitals, except for those in East Anglia which

served the Air Forces, themselves had to be plundered of their orthopedic personnel to supply the general hospitals which came into the theater without

qualified chiefs of orthopedic sections.

Needs of hospitals.—Normally, an orthopedic surgeon is unnecessary in

field hospital, and qualified orthopedic surgeons were not used in this manner

in the European theater.

The great bulk of work in an evacuation hospital consists of casualties who

must undergo debridement. At various times in the European theater,

teams of surgeons, each team working 12-hour shifts around the clock, could

scarcely keep up with the admissions. This did not mean, however, that orthopedic surgeons would have been properly utilized in these forward hospitals.

Theoretically, the argument is sound that, if injuries of the bones and joints

are treated correctly initially, the results will be better and correspondingly

less secondary surgery will be necessary in rear areas. On the other hand, even

if there had been enough trained orthopedic surgeons to assign to each evacuation hospital, these surgeons could not possibly have taken care of the

casualties. The solution, therefore, was to use trained general surgeons as well

as other less well trained surgeons who, after some instruction, proved able to

perform perfectly satisfactory debridement. This was what was done. In

times of stress, even otolaryngologists worked in evacuation hospitals, outside

of their specialty, itis true, but they performed entirely acceptable debridement.

If an orthopedic surgeon was assigned to an evacuation hospital, he was

most useful in the supervision of other surgeons and in the making of frequent

spot checks of the quality of the work. He could occasionally undertake

particularly difficult cases himself, but it was unwise for him to tie himself up

in run-of-the-mill cases if he was working in hospital with surgeons inexperienced in the management of bone and joint injuries. It is under such circumstances as these that consultant in orthopedic surgery assigned to field army

has his widest field of usefulness.

Originally, teams of orthopedic surgeons from auxiliary surgical groups

were attached to evacuation hospitals. This did not prove to be particularly

economical use of trained personnel. corpsman was satisfactory assistant,

and sometimes better assistant than trained surgeon, in almost all of the

operations permissible in an evacuation hospital. The feeling was frequently

expressed that it would have been better to give the assistant surgeon on the

orthopedic team table and an operating crew of his own and to let the orthopedic surgeon on the team operate with the assistance of corpsmen.

The opinion was also often expressed that the orthopedic surgeons in

evacuation hospitals in reserve could profitably have served on auxiliary
16 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

surgical teams during their periods of waiting. This plan would have provided

more flexible group of qualified orthopedic surgeons, without any increase in

personnel, and would undoubtedly have given satisfaction to the surgeons

themselves, who were always restless and unhappy during the long periods of

inactivity required by the Army policy of holding some evacuation hospitals

in reserve. Theoretically, this was sound suggestion. Practically, logistic

difficulties would probably have made it extremely difficult to carry out as

routine procedure.

According to the tables of organization, general hospital was supposed

to have chief and an assistant chief of the orthopedic section, both of them

well trained. In many instances it would have been desirable if this requirement could have been fulfilled, but it would have necessitated to times as

many adequately trained (MOS 3153) orthopedic surgeons as were ever available in the entire European theater.

As practical matter, most of the trained orthopedic and traumatic

surgeons in the theater, especially those with the highest ratings, were assigned

to the general and the large station hospitals. It was frequently necessary to

plunder evacuation hospitals and auxiliary surgical teams to fulfill the orthopedic needs of these hospitals. When the fighting on the Continent began, all

auxiliary surgical groups had orthopedic surgeons in their complement. By the

end of hostilities, most of these surgeons had been released and reassigned to

general hospitals which had entered the theater without orthopedic specialists

on their staffs.

Level of training.—Even when orthopedic surgeons were in numerical

sufficiency on hospital staffs, the level of training was not always adequate. In

the 19 hospitals which comprised the 802d Hospital Center, for instance, 7,500 of the 18,636 beds were assigned to orthopedic surgery. Of the 18 surgeons in

charge of these beds only had B-3153 ratings. The training of the average

chiefs of orthopedic sections in the and categories in this center, as well

as in other centers and hospitals, was often frankly inadequate, though, with

careful supervision, they were able to handle the compound fractures which

made up the bulk of the work. Before D-day, when the situation was not urgent, it had frequently been

possible, when officers in charge of orthopedic sections of newly arrived hospitals

were regarded as inadequately trained, to send them on detached service to one

or another of the older hospitals in the United Kingdom to serve on the orthopedic sections under chiefs of known competence. After several weeks, the

officers under whom these inexperienced officers were serving prepared an

evaluation of their current abilities and future potentialities. Certain chiefs of

section rendered extremely valuable service in this way; their judgment proved

almost unerring, and they were responsible for the training and assignment of

many originally poorly trained officers who later rendered valuable service in

their own hospitals. After D-day this plan of training naturally had to be

discontinued.
THE CONSULTANT SYSTEM 17

Utilization of qualified personnel.—From May through October 1944,

most of the older affiliated units in the United Kingdom were engaged in staging,

so that they could be set up on the Continent in the wake of the invasion.

They were replaced, in the hospitals which they had formerly manned in the

United Kingdom, by more recently arrived units. The arrangement was perhaps unavoidable under the circumstances, but the first result of it was that the

most experienced orthopedic staffs in the theater did not participate, as units,

in the first months of the invasion, though teams from some of them did

participate in the early care of battle casualties.

The second result was that the early care of these orthopedic casualties

was left to the newer and more inexperienced units, whose orthopedic sections,

in many instances, were staffed by officers who were not qualified orthopedic

surgeons. The professional personnel of these hospitals was frequently source

of great anxiety. On the whole, the work that was done was excellent, but it

would have been better if the surgeons of experience could have been fully

utilized in the first weeks of the invasion, to establish standards of orthopedic

care and to lighten the burden of the less experienced surgeons who were called

upon to assume heavier responsibility than their professional training qualified

them for.

The situation on the Continent was equally uneven. The hospitals which

went over first, as well as the hospitals which came up from Italy, were the

oldest and most experienced of the affiliated units There was, in all, nucleus

of perhaps 30 such hospitals. It may be, again, that under the tactical circumstances which prevailed, the uneven distribution of experienced and inexperienced hospitals could not have been prevented. It left, however, large areas

in which it was difficult to maintain high level of professional care. In

retrospect, from the orthopedic standpoint, it woidd have been better plan to

scatter the older hospitals, especially the affiliated units, in such way that they

could have served as nucleus or parent installation for the hospital centers

set up on the Continent.

This was not done, and the orthopedic setup on the Continent was often

far from ideal. One hospital center, for instance, consisted of four affiliated

units. Another, in total of hospitals, had affiliated units. third, in

total of 11 hospitals, had such units. In contrast, two hospital centers

located adjacent to each other consisted of total of 18 component hospitals,

all of them newly arrived, none of them with previous experience as functioning

organizations, and none of them with single adequately prepared and trained orthopedic surgeon in their personnel. As result, it was necessary to transfer

trained orthopedic surgeon, with an active orthopedic service, from another

center to these centers to serve as orthopedic consultant for both.

Exchange of personnel.—A few orthopedic surgeons in the European

theater served at various times in both the army zone and the zone of communications. This was highly desirable practice (p. 86). It gave these officers

more complete experience and also provided them with fuller and greatly

372572°—56
18 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

needed understanding of the problems in both areas. Had this policy been

carried out consistently, it would probably have ended most of the (unadmitted)

dissatisfaction of the orthopedic surgeons who worked entirely in forward areas

and who would have preferred to work in base areas where they could have

done definitive or reparative surgery which, of course, could not be performed

in forward areas.

It was the plan to develop more extensively the exchange rotation of personnel from forward to rear areas and vice versa, but the war ended before it

could be put into practice to any considerable extent. There were two practical objections to this policy. One was the unwillingness of commanding

officers to lose competent personnel. The other was the unconscionable length

of time it usually took medical officer to travel as casual from the rear to the

front and vice versa, though the actual distance was seldom more than 600 to

800 miles. Officers were known to spend as long as 10 to 14 days in various

depots awaiting transportation. This waste of time naturally tended to cool

the ardor of commanding officers of hospitals, whose orthopedic sections might

be left uncovered for long periods of time while exchange officers were en route

from one assignment to another.

Rank.—The matter of rank naturally had nothing to do with the treatment

of patients, but it played its part in the morale of orthopedic surgeons in the

European Theater of Operations just as it did in the morale of all other specialists, particularly toward the end of the war. At this time few 1,000-bed

hospitals were raised to 1,500-bed status, which theoretically provided for an

increase in rank for some specialists. With single exception, the hospitals

in this group were not the original affiliated units which had been in the theater

from the very beginning but were new hospitals, whose officers, in terms of

service, were not always entitled to increases in rank. number of last-minute shifts in personnel were effected, in an attempt to secure promotion for outstandingly qualified officers with long and meritorious service, but few of these promotions went to orthopedic surgeons.

Some hospitals entered the European theater from the Mediterranean

theater with 1,500 beds and with some of their specialists already lieutenant

colonels, though their service had been no longer than that of the orthopedic

surgeons in the European theater who had been denied promotion. The comparison in rank naturally was unfortunate.

It was the feeling of the senior consultant in orthopedic surgery that some

10 of the approximately 400 surgeons doing orthopedic work in the European

theater should have been advanced to the rank oflieutenant colonel by the end

of hostilities. All of this group had served approximately years in grade,

and all had made significant contributions to the Army effort. Because of

redeployment and freezing of promotions, of the 10 recommended increases in grade were never accomplished.
19

CHAPTER II

Tours of Hospitals

When new senior consultant in orthopedic surgery (Col. Mather Cleveland) was appointed in the European theater shortly before D-day, one of his

first duties was to visit as many hospitals as possible in the United Kingdom.

total of 40 were visited before the invasion occurred. The wards had been

stripped of patients, as far as was practical, in all of them, in the expectation of

the heavy casualties to follow D-day, and the planned demonstrations of diagnosis and management, including plaster techniques, were necessarily limited.

Otherwise, most of the visits fell into the same general pattern. The

qualifications of personnel were reviewed, and notes were made of suggested

changes of assignment. General problems of orthopedic management were

discussed with the chiefs of the surgical services and of the orthopedic sections,

and matters of policy were discussed with commanding officers. It was suggested to the latter that they utilize the services of orthopedic surgeons to

instruct all personnel in the management of bone and joint injuries and in the

application of plaster.

After D-day, the practice of visiting hospitals was continued as far as time

and other duties permitted. The situation in the United Kingdom was not too

difficult, because distances were short. On the Continent, however, as the

fighting moved farther and farther away from the beaches, distance introduced

considerable problem, and some hospitals were visited only twice in the 11

months that elapsed between D-day and V-E Day.

Two hospital tours made by the senior consultant in orthopedic surgery

late in 1944 are reported because they illustrate number of points, including

(1) the various functions of consultant; (2) the unevenness of the qualifications, both in training and experience, of chiefs of surgical services, under

which orthopedic sections functioned; (3) the resulting differences in the concepts of orthopedic surgery in the various hospitals; (4) the difficulties of providing orthopedic sections with trained and competent personnel; (5) the

techniques of instruction employed in the management of battle-incurred

injuries; and (6) the effectiveness of consultant supervision in detecting errors

of management and in providing for their correction.

For comparative purposes and as matter of convenience, the reports of

these two tours are summarized under general headings, instead of being

presented chronologically.

The first report deals with tour of 17 hospitals and hospital center in

the United Kingdom in early November 1944, when casualties with bone and

joint injuries were being treated in considerable numbers (table 2). The second

report deals with tour of hospitals and headquarters on the Continent in

late November and early December of the same year.
20 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Tour of Hospitals in the United Kingdom Base,

November 1944 Personnel

The general plan, at each of the hospitals visited, was to hold conferences

with the commanding officer and the chiefs of the surgical and orthopedic sections. Special reports were received from the chiefs of orthopedic sections who

were also serving as junior consultants in orthopedic surgery under the system

described elsewhere (p. 8). Newly assigned personnel were evaluated, and

arrangements were made for the evaluation, by competent officers, of orthopedic

personnel to be assigned to the orthopedic section in the immediate future.

Table 2.—Sample distributions of hospital populations in the United Kingdom November 1944

Sample reports of these evaluations and corollary recommendations

follow. Precise identification is omitted for obviousreasons.

1. At the General Hospital, the chief of the surgical service had had year’s

internship and 36-month residency in surgery at the University Hospital. He

is diplomate of the American Board of Surgery. His years in the Army have been

spent in executive and surgical positions.

The chief of the orthopedic section at this hospital was graduated from the University of Medical School in 1922. He practiced general surgery from 1926 through

1931, and thereafter, until he entered the Army in 1942, limited his practice to general

surgery and orthopedic surgery. He had had 13 years’ hospital training and years’

postgraduate training at the University of He is diplomate of the American

Board of Surgery. He had served on the orthopedic section at General Hospital

in the Zone of Interior. He was away on detached service at the time of this visit, but

on paper his qualifications seem adequate for the chief of an orthopedic section.

Another officer in this hospital may be of some value as second man on this

section, although his qualifications do not make him adequate to be chief of section.

General hospital

Patients

Total Surgical

(total) Orthopedic Holding

97th __________ 1, 029 539 165

102d _______ 910 750 350

103d 1, 100 350

104th 861 550 160

106th 795 684 226

22d ___ 791 83 260

216th _______

877 441 291

121st 734 700 300

159th _________

769 380 160

67th 1, 112 801 260 246

74th ___ 976 600 400

117th 1, 199 950 375 75

192d __

1, 072 966 374

Approximate.
TOURS OF HOSPITALS 21

He was graduated from the Medical School in 1939and has had total of 32 months

of hospital training and service as an orthopedic consultant in the Veterans Administration.

2. At the General Hospital, the chief of the surgical service had 2-year

internship at Hospital in and had practiced general and industrial surgery

for years before he entered the Army. He is not diplomate of the American Board

of Surgery. He served as chief of the surgical service at Camp ...

in the Zone of

Interior before being sent overseas. In private practice, he performed approximately

60 operations year, chiefly appendec omies, hemorrhoidectomies, and hernioplasties,

but his experience in fracture work is extremely limited.

The officer in charge of the orthopedic service is graduate of the Medical

School, class of 1935. He served 2-year internship in surgery; his experience in the

Army has been entirely surgical.

There is thus no officer in this hospital who is trained in, or familiar with, orthopedic surgery. competent orthopedic surgeon should be in charge of the orthopedic

section. Since the General Hospital has two officers with considerable experience

in fracture work, it will be suggested that one of them be assigned to the General

Hospital as chief of the orthopedic section and that his replacement be an officer with

adequate training in general surgery.

3. At the General Hospital, an excess of trained personnel was found, including young, very well trained orthopedic surgeon and an older officer (major) with considerable training in traumatic and fracture surgery. This hospital does not need the

services of both these trained men, especially at time when other hospitals in the

United Kingdom are short of trained orthopedic personnel. It will be suggested that

the orthopedicsurgeon be assigned elsewhere, where he can be more fully utilized.

4. At the General Hospital, it was interesting to observe how the level of

treatment of bone and joint injuries had risen since the senior consultant’s last visit

and after the change of personnel which had occurred in the orthopedicsection. Similar

improvement was observed in other hospitals where similar changes had occurred.

5. At the Station Hospital, the senior consultant in orthopedic surgery had

conference with Captain and received reports from him of the orthopedic work

at the and Station Hospitals, to which he had been assigned as

consultant. All were prisoner of war installations, but in spite of this handicap, Captain

reported that the orthopedic work was satisfactory in all respects. Captain

has done an excellent job as junior consultant and it has been recommended that

he be named consultant in orthopedic surgery for the Hospital Group (Center),

where he will work under the surgical coordinator. The commanding officer of the

hospital group (center) has approved this arrangement.

Administrative Details

At the 102d General Hospital, several wounded Free French soldiers were

encountered, and the consultant was questioned as to their disposition. Apparently, British hospitals no longer received them. note was made to investigate this situation.

At all hospitals visited, it was emphasized that patients who were neurosurgical problems should be transferred without delay to neurosurgical center.

Similarly, patients with complicated hand injuries were to be transferred to

special hand centers.

At the 117th General Hospital, no operative work was being done on the

neurosurgical service, because the neurosurgical officer was suffering from

dermatitis which precluded his scrubbing. It was recommended that this
22 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

officer be replaced or be given competent assistant. This hospital is capable

of doing excellent bone and joint work and should be fully utilized.

At the time of this visit, the 22d General Hospital was serving as holding

hospital and had not received battle casualties for considerable period of time.

Because of its superior equipment and staff, the senior consultant considered it

wasteful to use this hospital merely as holding unit and recommended that it

be given high priority for the treatment of battle casualties.

Evacuation Time

The time of arrival after wounding of patients transported from the

Continent to the United Kingdom hospitals showed wide range. Up to or

weeks before this visit, which was in early November, many of the hospitals

visited had received patients within or days. When air evacuation was

available, some patients were still being received within week after wounding.

In many installations, however, the average time had lengthened to weeks.

The 192d General Hospital received patients from Holland and from Belgium

by air within days, and sometimes as early as days, after wounding. These

patients, who were mainly paratroopers, were flown in by the British.

At the 104th General Hospital, several patients with compound fractures

had recently been received too late for skeletal traction, and patient had not

been received for 36 days. The position of the femoral fragments was not too

unsatisfactory in another, similarly delayed case, but shortening amounted to

almost an inch. Since these patients had already been evacuated to the Zone of

Interior, their names and serial numbers were not available. It was stressed

to the hospital staff that careful record should be kept of all patients delayed in

transit long enough to interfere with their care, so that such errors could be

investigated and corrected.

Experience varied from hospital to hospital. At the 106th General Hospital, hospital trains had been received since 25 July, but at the time of the

visit patients were chiefly being received by ambulance from the 79th General

Hospital and the 110th Station Hospital. Ambulance convoys brought from

60 to 90 patients per trip. At the 121st General Hospital, convoys were

received by air, train, and ambulance. In the first convoys, the wounded

were received from 24 hours to days after wounding. The timelag for the

fourth convoy was to 10 days, and for the fifth it was as long, for some cases, as 21 days. At the 74th General Hospital, total of 13 trainloads of patients

had been received, the mostrecent from 10days to weeks after wounding. No

patient had ever been received too late to be put in skeletal traction. At the

216th General Hospital, the last trainload of casualties, 50 percent of whom

were neuropsychiatric, had previously passed through from to hospitals.

During the last 12 weeks, the condition of the patients on arrival was not

as good as it had formerly been. The average timelag after wounding during

this period was 12 to 14 days, but some patients had been delayed for 21 days

or longer.
TOURS OF HOSPITALS 23

Wound Closure

At the 187th General Hospital, 90 percent of compounding wounds were

closed by delayed primary suture, and healing was usually complete when

the patients were evacuated to the Zone of Interior. At the 216th General

Hospital, closure of wounds over compound fractures was similarly successful.

At the 102d General Hospital, wounds were closed by suture over compound

fractures in about 80 percent of all cases and by skin grafts in the remaining

cases. The 15th Hospital Center had treated approximately 3,500 compound

fractures since D-day. Preliminary analysis of the material showed that

healing had been satisfactory in 80 percent of the first 1,500 wounds closed

by suture or skin graft.

At the 67th General Hospital, 62 compound fractures of the femur had

been treated since D-day; in 21 of these cases the wounds were infected when

the patients were admitted. Spontaneous closure occurred in 18 of the 62

wounds, and closure was undertaken in 23 others. Healing occurred in all 11

cases in which delayed primary closure was carried out from to 16 days

after wounding. In the 12 closures done later, in slightly infected wounds,

primary healing was not accomplished, but all wounds were healed before the

patients were evacuated.

At the 192d General Hospital, 71 compounding wounds closed by delayed

primary suture healed satisfactorily, and healing was partially successful in

18 others. Both surgical and orthopedic section chiefs agreed that patients

who were evacuated from the front in circular plaster-of-paris splints seldom

presented wound infections and were best suited for early closure of compounding wounds. Secondary debridement was seldom necessary in these

cases. Recently number of patients whose wounds had not been debrided

had been received through British hospitals, but this was an exceptional

experience.

The chief of the orthopedic section at the 121st General Hospital reported

that debridement of compounding wounds had been almost universally necessary before wound closure could be undertaken. As result, relatively few

wound closures were being performed. This experience was entirely contrary

to that of most other hospitals in the United Kingdom, where wound closure

was seldom delayed more than to 10 days after the patients’ arrival. The

senior consultant in orthopedic surgery wondered whether so many debridements were really necessary and suggested, instead, that wounds which did not

look healthy be treated by wet dressings for or days.

Very few compound fractures had been closed at the 103d General Hospital

in the past weeks, because of the attitude of the surgeon in charge of the

orthopedic section toward delayed primary wound closure. This policy was

to be remedied.

At the 192d General Hospital, it was observed that when patient was

received with large, metallic foreign body in the wound, healing almost

never occurred until the foreign body had been removed. The delay was
24 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

attributed not to the metallic object itself but to the bits of clothing that had

usually entered the wound witli it.

Plaster Techniques

Plaster of paris was, on the whole, well applied. At the 67th General

Hospital, the circular plasters were rather bulky, but this was because it had

been necessary to use cotton batting as substitute for sheet wadding, which

iiad been unobtainable.

At the 192d General Hospital, it was found that every patient who had

been evacuated in Tobruk splint had suffered great deal of pain during

transit. The chief of the orthopedic section said that in his experience it was

as hard to apply Tobruk splint correctly as to apply plaster spica, which

he thought was much more comfortable for the patient. It was also reported

that there was some loss of the skin of the dorsum of the foot whenever the

Thomas splint was used with the Army boot strap in place during evacuation.

The surgical coordinator of the 15th Hospital Center, who had recently

traveled with hospital train, said that in his opinion all patients in thoracobrachial spicas should be regarded as class 2. In few instances, the spicas

were too widely abducted. When plaster spicas were used for fractured femurs,

he thought that wicket should always be employed to protect the toes. No

foul-smelling plasters were encountered on the train.

When the holding unit was investigated at the 22d General Hospital, 24

patients were found whose status was not considered entirely satisfactory for

transportation. Their general condition was good, but the plaster casts in

which they were encased were not well applied. Since these patients had all

come from the 104th and 106th General Hospitals, it was suggested that the

commanding officers and the chiefs of the surgical and orthopedic sections of

these hospitals be asked to visit the 22d General Hospital and examine these

patients with the chief of the orthopedic section.

At the 67th General Hospital, similar criticism was made, and it was

similarly suggested that commanding officers and chiefs of the surgical and

orthopedic sections of the hospitals sending patients to be held should meet

at the 22d General Hospital for briefing on the proper preparation of patients

to be returned to the Zone of Interior.

It was noted that fractures of the humerus received from the 112th General

Hospital had been put up in thoracobrachial spicas in wide abduction. It was

agreed to correct this technical error in the future.

Skeletal Traction

At most of the hospitals visited, fractures of the femur, tibia, and fibula

were being correctly treated in skeletal traction. The use of traction in fractures of the femur was fairly general. At some institutions, it was not employed

consistently in fractures of the tibia and fibula. It was also not employed

uniformly in fractures of the humerus.
TOURS OF HOSPITALS 25

At some hospitals, the technique of skeletal traction had been greatly improved since the consultant’s earlier visit. Some criticisms, however, were

still necessary. At the 97th General Hospital, it was pointed out that more

adequate provision should be made for motion in the knees and the ankle

joints. At the 102d General Hospital, skeletal traction was adequate, but more than was necessary (up to 25 pounds) was being employed in injuries of

the tibia and fibula. One patient was observed in traction with distraction of

the fragments and some distraction at the ankle joint. Two men with compound fractures of the femur required dependent drainage which had not been

instituted. At the 159th General Hospital, Army splints were found not in

balanced suspension. One compound fracture of the femur was associated

with an abscess of the thigh which needed drainage. At the 216th General

Hospital, there was slight tendency to overpulling in fractured femurs. It was pointed out at every hospital that the great majority of fractures of the long bones should be treated by skeletal traction. When the technique

was not used generally or properly, the attention of the chief of the orthopedic

section was called to the directives on the subject, and he was urged to make

wider use of the method and to employ it for fractures other than those of the

femur. At the 216th General Hospital, where the use of skeletal traction was

limited almost entirely to fractures of the humerus, it was suggested that the

chief of the orthopedic section and the chief of the surgical service visit the 22d

General Hospital, which had an excellent and adequate program for the management, by skeletal traction, of all fractures of the long bones.

At the 106th General Hospital, the last convoy had brought only ambulatory casualties with no fractures of the long bones. Skeletal traction was

employed in this hospital, but only few patients were in it at the time of this visit. Two patients were observed in the Roger Anderson apparatus.

The chief of the orthopedic section was reminded that the use of apparatus for

external fixation should be limited to the special cases in which pedicle graft

was necessary. After the graft had been applied, balanced suspension skeletal

traction should be instituted. Pedicle grafts were to be performed only in

plastic centers, in which category this hospital was not included, and indications for the use of the Roger Anderson apparatus therefore should not have

arisen in it.

Amputations

At the 103d General Hospital, amputation stumps were lound in good

condition, with adequate skin traction. The condition of the stumps had been

greatly improved at the 104th General Hospital since the consultant’s previous

visit. At the 97th and 74th General Hospitals, the skin traction observed on

some of the amputation stumps was not altogether adequate. This matter

was called to the attention of the chiefs of the surgical and orthopedic sections

to be remedied.

At an occasional hospital, amputation stumps had been closed by suture,

in direct violation of the theater policy which required maintenance of skin
26 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

traction in all circular amputations until healing had occurred. This matter

was called to the attention of the surgical and orthopedic staffs and of the

commanding officers, and it was directed that skin traction be employed thereafter on all amputation stumps.

At the 121st General Hospital, patients with amputation stumps were

received in good condition. Only one amputation for gangrene of circulatory

origin had been necessary at this hospital.

At the 216th General Hospital, the question arose whether to amputate

viable foot which was functionally useless or to return the patient to the

Zone of Interior for definitive surgery. The senior consultant in orthopedic

surgery expressed the opinion that whenever patient could be transported

without risk, amputation should be deferred until he reached hospital in the

Zone of Interior.

Infections Three patients with suppurative arthritis of the knee joint were observed

at the 192d General Hospital. Symptoms had subsided under treatment with

aspiration and instillation of penicillin, and considerable amount of motion

in the knees had already been gained.

Very little gas-bacillus infection was observed at most hospitals, but this

was not invariably true. At the 67th General Hospital, of 21 patients received with infected wounds had Clostridium welchii infections, and died of

gas gangrene. The other were treated by debridement, and most of the

wounds were well healed before the patients were evacuated to the Zone of

Interior.

At the 216th General Hospital, patients in convoy were received moribund from clostridial myositis, and both died promptly. Inquiries produced

no information concerning the hospitals through which they had previously

passed.

The incidence of frank osteomyelitis had increased materially at the 216th

General Hospital in the last several weeks. Healing of the wounds in these

cases was seldom complete before the patients were evacuated to the Zone of

Interior, though drainage had usually decreased. At this installation, every

patient with compound fracture of the pelvis had developed osteomyelitis, and

many had required sequestrectomy.

Hand Injuries

At every hospital visited, an attempt was made to make the staffthoroughly

conscious of the importance of early mobilization of wounded hands and fingers.

In some instances, prolonged immobilization was still being practiced. Whenever possible, as at the 103d General Hospital, clinic was held on hand injuries,

and the importance of early, active motion was stressed. Emphasis was put

upon the definitive management of wounds of the soft tissues, with secondary

emphasis upon the skeletal injuries.
TOURS OF HOSPITALS 27

At some hospitals, as at the 117th General Hospital, plastic surgery on the

hands was of very high caliber.

At the 22d General Hospital, Capt. (later Maj.) Marshall R. Urist, MC,

reported an interesting and useful study. After amputating finger, he fixed

the digit at various levels with Kirschner wire. He found that the entire

proximal phalanx is influenced by the tendons, and that, with single exception,

it is not possible to insert Kirschner wire without transfixing them. The single

exception, and the only area in the finger entirely free of tendinous structures, is small triangle on the dorsal surface of the middle phalanx, just distal to the

proximal interphalangeal joint. At this point, small dental drill could be

inserted into the marrow cavity, and adequate skeletal traction could be assured by passing hook into the hole made by the drill. The consultant regarded this as the best means of skeletal traction of the fingers which he had

encountered in his experience.

New Devices

At the 22d General Hospital, number of appliances had been devised for

the management of compound fractures, including:

1. suspended long leg cast, utilizing the Pierson attachment, which is

incorporated in the plaster of paris above and at the knee (p. 45).

2. rotating Bradford frame to facilitate the care of extensive wounds of

the extremities and trunk associated with compound fractures (p. 50).

3. Bohler-Braun type of traction cradle (p. 50).

Special Cases

At the 121st General Hospital, an autogenous bone graft had been perfoimed on compound fracture of the humerus before the compounding wound

was closed, with the tibia as the donor site. The graft was put in place with

four vitallium screws. In the course of the operation, the surgeon disposed of

number of bone fragments at the site of the fracture which, from the description, might very well have served as autogenous grafts if they had been left in

place. Purulent exudate was present at the site of the fracture at the time of

the operation, which, in itself, should have contraindicated the use of large

tibial graft.

In another case at this same hospital, open reduction and internal fixation

were performed on compound fracture of the femur with vitallium plate

and screws. This wound had previously been closed.

These cases are cited as instances of questionable surgical judgment, and

the commanding officer, the chief of the surgical service, and the chief of the

orthopedic section were directed to refrain from such surgery in the future.

Whether or not the outcome in these cases would be favorable did not alter the

fact that neither operation should have been performed.

At the 67th General Hospital, patient was seen with an unrecognized

dislocation of the elbow joint. He had been injured 25 October 1944, near
28 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Aachen, Germany. At the second evacuation hospital to which he was admitted, roentgenograms were taken of the elbow joint while he was in an upperextremity traction splint. The views were oblique, and, because of the presence of the traction apparatus, the nature of the lesion was not appreciated and

the roentgenologist failed to discover the dislocation. The surgeon listed the

lesion as sprain. The patient was evacuated to the 203d General Hospital

days after operation and remained there for another days. At this time,

note was made that he had very marked regional swelling, probably resulting from dislocation which had spontaneously reduced. When the patient

finally arrived at the 67th General Hospital, 10 days after wounding, he was

found to have complete dislocation of the elbow, which was reduced with

considerable difficulty. The case was cited simply to ensure more critical

and inquiring attitude on the part of medical officers through whose hands

casualties pass.

At the 22d General Hospital, three interesting fractures of the hip were

observed, all beautifully handled. One, dislocation with separation of the

symphysis, had been treated by vertical traction. The second, trochanteric

fracture, had been fixed with Smith-Petersen nail. The third, another dislocation, had also been treated by vertical skeletal traction.

At this same hospital, medical officer was examined with onychogryphosis

of both great toenails. The condition had originally been diagnosed as ingrowing toenails. It was recommended that he be treated by excision of the

nail and bod, with amputation of part of the distal phalanx and folding of the

plantar skin over the dorsal surface of the remaining portion of the toe. This

type of surgery was not indicated in an overseas hospital, and disposition board

had recommended transfer to the Zone of Interior.

At the 140th General Hospital, the roentgenologist was examined because

of pain in the right wrist and arm. It had been present for several years but

had recently become much more severe. Roentgenograms taken during the

past weeks showed punched-out areas in the right capitate and unciform

bones, as well as in the head of the right humerus and in the right tibia near the

articular surface of the knee joint. The wrist was swollen and tender. Although the officer felt well and had recently gained weight, he was frequently

incapacitated by pain. The staff was of the opinion that the condition was

Boeck’s sarcoid but believed that an atypical gouty lesion should also be considered. The consultant suggested biopsy on the right capitate bone to establish the diagnosis, and also recommended the tentative use of colchicine for

long-enough period to see if it would relieve the symptoms.

At the 67th General Hospital, patient was observed with rarefying

lesion of the tibia, probably an osteitis fibrosa cystica. Brodie’s abscess of

the lower end of the radius with perilunate posterior dislocation of the carpus

was also observed. Open reduction was to be employed because the dislocation

was month old. There was no fracture of the carpal scaphoid.

Eight or nine patients observed at the 216th General Hospital were suffering from symptoms of mild immersion foot. Objective findings were minimal.
TOURS OF HOSPITALS 29

Treatment consisted of keeping the foot in tent at room temperature, with

injection of the posterior tibial nerve with Novocain (procaine hydrochloride),

or Pontocaine (tetracaine hydrochloride). Weight bearing was permitted

after the injection and was possible for considerable period of time without

pain.

Tour of Hospitals on the Continent

23 November-3 December 1944

The following report concerns the visits of the senior consultant in orthopedic surgery to hospitals (2 general hospitals, evacuation hospitals, and

field hospitals) and headquarters on the Continent between 23 November

and December 1944. The general plan of this tour followed the plan described

for visits to hospitals in the United Kingdom Base.

Alost of the hospitals visited on this tour were either in or supporting the

First and Ninth United States Army areas. The Ninth Army had both

surgical consultant and consultant in orthopedic surgery. The First Army

had only surgical consultant.

Hospital Population

The 62d General Hospital had population of 1,307. At this time, 302

patients had bone and joint injuries. During October, there had been 3,337

admissions, 1,039 of them to the orthopedic service. Of the 2,484 surgical

admissions, 1,884 had been battle casualties. On the whole, 50 percent of the

battle casualties received in this hospital were handled on the orthopedic section. The 77th Evacuation Hospital had 800 patients, 602 on the surgical service. Alost of them had already had as much surgery as was permissible in this

area.

The 2d Evacuation Hospital had had 15,117 admissions since October,

the first 2,000 of them during the period the hospital was acting as transit

hospital. Since it had arrived on the Continent in June 1944, it had been in

previous locations and had received approximately 27,000 patients; 3,583 operations had been performed, with 137 deaths.

The 44th Evacuation Hospital had been in six previous locations since its

arrival on the Continent. During the busiest period, from July to August,

inclusive, it had received between 600 and 700 patients daily for several days.

It had done considerable amount of station hospital work. The total

population between 21 June and 31 October had been 11,094. Between 35

and 40 percent of all battle casualties had compound fractures.

At the time of this tour, the sector immediately in front of the Ninth

United States Army was relatively quiet. At one clearing station visited,

only five patients had been received during the day; all had minor complaints

and none were battle casualties. At the 53d Field Hospital, only 25 patients

had been admitted.
30 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

drainistrative Considerations

At the 41st Evacuation Hospital, the chief of the surgical service reported

that he had sent out between 750 and 800 cards on nontransportable patients

whose subsequent condition he was anxious to check. He had received only

21 replies. Possibly many of these cards were overlooked because the field

medical record of evacuation was not completely studied. It was suggested

that the matter be taken up with the surgical consultant at the United Kingdom

Base.

At the 2d Evacuation Hospital, the consultant attended meeting at the

office of the commander of the 68th Medical Group. This was daily meeting at which tactical report was made on the entire Army situation. It was an

extremely interesting meeting and seemed worthwhile plan.

At ADSEC (Advance Section) Headquarters, it was reported that evacuation was progressing much more smoothly than at the time of the last report.

On one day, there had been an airlift to the United Kingdom of 1,200 patients

and on another day an airlift of 800.

Plaster Techniques

Much of the discussion at the various hospitals had to do with the advantages and disadvantages of the Tobruk splint.

At the 62d General Hospital, only one patient had arrived in Tobruk

splint. The case was well selected, and the patient was comfortable. The

splint was changed to plaster-of-paris spica before he was evacuated to the

United Kingdom. At this hospital, it was reported that plaster-of-paris splints

in which the patients arrived from evacuation hospitals had to be changed in

about 10 percent of all cases before their transshipment to the United Kingdom.

At the 41st Evacuation Hospital, number of patients were observed in

Tobruk splints. All appeared comfortable. In each instance, the knee had

been put up in about 15 to 20 degrees of flexion, and elastic cords had been used

to secure traction. It was pointed out that the use of this splint achieves an

enormous saving in plaster. The plaster splint requires four 6-inch rolls of

plaster for the posterior component and another four 6-inch rolls for the outside

casing which grips the wide bars of the Thomas splint.

At the 44th Evacuation Hospital, the chief of the orthopedic section had

had good deal of experience with the Tobruk splint and much preferred the

plaster spica. If the patient’s general physical condition at the end of debridement in compound fracture of the femur did not warrant the application of

spica, it was his opinion that Thomas splint with adhesive-plaster traction

should be employed until there was sufficient improvement to permit the application of the plaster spica.

At ADSEC Headquarters, it was reported that detailed investigation

was being conducted by the consultant in orthopedic surgery for the Ninth

United States Army on the advantages and disadvantages of the Tobruk splint

in compound fractures of the femur. It was hoped that this report would be
TOURS OF HOSPITALS 31

available at the next meeting of the Anglo-American consultants. The study

was to be correlated with the senior consultant in orthopedic surgery. It was

felt that this investigation (p. 110) would be of great value.

The Tobruk splints observed in the various hospitals were usually well

applied, and the patients put up in them were comfortable. Their chief advantage in busy evacuation hospital was that they could be applied in 12 to

15 minutes. An orthopedic surgeon who as thoroughly familiar with plaster

techniques could, however, apply an adequate plaster-of-paris spica almost as

rapidly and was therefore much more likely to use it. It was the consultant’s

opinion that the chief field of usefulness of the Tobruk splint was in certain

selected fractures involving the supracondyloid region of the femur.

Trenchfoot On this tour, considerable amount of trenchfoot was observed and discussed, though cold injury was not true orthopedic problem. The following

experiences were typical:

At the 41st Evacuation Hospital, trenchfoot was of mild type, and very

few severe cases had been seen. Patients were treated on the medical service.

The observation was made that anybody with sore foot was now supposed

to have trenchfoot. About 50 percent of the patients with this diagnosis had

minimal physical signs, or none at all, but it was believed that not more than

10 percent of them were in any sense malingerers.

At the 77th Evacuation Hospital, about 100 patients with trenchfoot had

been received daily over period of several days some weeks ago. At the

present time, relatively few were being received. The unit from which these

men came had not been properly instructed in the care of the feet. It was

reported that some soldiers who had fought in Holland had worn overshoes

over felt slippers and two pairs of socks and had escaped cold injury entirely;

this arrangement kept their feet warm and provided room for adequate movement of the toes. The chief of the surgical service at this hospital felt that

exercise must be taken and constriction must be avoided if this crippling

disability was to be prevented.

At the 102d Evacuation Hospital, 85 of 119 surgical patients recently received had come in with the diagnosis of trenchfoot. They were chiefly from

the 28th Division where, they said, little or no instruction was given about

the care of the feet necessary to prevent this condition.

The professional services of the Ninth United States Army were extremely

foot conscious. The chief of the Preventive Medicine Division had had an

effective poster made, embodying the salient etiologic features. Immobilization and constriction of the extremities were thought to be the chief causes.

The term “trenchfoot” was thought to be misnomer. In large, roomy

trenches the men could move about freely, and the condition seldom occurred.

In foxholes they could not, and “foxhole foot” was suggested as much better

term.
32 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

total of 511 patients with this condition had been received from the

84th Division, within 12 days. The great majority of these soldiers came from

single infantry regiment which had bogged down in swamp, where it was

pinned down by gunfire and unable to move. Each patient admitted with

trenchfoot had to fill out questionnaire on the details of the injury.

At Headquarters, First United States Army, the subject of trenchfoot was

discussed in detail. The 91st Medical Gas Treatment Battalion had been

taking care of these cases, the number of which was now decreasing. One

company, set aside as study center, had 70 patients. Another had 200

under treatment. Patients considered convalescent were sent to the 4th

Convalescent Hospital for 10-day period. The total holding time for this

Army area was only 10 days, but for purposes of study some patients had

been held as long as 21 days.

All patients who presented discoloration, marked edema, or associated

injuries of the feet were evacuated as promptly as possible. The possibility of

psychic factor had been recognized promptly, and it was now the policy to

hold these men in corps and division areas in the absence of positive physical

findings. Buerger’s exercises were instituted at the walking stage, with unilateral sympathetic block, but this regimen seemed of no help in the earlier

stages. The first patients treated were now returning to duty and would be

observed carefully for possible recurrences.

It was clearly recognized that control of trenchfoot is command function,

and medical officers were investigating how control was being carried out.

Amputations

Amputation stumps were generally in well-applied transportation plaster

of paris with skin traction obtained by stockinet and elastic attached to wire

ladder loop incorporated in the plaster.

At the 44th Evacuation Hospital, many casualties had been received

after injuries from land mines and had to be treated by amputation. It was

observed, however, that if good covering of snow was on the ground, traumatic

amputation did not occur, as it usually did when the ground was bare and there was directhit on either the foot or theleg, which was totally or partially

torn off.

Tour of Field Hospital

The 8th Field Hospital was visited December. At this time it was

located near an airfield in the Seine Base Section and was serving as holding

unit. It had 750 patients, all to be transported to the United Kingdom.

Patients arrived from to days after wounding, and the average holding

time was 24 to 36 hours, with maximum of days. The order of priority

for evacuation was head wounds and maxillofacial injuries, chest wounds with

hemopneumothorax, multiple fractures of the long bones, and amputations.

Up to 1,400 litter cases had recently been evacuated from this hospital

in single day, November having been better month for air evacuation than
TOURS OF HOSPITALS 33

October. The weather was the one great stumbling block. Approximately

in every 500 litter patients was returned to the receiving hospital as nonevacuable. This was an excellent record.

Approximately 150 patients were observed in the wards visited. They

were all in good condition, and the plaster work seen was on the whole excellent.

Fractures of the femur were for the most part received in plaster-of-paris

spicas. Only few were in Tobruk splints. The officers stated that plaster

techniques had greatly improved and that very few casts now had to be changed.

Practically no orthopedic surgery had been necessary at this hospital.

No gangrene had developed and no amputations had been required.

Four patients were encountered who were improperly prepared for transportation;

1. staff sergeant with compound comminuted fracture of the first left

metacarpal, caused by gunshot wound, had had pulp traction applied at

field hospital 22 November. On 24 November, he was evacuated to the 203d

General Hospital, where he remained until 26 November. His wound was

inspected, and pulp traction was continued. It was also continued when he

reached the 8th Field Hospital.

2. Another staff sergeant, who was wounded in action by land mine,

also sustained fracture of the second metacarpal. He was evacuated through

the filth Evacuation Hospital to the 76th General Hospital, where pulp traction was applied through the soft tissue of the distal phalanx of the second

finger. He was then transferred to the 40th General Hospital, where he

remained until December. Ho was still in traction when he was seen at

the 8th Field Hospital December.

The senior consultant suggested that pulp traction be discontinued at once

in both of these cases. Neither patient up to this time had showed any untoward effects from it, but the danger of ulceration and of loss of fingertips had

been established by experience, and pulp traction had been forbidden in the

most recent Circular Letter (No. 131, November 1944), Office of the Chief

Surgeon, European Theater of Operations. It was suggested that this matter

be called to the attention of the officers responsible for instituting this kind of

traction, and that its further use be avoided.

3. private wounded 28 November received compound comminuted

fracture of the right tibia, perforating wound of the right leg, and cold injuries

of both feet. Circular plaster of paris was applied at the 45th Evacuation

Hospital, but the cast was not split through to the skin and was not spread.

Thereafter, thepatient was passed through the 46th Field Hospital and through

general hospital in Paris, the number of which was not available. When

the patient was seen in the 8th Field Hospital by the senior consultant in orthopedic surgery, he complained of considerable discomfort. Examination

revealed that the circulation in the foot was apparently adequate, but that the

plaster was too snug.

See appendix A, p. 325.

372572°—56
34 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

4. Another private, wounded 17 November, sustained penetrating

wound of the urinary bladder, penetrating wounds of both legs with compound

comminuted fractures of both patellas and the lateral condyle of the right

femur, penetrating wound of the right buttock, and penetrating wound of

the right arm, with compound comminuted fracture of the right radius and

ulna. Circular plaster was applied to the left leg at the 51st Field Hospital,

Tobruk splint was applied to the right leg, and circular cast was applied

to the right arm. The splints on both legs were incompletely split and were

not spread at all. The man arrived at the 48th General Hospital on 30 November and at the 8th Field Hospital on December. When he was seen by the

consultant shortly afterward, he was complaining of pain around both ankles.

These two patients were both examples of failure to carry out the specific

instructions from the Office of the Chief Surgeon that circular plaster casts

should be split to the skin or to the dressing overlying the wound and should

then be spread. It was suggested that the plaster in both these cases be split

at once and that the officers responsible for its application be notified of their

error and requested in the future to follow instructions about splitting and

spreading primary circular plaster-of-paris casts.

See footnote 1, p. 33.
35

CHAPTER III

Training of Personnel

General Considerations

Almost years were spent in the United Kingdom in preparation for the

care of casualties with bone and joint injuries expected in the campaigns to be

conducted on the Continent. When the time came, these campaigns lasted

only 11 months. Orthopedic care began, of course, with the arrival of the

first troops in the United Kingdom in 1942, and the period between June 1944

and May 1945 was the summation of all the previous efforts.

This preparation had to be accomplished in the face of certain difficulties

not apparent in the bare statement of the facts:

1. The period of training was not the same for all surgeons. Only few

hospitals were in Great Britain for the full 2-year period mentioned. Some

arrived shortly before D-day and had only few weeks of training; many

others arrived long after D-day.

2. The training of physicians in special skills is difficult to accomplish in

limited period of time, particularly when they have had no previous surgical

experience at all, though in times of great need there is no choice but to rise to

the emergency. The results of the training of orthopedic surgeons before

D-day were extremely good. Many medical officers who had had little or no

surgical experience and who acted as ward officers in the first hospitals which

arrived in the theater served with usefulness and even distinction as chiefs of

orthopedic sections in hospitals which arrived later. This was result of the

training they received during the period of preparation.

3. major problem was that even the most experienced surgeons in the

theater had had, for the most part, no experience at all in the mass management

ofbattle casualties with injuries of the bones and joints. The senior consultant

in orthopedic surgery is case in point. He had had wide civilian experience.

From previous experience in the Zone of Interior, he had had extensive experience in accidents which occur in training for combat. He had served overseas

in World War I, though, as matter of fact, this experience was less useful

than his civilian and Zone of Interior experience. He had had, however, no

experience at all in the mass management of casualties with bone and joint

injuries as they were to be encountered in World War II. Furthermore, he

assumed his duties in the United Kingdom Base only few weeks before D-day,

and he was therefore additionally handicapped by lack of knowledge of the

location and personnel of the various hospitals which had been set up in preparation for the invasion.
36 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Methods of Training

Medical Officers

The Medical Field Service School organized at Shrivenham, Berkshire,

England, in 1943 was staffed by instructors who were handicapped, as already

noted, by their own lack ofbattle experience. Instruction in the care of battle

casualties and in plaster techniques was therefore, as matter of necessity,

chiefly theoretic. Medical officers who attended the courses came from evacuation and field hospitals and from divisional medical units.

No formal Army program of orthopedic training was instituted, but each

unit was provided with full file of theater circular letters and administrative

memoranda, Army medical circulars, and the material in the Manual of Therapy prepared shortly before D-day. It was recommended that all of this

material be used for instructional purposes.

As far as was practical, the large battle experience which the British had

had and the techniques of care which they had developed were disseminated

to American medical officers. Opportunities were provided to attend the

meetings of the Orthopaedic Section of the Royal Society of Medicine, the

semiannual meetings of the British Orthopaedic Association, and the monthly

Inter-Allied medical meetings. Every months, Sir R. Watson-Jones, Royal

Air Force consultant in orthopaedics, and Air Vice-Commodore Osmond-Clarke

conducted 5-day courses of instruction in fractures in the hospitals in and about

London. These were enthusiastically attended by as many of the younger

orthopedic surgeons in the American forces as could be enrolled.

Some American surgeons had the opportunity of working in British hospitals. British arrangements for the care of their wounded differed materially

from those in the United States Army. The care of casualties was function

of the Emergency Medical Service, civilian organization manned by civilian

physicians. In England and Scotland, only few Army, Navy, and Air Force

hospitals were operated as service hospitals. The wounded British soldier,

sailor, or airman was cared for by the medical corps of his special branch of

service as long as he was overseas. As soon as he reached the British Isles, his

care reverted to civilian physicians. This particular arrangement was made at

the outbreak of hostilities because it was expected that there would be an enormous number of civilian casualties incidental to bombings. It also necessitated

the withdrawal of far fewer physicians from civil life, in proportion to the population and the total available supply of physicians, than in the United States,

Although the number of civilian casualties was smaller than had been expected,

British civilian hospitals were generally understaffed and their personnel was

generally overworked. Early in the war, therefore, number of United States

orthopedic surgeons in the European theater had the opportunity of participatproposed revision of the orthopedic section of the Manual of Therapy, in the light of the European experience,

was drafted in June 1945 but was not officially published because the warin the Pacific ended withinthe next few weeks.

It appears as an appendix in this volume (appendix B).
TRAINING OF PERSONNEL 37

ing in the care of the British civilian population after bombing. This provided

greatly needed help for the British, established invaluable contacts between

American and British orthopedic surgeons, and gave American orthopedic surgeons excellent experience in the management of what were, in effect, battle

casualties.

The response of untrained and inexperienced surgeons to such rapid training in orthopedic surgery was, as might have been expected, extremely uneven.

Many instructors remarked that poor surgeons who worked with orthopedic

surgeons of superior ability often failed to improve their techniques in either

orthopedic surgery or the application of plaster, while poor surgeons continued

to do poor debridements no matter what their specialty or training might be. Men in this group were inclined to excuse their inefficient performance on the

ground that they were not trained orthopedic surgeons.

fundamentally good surgeon, however, while he might do unsatisfactory

work for brief time, when once he realized the principles of debridement and

the application of plaster, immediately improved his technique. There were

many illustrations of the fact that well-trained general surgeon can readily adapt himself to the needs of specialty in which he has had no previous experience. One general surgeon, for instance, although he had never before seen

the Smith-Petersen approach to the hip joint, once it had been described to him,

extracted foreign body from the joint and performed an extensive debridement

as competently as if he had done the operation dozen times.

One of the greatest difficulties with new surgeons who were without military experience or previous training was making them understand the fundamental principles of debridement. There were two chief errors, (1) tendency

to excise skin and superficial layers of tissue, and (2) failure to make bold incisions through the fascial planes, so that the deeper layers of tissue could be

adequately debrided. wound treated in this superficial manner was seldom

ready for closure within to days after wounding. Wound closure at that

time was the objective of reparative surgery. With proper supervision, these

errors could be corrected, but they would have been corrected more rapidly if

the consultant system had been somewhat more flexible.

It was an excellent plan, when possible, to attach officer and enlisted personnel from new hospitals to older hospitals for instruction before they were

permitted to receive patients. Another excellent plan was to attach small

number of officer, nurse, and enlisted personnel to an older hospital for few

weeks in exchange for like number of personnel from new hospital. In this

manner, it was possible for the group from the older hospital to supervise and

train the staff at the new hospital, while at the same time key personnel from

the new hospital received intensive training at the old hospital.

Still another plan was to attach one or two teams from an auxiliary surgical

group to each new hospital for the first few weeks after it opened. Finally, arrangements could sometimes be made with nearby established hospitals for

personnel from new units to visit them frequently, observe the wounded as they

arrived, and study the techniques of surgical management. The plans just
38 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

described were very frequently used in evacuation hospitals as they arrived on

the Continent.

Nursing Care

Nursing care of bone and joint casualties was of high quality, though the

policy of certain hospital chief nurses of rotating nurses through all services in

the hospitals was regrettable. Orthopedic surgeons, like all other specialists,

frequently complained that few nurses remained on their sections long enough

to become really proficient in the care of these casualties. Repeated requests

were made for key nurses and key enlisted men to be given permanent assignments, without rotation, and in some hospitals this practice was carried out as

well as circumstances permitted. In others, therecommendations were ignored.

Enlisted men who served as ward attendants had been carefully trained in

their duties before D-day. few had had additional training at the Derwin

Training School for cripples in England. The more instruction these men received, the better, naturally, was their work. Some of them became extremely

proficient in setting up traction and in caring for patients immobilized in

plaster.

Plaster Technicians

Plaster of paris was used so extensively in bone and joint injuries, both

in evacuation and in general hospitals, that surgeons and ward officers could

not possibly take care of it themselves. It was always desirable for the surgeon

to apply the plaster of paris after operation, but frequently this was impossible,

and it had to be applied by enlisted technicians under his supervision. After

several months’ experience in this work, these enlisted men became extremely

proficient and were able to change casts, as well as apply them, under the supervision of medical officers, thus saving great deal of professional time and

effort for other purposes.

The ideal arrangement was the assignment of technicians specifically for

these duties, but such arrangements were often accomplished after considerable

delay and much argument. In one general hospital, for instance, which served

as transit hospital at D-day, the orthopedic staff consisted of chief of section,

an assistant chief whose only orthopedic experience was year in the Army,

and three ward officers with no orthopedic training at all. The enlisted

assistants were supposed to be any of the several men assigned to the operating

room who happened to be available when the need for plaster arose. It was

with the greatest reluctance that an enlisted man was finally assigned for fulltime duty in the plaster room and was given an assistant who could be called

upon when necessary. This reluctance soon disappeared before the weight

of facts, and eventually five men were assigned full time to plaster duty in

this particular hospital.

The most efficient arrangement was to assign enlisted men to the plaster

room—3 to be on duty from a. m. to p. m. and to be on duty from p. m.
TRAINING OF PERSONNEL 39

until the day’s work was completed. It was sometimes necessary for them to

remain on duty until a. m. This arrangement permitted an overlap of

personnel during the afternoon, when the work was likely to be heaviest, and

provided technicians around the clock. It also established good working relationship between the day and night hospital staff.

When men assigned to plaster work were not applying casts or changing

them, they prepared supplies and kept abreast of the daily heavy needs. The

best plan was to put single man in charge of the preparation of plaster bandages, though when casualties were heavy this arrangement was not always

practical. Enlisted men assigned to plaster work frequently also took care

of the braceshop and the preparation of external appliances for shoes. This

was not as desirable an arrangement as having trained craftsmen in charge of

this work, but it served the purpose when they were not available.

Professional Conferences

It was strongly recommended that each hospital set up some type of

professional meeting or conference at which all orthopedic problems could be

discussed and policies of management could be clarified and modified. Theoretically, and under the conditions which existed, there was no better way to

improve the work of general surgeons and of others not trained in orthopedic

surgery. The presentation and discussion of special cases were particularly

valuable. This method, however, was not as practical as it might seem on the

surface. Before D-day, when there was ample time to hold such meetings,

the orthopedic material was not available. After D-day, when casualties

were heavy and surgeons often had to work on long day or night shifts and

sometimes around the clock, there was no time for such meetings. Finally,

when the hospital was not receiving patients, it was difficult to arouse interest

in any sort of professional meeting among medical officers who were tired and

needed rest.

Between D-day and V-E Day, three formal conferences were held with

the British and Canadian consultant staffs, and similar conferences were held

with the French and Belgian medical services. The personnel in attendance

included both civilian and military authorities of high rank. There was always,

in addition to formal exchanges, free interchange of ideas and professional

techniques between the American and other Allied forces, with great advantage

to both.

meeting of the junior consultants in orthopedic surgery in the United

Kingdom was held in London in December 1944, and second meeting was

held in June 1945. meeting of the junior consultants serving on the Continent was held in Paris in June 1945.

These meetings, like all the others, were in effect training sessions. Clinical, administrative, and associated problems were discussed and clarified, and

the exchange of experiences proved extremely profitable.

41

CHAPTER IV

Hospital Facilities and Orthopedic Equipment

Hospital Facilities

Bed capacity.—Orthopedic sections of general and station hospitals

occupied, on the average, about third of the total bed space. This was in line

with realities. Bone and joint injuries constituted from 35 to 40 percent of

all battle-incurred injuries and also constituted the major number of nonbattle

injuries.

Allotments varied from hospital to hospital, as well as from time to time

within the same hospital. The 217th General Hospital, for instance, when it

served as 1,000-bed transit hospital, set aside ward buildings, each containing

40 beds, for casualties with bone and joint injuries. When it moved to the

Continent, it occupied the Hopital de la Pitie in Paris, large city hospital with

capacity of about 1,500beds. surgical pavilion contained large operating

rooms and other facilities. The orthopedic section was assigned the second

floors of each of buildings, each floor consisting of wards. The total bed

assignment was 403, and this number could be expanded to 550 during periods

of stress, by placing the cots in corridors and elsewhere.

At Commercy, France, the 50th General Hospital occupied an old 3-story

barracks, in which it could house as many as 460 orthopedic patients at one

time.

Tented hospitals sometimes had to serve as fixed hospitals on the Continent, and during the spring, summer, and early fall, these arrangements were

generally satisfactory. During the incredible mud of late fall and early winter,

buildings with solid floors and modern heating were distinctly better for men

with bone and joint injuries, even though itrequired longer haul to get them

there.

Tented hospitals, while satisfactory for this purpose, did not lend themselves as well as conventional buildings to the definitive treatment offractures of

the long bones, which require Balkan frames for satisfactory skeletal traction.

As far as possible, their use was limited to prisoners of war.

The bed capacity of tent was about half that of an ordinary ward, and

there were several other disadvantages. One was the difficulty of moving the

portable X-ray machine. Another was the darkness of the tent, which required

artificial light around the clock. This made for monotonous existence and

had depressing effect on the soldiers’ morale. Nonetheless, when it was

necessary, Balkan frame could be shortened at the head of the bed to meet the

sloping tent roof, and concrete floors could be provided to give stability for

both the fracture setup and the making of roentgenograms.
42 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Location of space.—The location of the space assigned to orthopedic

surgery was not always convenient, especially in hospitals in which it was the

practice to locate septic wards immediately adjacent to the operating rooms.

The orthopedic wards were often at considerable distance from the operating

facilities and from the X-ray facilities.

Sometimes these inconveniences were unavoidable. At other times they

could be attributed to failure to grasp the realities of military surgery. Some

commanding officers and some chiefs of surgical sections were slow to appreciate

the magnitude of the trauma sustained by the extremities and spine by men in

training, to say nothing of the greatly increased volume of bone and joint in- juries which could be expected when combat began. As time passed and lessons

were learned by experience, most of these difficulties were smoothed out, though until the end of the war some chiefs of surgical services did not realize

the importance of segregating fractures from general surgical cases and placing

them in the charge of special personnel.

It was always great convenience to have the plaster room located near the

operating room, though this advantage was canceled out when its supervision

was put into the hands of operating-room personnel rather than those of trained

orthopedic personnel.

When orthopedic facilities were set up in buildings which had not been

constructed primarily for hospital purposes or in which space had not been adapted and fitted for orthopedic use, plaster facilities were frequently inadequate. The experience of the 217th General Hospital is an illustration. When

it served as transit hospital after D-day, the plaster room, which measured 10

by 20 feet, was off the main operating room and had been set up for minor

surgical procedures. It therefore had no plaster sink, and the water supply and

drainage were both entirely inadequate. Storage space was also insufficient,

and it was impossible to provide backlog of plaster bandages and other

supplies.

Equipment and Supplies

United Kingdom hospitals.—Most hospitals and hospital centers in the

United Kingdom were furnished with combination of British and American

orthopedic supplies. The 68th General Hospital, for instance, was located close

to British orthopedic hospital and secured from it many items not obtainable

in United States Army issue. At the 217th General Hospital, when it served

as 1,000-bed transit hospital, all orthopedic wards were equipped with British

fracture beds with segmented mattresses and with single bar overhead frames.

On the other hand, some centers, such as the 802d Center in the Blandford

area, England, had full United States Army table-of-equipment supplies,

including orthopedic beds, Balkan frames, fracture tables, full supplies of surgical instruments, and many nonstandardized items. Work in such center

was naturally facilitated, but it was still possible to do excellent orthopedic

work with less complete equipment.
HOSPITAL FACILITIES AND EQUIPMENT 43

Numerous desirable orthopedic items were missing from the standard

equipment of general hospitals, such as curved osteotomes, stainless-steel brads,

bone nails, bone punches, stainless-steel rules, and suture wire for tendon repair.

The drill points supplied did not contain sufficient variety of small points.

Metal hammers of suitable weight were not available, and the wooden hammers

provided did not stand up under repeated sterilization. Smith-Petersen nails

were available but only in sizes smaller than those generally used. Nails

measuring 4, 4}i, 4%, 4%, and inches should also have been provided.

These deficiencies, as in the case of larger items of equipment, did not prevent the performance of high-quality orthopedic work. The items listed were

needed only in general hospitals in the United Kingdom Base, where definitive

orthopedic surgery was done. Medical supply did an extremely good job

throughout the war in furnishing promptly all reasonable and necessary supplies. It would be unreasonable to expect many of the special items listed to be carried as standard supply items in an overseas theater.

There were occasional instances of insufficient supplies and procrastination

before D-day. In one hospital in the United Kingdom, for instance, it took

constant prodding of the medical-supply officer to obtain anything like the

proper amount of orthopedic supplies. Eventually, 1,500rolls of sheet wadding

and 1,000 rolls of plaster bandage were obtained, but ambulatory patients had

to be used to help the personnel of the plaster room get the supplies ready in

time. Enough orthopedic instruments were finally obtained after hunt

through medical supplies, but the Scanlon Morris fracture table was not obtained until the day after D-day. This was, however, an isolated instance.

For the most part, supplies were ample for the work which had to be done.

Col. (later Maj. Gen.) S. B. Hays, MC, after his assignment as Chief, Supply

Division, Office of the Theater Chief Surgeon, did splendid job of procuring

and distributing needed orthopedic supplies throughout the war in Europe.

Supply difficulties sometimes arose when hospitals were shifted from their

assigned function, as was sometimes necessary just after D-day. The 68th

General Hospital, for instance, did the work of an evacuation hospital for

number of weeks. general hospital is equipped to handle only certain

number of surgical patients and is not equipped for unlimited emergency surgery. When the population in this hospital suddenly became 90-percent surgical

and most of the operations were urgent, there were not sufficient sterile supplies

and not enough laundry facilities to take care of the large turnover in the operating room. As result, some debridements had to be delayed longer than was

desirable, though the results indicated that very little real harm had been done

by the prolonged timelag.

Hospitals on the Continent.—The equipment of fixed hospitals on the

Continent, while usually adequate, was seldom equal to that of hospitals in the

United Kingdom. Hospitals in the British Isles almost invariably had modern

American fracture tables. Those which crossed the channel had only the

Army type of portable fracture table, which left much to be desired.
44 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Every hospital on the Continent required multiple supply of fracture

tables, and all of them were frequently in use at the same time for the application of plaster. It was uncommon, in an evacuation hospital, for at least one

fracture table not to be in continuous use around the clock.

Plaster

The most universally useful roll of plaster was inches wide and 4% yards long. Plaster reinforcements were made of individual layers of plasterimpregnated crinoline, inches wide and feet long. These were folded in

squares and stored in paper wrappings. The most satisfactory mesh was

American No. 11 gage crinoline, which corresponded to the British No. 14 gage

muslin.

As far as possible, all plaster supplies were kept in dry storage, with the

rolls wrapped in paper. Lukewarm water was used for soaking the plaster

before it was applied.

Braces and Arch Supports

As rule, the 1,000-bed general hospitals sent to theEuropean theaterhad

few or no facilities for making braces, arch supports, and minor adjustments to

shoes. With few exceptions, patients wdio required braces had to be returned

to the Zone of Interior.

At first, the provisions for arch supports and for making minor adjustments

to shoes were extremely haphazard. Before D-day, there was no provision at

all in Army general hospitals for arch supports, Army issue, which few noncombatant soldiers required.

These supports were chiefly for the use of the troops in the London area.

Combat troops seldom required them; soldier who needed one, in fact, did not

belong in combat unit. considerable number of these supports, which were

satisfactory and ell made, were obtained by purchase from British civilian

sources. Each transaction was an individual one and was usually conducted

through one of the United States dispensaries in London. This did not wholly

solve the problem, for shortages of leather and labor made it impossible to rely

entirely upon the British for these and other orthopedic supplies. An occasional hospital solved the problem as did the 68th General Hospital, which took

part of the wards originally assigned to venereal disease and converted the space

into four excellent plaster rooms, with an adjoining shoe and brace shop. This hospital could thus care for orthopedic shoe prescriptions and for arch corrections on the post without delay.

The disciplinary center at SheptonMallett, England, had among its officers

young man who in civil life had run successful chain of shoe-repair shops

in Florida. It was possible to work out with this officer plan for utilizing

labor of imprisoned United States soldiers to repair shoes and make prescribed

adjustments. As far as shoe repairs were concerned, this arrangement was

fairly satisfactory. On the other hand, the arch supports provided on pre-
HOSPITAL FACILITIES AND EQUIPMENT 45

scription left much to be desired. An incidental result of this plan was the

good effect on the morale of the prisoners, through their feeling that, in spite

of their incarceration, they were still contributing to the war effort.

While hospitals were static in the United Kingdom and the number of

patients was relatively small, these improvised arrangements worked out satisfactorily. Later, as the number of troops increased and soldiers were moved to

the Continent and widely dispersed, other and more elaborate plans had to be

worked out. Prefabricated leather and sponge-rubber arch supports began to

arrive in the theater and became available through Army medical supply channels early in January 1945. At first, only the 10th General Dispensary in London and the 9th General Dispensary in Paris were authorized to stock these

items. As supplies increased, distribution was widened, and eventually certain

authorized hospitals and general dispensaries stocked specified levels which

could be replaced on requisition. When it was practical, patients were sent to

these hospitals for fitting. When it was not, supports were requisitioned.

Final arrangements for orthopedic corrective devices were not made until the

spring of 1945, and it is not known how effective they were, in view of the constant deployment and shifting of units after V-E Day. If there had been any

degree of stability, the new arrangements should have been satisfactory.

Whenever possible, quartermaster shoe-repair units and local shoemakers

were used to make minor shoe adjustments. special graphic, bilingual order

form for French shoemakers was devised by the Chief Quartermaster, European

Theater of Operations, and the senior consultant in orthopedic surgery and

proved very satisfactory.

Improvised Equipment

At number of the hospitals in the European Theater of Operations,

good deal of ingenuity was shown in the construction of special devices, frequently

out of salvaged material, for the care of casualties with bone and jointinjuries.

Several devices of this kind were made and employed at the 22d General Hospital in the 802d Hospital Center by Lt. Col. Thomas B. Quigley, MC, Maj.

Marshall R. Urist, MC, and Capt. Lincoln Ries, MC.

Plaster traction splint.—The plaster traction splint for compound comminuted fractures of the tibia and fibula was devised at the 22d General Hospital

in Blandford, England, and tested there and at the 97th General Hospital in

England and on the Continent, between May 1944 and December 1945. It was

constructed and employed as follows (figs. through 6):

plaster cylinder, padded with felt in the upper thigh and the popliteal

and malleolarregions, was applied from the groin to the ankle while the knee and

hip were flexed 45 degrees. U-shaped wire hoops, fashioned from No. 12 iron

wire or any other available metal, were incorporated in the plaster at the midthigh and the malleolus in such manner that the closed portion encircled the

lateral and posterior aspects of the leg (figs. and 3). Two similar wire hoops,

or single heavier metal hoop, were incorporated in the same manner in the
46 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

in. ROLL SHEET

WADDING FELT CUFF FOR THIGH WIRE

HANGER FOR THIGH

FIXATION

•-WIRE 4in. PLASTER OF

FELT ANKLE PAD PARIS BANDAGE FELT KNEE PAD WIRE HANGERS FOR KNEE

PULLEY

WIRE FOR FIXING THE

DESIRED ANGLE OF THE

PIERSON ATTACHMENT

PIERSON ATTACHMENT,

THOMAS SPLINT

in. PLASTER OF

PARIS BANDAGE joR VIEW OF

COMPLETED SPLINT

Figure 2.-—Materials required for construction of plaster traction splint for compound

fractures of tibia and fibula with interior view, from above, of assembled splint.

They include:

Four pieces of heavy wire, }i-inch gage, each 20 inches long, bent into the shape of U,

to fit about the posterior aspect of the cast at, respectively, the middle third of the thigh,

the tibial tubercle, and the leg, inch above the ankle joint. One or two wires were used at

the knee, to provide strong fitting for the Pierson attachment. The ends of the wires were

turned into loops, so that they could serve as hangers for suspending the completed splint in

Balkan frame.

Three felt pads, suitably cut to encircle the upper third of the thigh under the plaster

cuff, to fit the popliteal space and cover the tibial tuberosities, and to fit the posterior aspect

of the lower third of the leg.

standard Army Pierson attachment.

Six rolls of 4-inch plaster-of-paris bandage.

Four rolls of 6-inch plaster-of-paris bandage.

Three rolls of 3-inch sheet wadding.

Cramer wire ladder splint (fig. 4) used as frame for the foot support.

plaster at the knee. Pierson attachment, with pulley fastened to the crossbar, was placed over the leg in the sagittal plane and clamped in place to the

hoops at the knee (figs. and 3). The ends of the wire at the malleolar level

were wound about the Pierson attachment. The anterior portion of the cast

was cut away between the open ends of the hoops from the superior pole of the

patella to the ankle. If access to soft-tissue wounds was necessary, windows

were also cut on the posterior and lateral aspects of the cast.

suitable weight was attached and traction was applied, with the leg

suspended in Balkan frame (figs. and 5). The foot was supported by

stockinet or moleskin sling fastened to Cramer wire which was attached to the
HOSPITAL FACILITIES AND EQUIPMENT 47

long bars of the Pierson attachment. When minor corrections in alinement

were necessary, the distal fragment could be moved up to 10 degrees in the

sagittal or coronal planes by shifting the pulley from side to side and elevating

or lowering the end of the Pierson attachment.

Overhead suspension was continued during the first weeks of healing or as

long as nursing care, including the bath and the use of the bedpan, were painful.

It was then discontinued, and the patient was allowed more freedom in bed.

At the end of to weeks, when movement had ceased to be painful, he could

be up in wheelchair (fig. 6). At the end of weeks, when callus formation

was usually adequate and the fracture site had become sufficiently stable,

traction was discontinued, and long leg cast was substituted for the original

cast. Ambulation on crutches was then instituted as rapidly as possible.

The efficiency of this plaster traction splint was tested, as already noted,

under military circumstances in the 22d United States General Hospital in

England and the 97th General Hospital in England and on the Continent

between May 1944 and December 1945, on 65 battle-incurred fractures of the

tibia and fibula in 63 patients, and in 11 simple and compound comminuted

fractures of the same bones which were sustained accidentally. During the

early months of this period an approximately equal number of similar fractures, which served, in effect, as control series, were treated in the BohlerBraun splint or in the Thomas splint with Pierson attachment. The comFigure 3.—Mechanism of action with splint in traction obtained through Pierson

attachment incorporated in long leg plaster cast. The countertraction is mainly from hoop

to which the Pierson attachment is clamped at right angles, and also, but slightly, from the

ventral aspect of the cast around the thigh.

Urist, M. R.; Ries, L.; and Quigley, T. B.: Plaster Traction Splint for Compound Comminuted Fractures

of the Tibia and Fibula. Surgery 23: 801-805, 1948,
48 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

DETAILS OF CONSTRUCTION

OF THE KNEE JOINT SECTION

REARRANGEMENT OF THE FOOT SUPPORT RENDERS IMMOBILIZED LEG PORTABLE

Figure 4. Diagrammatic showing of method of suspension of splint and use of trapeze

by which patient can lift himself off bed and aid in his own nursing care Details of construction of the knee-joint section are shown in lower left insert. Method of mobilizing splint and

adding foot support is shown in lower right insert.
HOSPITAL FACILITIES AND EQUIPMENT 49

Figure 5.—Ward at 22d General Hospital showing battle casualties recently evacuated

from Germany put up in plaster traction splints to maintain reduction of compound comminuted fractures of both bones of leg.

bination splint was at first used only tentatively, but as its advantages became

apparent it was used more frequently.

The combination splint was found to compare very favorably with the

classical traction splint from the standpoint of providing skeletal traction and

securing immobilization of the fractures in plaster. It was also found to

possess several additional advantages:

1. It furnished better protection for the reduced fractures.

2. It made movement less painful during the early days of healing.

3. It eliminated the uncomfortable counterpressure of the ischial ring of

the Thomas splint.

4. It also eliminated the painful play at the fracture site permitted by the

Bohler-Braun frame.

5. It did not require the time-consuming, continuous, expert attention

necessary when the Thomas splint with Pierson attachment was used. This

was particular advantage when heavy casualties had been received and

experienced personnel were in short supply.

6. The combination splint proved of great usefulness in patients received

more than to 12 hours after injury, when internal fixation was contraindicated

by the risk of infection or when extensively comminuted fractures of the shaft

of the tibia would have required undesirable dissection of the whole leg for the

safe application of plates and screws.

372572°—56
50 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 6.—Patients in traction splints after overhead suspension has been discontinued,

Traction cradle.—At the 22d General Hospital in England, the use of

an improved Bohler-Braun type of traction cradle, for the management of

battle-incurred undisplaced or incomplete fractures, was found to have several

advantages. This cradle permitted easy access to the compounding wound.

Alinement of the bone fragments was maintained. The patient could be

transported from the ward to the operating room with ease and safety. Most

important, the atrophy which was often extreme in limbs treated in plaster

was minimized by this type of open immobilization, which permitted exercise

of muscles of the uninjured segments of the extremity.

The cradle was fashioned (figs. and 8) of packing box, into the top of

which trough had been built. The felt padding which covered the top of

the box was covered with surgical oiled silk. An adjustable thigh support was

attached to the top of the box at one end by means of hinges and wire stanchion. The angle between the end of the box and the thigh support was adjusted to the plane which provided maximum comfort for the knee; the angle

varied with the stature of the patient. The box was supported in bed by

transverse base extension made of basswood splint. slot in the side of the

box allowed for the insertion of an X-ray cassette for portable roentgenograms

to be taken.

This cradle proved simple to construct and provided maximum comfort

for the patient. It was suitable for use with skeletal or skin traction and also

was useful simply as support for the bony and soft parts of the leg. When

it was used with traction, adjustments of the position of the pulley and weight,

and the use of crossbar of the Balkan frame, permitted alinement of minor

anteroposterior and mediolateral angulation.

Revolving orthopedic frames.—Compound fractures of the hip joint

and pelvis were always, in themselves, serious orthopedic problems. They
HOSPITAL FACILITIES AND EQUIPMENT 51

Figure 7.—Details of construction of Bohler-Braun type of traction cradle made from

|)j| ordinary packing box.

Figure 8.—Management of compound fractures of both bones of leg in improvised

traction cradle.
52 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

wore considerably more serious when, as often happened, they were associated

with injuries of the genitourinary and gastrointestinal tracts. These injuries

required suprapubic cystost omy or colostomy or, occasionally, both, and

nursing care was extremely complicated, since the orthopedic injuries required

complete immobilization for several months in plaster-of-paris spica. The

most careful precautions often did not prevent the development of decubitus

ulcers over the sacrum. The situation was also difficult one for the physiotherapist.

One solution of these problems at the 22d General Hospital was the construction of wooden frame (fig. 9), which reenforced the plaster spica or

plaster bed and compensated for the weakening caused by the large windows

that had to be cut into it, to allow care of the bladder and intestinal wounds.

This frame supported the patient on an inclined plane, with his hips above the

level of his thorax, position which eliminated pressure on wounds of the

buttocks and sacrum. When he was turned from the recumbent to the lateral

or prone position, as was usually done in such cases at hourly intervals, attendants could easily lift and rotate both frame and patient 90 or 180 degrees

as was desired (fig. 10).

Other frames devised at the 22d General Hospital not only reenforced

fenestrated plaster-of-paris casts but also turned the patient. They could be

constructed from the salvage material available at any Army Ordnance depot.

The principles of both the Bradford and the Stryker frame were employed in

their construction.

Figure 9. —Improvised frame used to suspend and reenforce plaster cast with multiple

windows.

M. Sgt. Robert Ferguson, Army Ordnance Department, assisted in the construction of these frames.
HOSPITAL FACILITIES AND EQUIPMENT 53

Figure 10.—Cast in frame. Patient has been turned to relieve pressure on hip wound and on

colostomy.

In one type of revolving Bradford frame, the boiler-plate rims rolled in

tracks on ball bearings (fig. 11). One nurse or other attendant could turn the

patient 90 or ISO degrees simply by removing the wing nut and turning the

hinge-locking device, so that the rims could revolve. When revolving twin

Bradford frame was indicated, an apparatus could be constructed (fig. 12) in

which, by means of worm gear, turn of 360 degrees coidd be accomplished.

In the frame shown, the self-locking worm gear was made from the elevating

mechanism of salvaged 75-mm. gun which has 40:1 gear ratio, making

360-degree turn possible. The rod for the base consisted ofK-inch by 1%-inch cold mild steel with %-inch rod for the base. The basswood splint was

provided for additional fixation.

Devices such as these greatly facilitated the care of the patient and saved

time and effort for nurses and corpsmen, who were almost always overworked.

The usefulness of these frames was not limited to compound fractures of the

hip joint and pelvis. They were also useful in injuries of the spine, in paraplegia, and in any other condition in which it was necessary to change the

position on regular schedule. The patient was simply sandwiched between

two full-length sheets of canvas which were laced to the frames. It was also

possible, when plaster of paris was not required, to attach self-retained

extension apparatus to the head rim and equip it with pulley. When traction

was required, this was convenient method of caring for patient with

fracture of the cervical spine who was being treated by Crutchfield tongs.

One patient was evacuated to the Zone of Interior in revolving Bradford

frame which was bolted to litter.
54 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 11.—Improvised revolving Bradford frame.

Figure 12.—Improvised revolving Bradford twin frame with patient in fenestrated bilateral

hip spica.
55

CHAPTER

Mass Management of Casualties With Bone

and Joint Injuries

Methods of mass management of casualties depended upon the type and

mission of the particular hospital, the kind of injuries to be handled, and the

size of the casualty load, as well as upon the cumulative experience of the staff.

In evacuation hospitals, no segregation was attempted, other than the assignment of priorities according to the necessities of the special cases. Patients

with severe abdominal, chest, and vascular injuries seldom reached evacuation

hospitals. As rule, they were diverted to field hospitals, to which patients

with only bone and joint injuries were seldom sent unless they were in state

of shock or had associated injuries which required immediate attention. The

principal function of evacuation hospitals was the performance of initial wound

surgery (debridement), which was essentially the same for all patients received

in them.

When peak loads were being handled, regardless of the type of hospital, as

many operating teams as were available worked at the same time. Surgical

efficiency was greatest when shifts could be limited to 12 hours, but in times of

stress both temporal and physical limitations frequently had to be exceeded.

Transit Hospitals

Adjacent to ports of embarkation for the invasion of the Continent were

about dozen hospitals designated as transit hospitals. They consisted, for

the most part, of station hospitals, though few general hospitals were included.

The mission of these hospitals was triage of returning wounded and the performance of such emergency surgery as had not been done on the far shore or

on returning landing ships, tank (LST’s), and other ships. For all practical

purposes, these transit hospitals functioned as evacuation hospitals. Only

those patients were held who could not be safely evacuated. Patients who

could be evacuated were sent, as rapidly as possible, to general and station

hospitals farther north. As evacuation hospitals were set up on the Continent,

these transit hospitals reverted to their regular status. Many of them later

moved to the Continent themselves and were replaced by units more recently

arrived from the Zone of Interior.

The report of the 217th General Hospital is cited as typical of the organization and work of general hospital which served as transit hospital during

this period. The original plan was that this hospital receive casualties soon

after injury. They were to be transported from the far shore by air and

brought to the hospital from an airfield miles away. At this airfield, field

hospital had been set up for the direct reception and care of any emergencies
56 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

that might have arisen in transit. With these exceptions, the patients were to

receive initial treatment at the transit hospital. Then, if they were transportable, they were to be taken within 48 hours to general hospital, where they

would be retained. This general hospital, while it served as transit hospital,

was thus to act essentially as an evacuation hospital.

The first patients with bone and joint injuries to arrive at the 217th

General Hospital after the initial assault on the Normandy beaches were

received in the afternoon of D-day. Five transport pilots were admitted with

compound fractures caused by small-arms fire as they had gone in low to drop

supplies to paratroopers. paratrooper was also admitted who had fractured

his ankle when struck by the door load during evasive action of the plane over

the drop zone.

The next casualties with bone and joint injuries arrived on the afternoon

of D-day plus 4. They were mixed group of 20 wounded, consisting of

American officers and men, French civilian, some Gorman prisoners of war, and several Mongolian-Russian slave laborers. Thereafter, patients arrived

daily in increasing numbers until, in July, the maximum received in single day

from the airfield was 740. Air evacuation from the far shore had begun to

function within week of the landing on June.

The transportability of the patients received at the 217th General Hospital

varied according to the severity of their injuries and the treatment they had

previously received. Some had received thorough surgical care on thefar shore

and were immediately transportable. Others arrived wearing their original

field dressings. The untreated patients had usually been injured from 24 to

36 hours before their arrival, but it was entirely possible, and by no means

infrequent, to receive patients who had been wounded in France on the same

day on which they were injured. These variations were caused by differences

in the number of hospitals available near the front, the casualty load in these

hospitals, and the proximity of air evacuation strips to the frontline.

Most transit hospitals, like the 217th General Hospital, received only

few patients in the first day or two after D-day, and for the next few days

received only limited number of seriously wounded patients. At the 38th

Station Hospital, for instance, only of the 107 patients received June were

severely wounded. Most of the chest and abdominal injuries were apparently

being cared for on the beachhead by field-hospital platoons whose normal staffs

were augmented by surgical teams from auxiliary surgical groups.

The pace in the transit hospitals then began to step up. The 110th Station

Hospital received 1,000 patients in 20-hour period June. By 12 June most

of the transit hospitals were fully occupied. As rule, between 250 and 500

patients were received in each convoy, with the percentage of urgent surgical

cases varying according to the proportions of walking wounded and litter

patients.

The average stay at the transit hospitals was 36 hours or even less, which

was well within the 48-hour maximum planned. Wounded were evacuated by
CASUALTIES WITH BONE AND JOINT INJURIES 57

hospital trains to the general and station hospitals farther inland, most of which

were fully engaged by weeks after D-day.

Routine of Management

The management of casualties with bone and joint injuries received in

moderately large to large numbers at transit hospital was often as follows:

Triage was conducted in the admitting section for all patients. Those

whose wounds had already been debrided and immobilized, and who were in

obviously good condition, were sent to medical ward, not to an active orthopedic ward. The other patients were sent to single orthopedic ward which

had previously been designated by the chief of section, and, when it was filled, to another ward intended to take care of any overflow. All the beds in these

wards were empty, except for occasional nonevacuable patients who had been

moved to one end of the ward.

The dressing cart was in the center of the ward, with the plasma units

already open. The traction cart was available. table was conveniently set

up with request forms for X-ray examinations and laboratory tests. Additional nursing and other personnel had been assembled for the care of the

patients, including two litter teams for taking patients to the X-ray department and the operating rooms. Finally, the kitchens had been warned of the

need for extra food, some of which had been brought to the ward. As soon as

patients began to arrive, additional workers were sent to the designated wards,

including physical therapist, Red Cross worker, and an enlisted man ordinarily assigned to the orthopedic clinic.

The advantage of admitting all casualties with bone and joint injuries to

single ward or to two adjunct wards at the same time was twofold;

1. The other wards were kept free of the movement of patients.

2. The fact that the recently arrived patients were all in one place, with all

necessary facilities at hand, facilitated their examination by the chief of section

and the ward officers.

As soon as each patient was put to bed, his pulse, temperature, and blood

pressure were taken and recorded. He was also given sulfadiazine (2 gin.).

X-ray and laboratory blanks were filled in with his name, serial number, and

other necessary information, and the hospital number was filled in on the 55C

record form. By the time this was done, the patients had been allotted in

groups of or to the medical officers on the orthopedic service.

brief history of each case was taken. complete examination was made,

exclusive of the wound, and the findings were recorded. As soon as these details

had been completed, the patient was presented to the chief of service and the

ward officer, who made whatever additional examinations were necessary and

decided what laboratory work and X-ray examinations were required. Finally,

tentative plan of treatment was formulated.

Patients who needed emergency care or who were to be operated on were

designated by pieces of red flannel, pinned conspicuously to the bed covering
58 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

on their beds. Patients who did not need surgery were given hot drinks and

sandwiches at once.

The first patients who were examined and who required surgery were sent

to the operating room and cared for there by designated officers from the

orthopedic section. When all patients had been examined and evaluated, the

chief of service and the ward officer themselves went to the operating room to

continue the necessary surgery.

Wounds were not uncovered on the wards. They were first uncovered

under sterile conditions in the preparation room, where an enlisted technician,

in cap and mask, made sterile preparation of the wound, after anesthesia had

been induced. Preparation before induction of anesthesia would have been too

painful. The entire procedure was repeated in the operating room by the

surgeon after lie had prepared his hands. The skin was then prepared chemically by an instrumental technique. The wound was draped and the operation

started after the surgeon and assistant had rescrubbed their hands and put on

gowns and gloves.

Most of the extremity wounds which required operation at transit hospitals

were managed by wound excision or debridement, with the application ofplaster

of paris.

The patients who were operated on, depending upon their number, were

put on one or two wards, where they could be easily kept under observation by

experienced medical officers and nurses. The ward officer on the designated

wards might well operate the entire night, but for the next day or two he would

be assured of no admissions.

Finally, 48 hours after the reception of the first patients, the ward was

emptied in mass movement, beds were made up, and facilities were again

prepared to receive fresh patients.

General Hospitals

The United Kingdom, owing to the stability of its hospital sites, was

designated as base center after the invasion of the Continent. In addition

to the general hospitals which operated in it, seven hospital centers had been

set up, each one under its own commanding officer. This arrangement was

notable step in increasing the efficiency and improving the results of professional care, and it also resulted in significant saving in orthopedic personnel.

The routine of management of mass casualties in general hospitals and

hospital centers varied from installation to installation. The important consideration was that some general plan of management be set up. At the 803d Hospital Center, the following routine was found efficient:

Casualties arrived at this hospital center by ambulance or hospital train,

after having been brought from the Continent by air or boat and having spent

24 hours or more in transit hospital, before being distributed to various installations in the United Kingdom.
CASUALTIES WITH BONE AND JOINT INJURIES 59

As soon as they arrived, they were subjected to triage by the chief of the

surgical service, assisted by the chief of the orthopedic section. It was thus

determined immediately what types of injuries had to be dealt with and which

wounds required priority of treatment. These were matters of great practical

importance when 200 to 300 patients were received at the same time.

The patients were first divided into three groups; (1) Those who needed

immediate attention; (2) those who could wait brief period for treatment; and

(3) those whose wounds were not urgent at all.

Patients were next segregated according to type of injury. Those with

fractures of the long bones were sent to wards equipped with facilities for

traction. Those who had undergone amputation and those with hand injuries

were sent to special wards designated for the management of those injuries.

Those with multiple injuries, whose condition was more or less critical, were sent

to the shock ward, which was equipped for the combined management of abdominal, chest, bone, and other injuries, in addition to the treatment of shock.

At the 802d Hospital Center, plan similar in principle but somewhat

different in detail was followed:

All casualties with bone and joint injuries were sent directly to the orthopedic section, unless other wounds required some departure from this practice.

Then, when the casts had been removed and the nature of the injury clearly

defined, the following channels of distribution or courses of treatment were

adopted;

1. Seriously injured men with compound fractures were sent to the orthopedic wards, which were equipped withBalkan frames, elaborate dressing carts,

and supplies which permitted wound management by scrupulous aseptic

technique. These wards were staffed by young medical officers who were on

24-hour call. As far as possible, the nurses most skilled in the care of orthopedic injuries were also assigned to them.

2. When skeletal traction was not required, the patients were transferred

in plaster casts to various other sections of the hospital, depending upon the

necessities of the case, such as the need for plastic surgery, neurosurgery, or

genitourinary surgery. The orthopedic surgeons followed the patients on these

wards and continued treatment at the convenience of the officer who was in

charge of the major problem.

Nerve injuries were always given priority of treatment whenever some

graver injury did not prevent it. Patients with injuries of the sciatic or other

major nerves were transferred, in the original plaster casts, to neurosurgical

center or to hospital equipped for neurosurgery, unless there was some contraindication or some necessity for further evaluation. Peripheral nerve surgery could be provided at two of the hospitals which made up the 802d Hospital

Center.

Certain plastic procedures had to be performed immediately. Exposed

tendons, for instance, had to be covered, and orthopedic management had to be

modified to suit the requirements of pedicle flaps.
60 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Patients with compound injuries of the hand were eventually transferred

to the hand-surgery section, but only after they had been studied on the orthopedic section.

3. Patients with injuries of the rectum and other injuries which required

colostomy were retained on the orthopedic wards, where their wounds were

treated by general surgeons. Whenever possible, patients with injuries of the

rectum were managed in special septic section, with special precautions against

infection.

4. Patients who did not require traction, plastic surgery, or other special

treatment and who were not acutely ill were immediately transferred to the

convalescent ward, where rehabilitation program could be pursued with the

elaborate facilities provided. From this section, they were transferred to convalescent centers, rehabilitation hospitals, or, in some instances, directly to

duty.

Each ward officer could usually care for total of 72 patients and was

likely to average 15 to 25 new patients with each mass admission. It was his

responsibility to see them all as soon as they entered the ward to determine

their priority for surgery; to evaluate their general condition; to observe them for possible complications, such as wound infection; and to continue the administration of penicillin or sulfonamide if it had already been begun. Otherwise, an order was written for the administration of one agent or the other.

After all patients had been distributed and examined, the chief of the

orthopedic section visited each ward in turn, examined each patient to check

the ward officer’s evaluation, and then made the operating-room schedule, listing the patients in the order of priority for surgery.

Each newly admitted patient who required surgery was taken to the operating room as soon as possible. In all general hospitals, there were complete facilities at hand for any indicated procedure. Three operating tables

were usually employed for orthopedic surgery. Each was set up with complete set of orthopedic instruments, as well as with sets of instruments for skin

grafting. Fracture tables, plaster of paris, full traction equipment, and portable X-ray equipment were also provided in the operating room. As rule, not more than orthopedic operations could be done at each table in the course

of the day, in the morning and in the afternoon. Ward officers worked in

the operating room either in the morning or in the afternoon, spending the rest

of the day in the care and supervision of the orthopedic patients on their wards.

Personnel assigned to each orthopedic operating table consisted of trained

orthopedic technicians, surgical technicians, sterile nurse, and circulating

nurse. As many shortcuts were employed as possible. Trained enlisted personnel performed the preliminary procedures, removing splints, preparing the surgical field, and frequently applying the plaster casts after operation.

When these men were well trained, as they usually were, and were adequately supervised, this system was perfectly satisfactory and saved great deal of

time for professional personnel.
CASUALTIES WITH BONE AND JOINT INJURIES 61

By the time patient had left the operating room, good deal had been

accomplished for him. Bones had been set in the best possible alinement and

were maintained in reduction by whatever method was indicated. If sepsis

was not present, the wound had been closed either by delayed primary closure

or skin graft, or by combination of these methods. Not infrequently, the

patient required no more active management of any kind until he was ready

to be evacuated to the Zone of Interior.

Under this or some similar scheme of management, if from 200 to 300

casualties were received at time, all of them could be operated on or otherwise

disposed of in about days.

Principles of Management

Whatever plan of mass management was followed in general hospital,

the principle of segregation of like cases was always followed whenever appropriate specialists were available. If they were not, there was no point in

separating the orthopedic service, even in name, from the general surgical

service. The best plan, in these circumstances, was to direct the patients who

required specialized care to centers in which trained orthopedic surgeons wore

available. This policy was quite generally followed, except in the occasional

instance in which commanding officer failed to recognize that orthopedic

surgery is quite as much specialty as neurosurgery or radiology.

Segregation had two great advantages, as follows:

1. It was of great aid to newly wounded man’s morale to be assigned

to ward in which patients with injuries similar to his own were being cared for.

newly admitted man with midthigh amputation, for instance, was much less

perturbed when cared for with 30 to 40 similar amputees and could see how well

they had already become adapted to their disability.

2. Ward officers assigned to special wards soon became skilled in handling

special types of injuries, even if they had had no particular training directed

toward this end in civilian life.

When mass admissions required the united effort of all hospital personnel,

it was particularly important that their potential capabilities be used to the

fullest possible extent. This principle was violated when trained orthopedic

surgeons were assigned to ward work instead of operating-room work; when the

chief of surgery made out the operating-room schedule without consultation

with the chief of the orthopedic section, who might not know what was being

done in his section, or by whom, until just before operation; and when ward

officers were assigned to work in teams, which often prevented them from assisting at operation on their own patients. In enlightened hospitals, these

practices were not followed. Ward officers were assigned in the operating

room to their own patients and were encouraged to follow them into the recovery wards, even though other officers were detailed to these wards. Even

in wartime, some semblance of physician-patient relationship could thus be

maintained.

63

CHAPTER VI

Management of Bone and Joint Injuries

in Prisoners of War

Prisoners of war who fell into Allied hands were always treated humanely

and according to the best Allied medical practices. They seldom, however, received first aid and initial wound surgery as promptly as Allied wounded.

This was to be expected, not onty because preference was naturally given to

Allied wounded but also because of the tactical situation. In all wars, prisoners

abandoned during retreat are always the most seriously wounded. The

high incidence of infection among prisoners was easily explained by the

usually unavoidable delays before initial wound surgery, combined, in many

instances, with the extremely serious character of their wounds.

Circular Letter No. 39, Office of the Chief Surgeon, European Theater of

Operations, May 1945 (see appendix A), directed that the Manual of Therapy, European Theater of Operations, and CircularLetters Nos. 71,15 May 1944; 101,

30 July 1944; 131, November 1944; and 23, 17 March 1945 should be made

available to captured German medical officers as guides for treatment, with the

understanding that when these officers were caring for protected prisoner personnel they would be permitted to practice such methods of their own as wore in

accord withreasonable medical care.

CircularLetter No. 39 directed that commanding officersofhospitals utilizing

the services of protected prisoner medical personnel should instruct German

medical officers that skeletal traction must be used in the treatment of fractures

of long bones and that wounds must be closed by suture, by skin graft, or both.

The reason for the regulation was that, in the hands of United States Army

medical officers, these methods had materially reduced the periods of hospitalization and of subsequent disability.

Equipment for the treatment of fractures of the long bones by skeletal

traction was, according to these directives, to be furnished to German medical

officers who were capable of using it. Simple illustrations demonstrating correct

techniques of fracture management in various locations (figs. 13 through

16) were prepared by Maj. Floyd H. Jergesen, MC, and distributed to these

officers. They were permitted to employ Steinmann pins or Kirschner wire,

but splints for external fixation, such as the Roger Anderson and the Haines

apparatus, were not distributed to them.

When skeletal traction was not employed in the management of compound

fractures of long bones, German medical officers were expected to employ

circular plaster-of-paris splints. If wounds could not be closed by delayed

primary suture, the closed plaster technique was to be employed.
64 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

ABTEILUNG FUER ORTHOPAEDISCHE CHIRURGIE

STRECKVERBAND OBERARMBRUCH

Figure 13.—Instructional charts prepared for use of German surgeons caring for protected

prisoner personnel. Technique of traction in fractures of humerus.

ABTEILUNG FUER ORTHOPAEDISCHE CHIRURGIE

STRECKVERBAND BRUCH DES DISTALEN TEILES DES OBERARMS

Figure 14.—Instructional charts prepared for use of German surgeons caring for protected

prisoner personnel. Technique of traction in fractures of lower humerus.
BONE AND JOINT INJURIES IN PRISONERS OF WAR 65

ABTEILUNG FUER ORTHOPAEDISCHE CHIRURGIE BRUCH DES OBERSCHENKEL’S

MIT WUNDEH NAHE DES KNIE’S UND ANWENDUNGSMETHODE DES STRECKVERBAND’S

Figure 15.—Instructional chart prepared for use of German surgeons caring for protected

prisoner personnel. Technique of traction in fractures of lower femur near knee joint.

ABTEILUNG FUER ORTHOPAEDISCHE CHIRURGIE

ANWENDUNGSMETHODE DES DRAHT STRECKVERBAND’S BEI UNTERSCHENKEL BRUCH

Figure 16.—Instructional chart prepared for use of German surgeons caring for protected

prisoner personnel. Technique of traction in fractures of bones of leg.

372572° 56——6
66 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

As practical matter, captured German medical officers served, as far as

possible, only as ward officers. This limitation was necessary because so many

of them were poorly trained. Internal fixation of compound fractures, bone

grafts, or pedicle grafts wore performed by United States Army medical officers.

At one of the large prisoner-of-war hospitals in Normandy, Major Jergesen

had some 2,000 compound fractures under treatment, and he himself did the

great bulk of the definitive surgery there. The prisoners of war could not be

evacuated, as could United States Army wounded, and Major Jergesen did the

work that would normally be done for American wounded in Zone of Interior

hospitals.

It was generally observed that German military surgeons, when placed in

charge of their own wounded, under Allied supervision, were inclined to advise

amputation with great frequency, in preference to making prolonged attempts

to clear up infection and close wounds, while employing skeletal traction to

stabilize fractures. If there was chance that badly infected limb could be

saved, they preferred to salvage it by the closed plaster method, even though it

meant prolonged suppuration.

The experience at the Hopital de la Pitie in Paris illustrates why careful

supervision of German military personnel was necessary. When the 217th

General Plospital took over this hospital in detachments, 29 August and

September 1944, it was filled almost to capacity with German wounded, who

had been left behind with medical officers, nurses, surgical technician,

and chaplain. Among the wounded were few American and British prisoners.

The incoming staff was impressed with the lack of cleanliness, which was, however, partly explained by the shortages of personnel during the preceding week

or two; the paper bandages; the wire ladder splints and metal trough splints,

which were widely used instead of more efficient traction; the overgenerous

use of morphine; the high incidence of osteomyelitis; and the large number of

amputees. In spite of the condition in which the Gorman wounded were found,

it was possible, by vigorous treatment, to get most of them ready within few

weeks for safe evacuation to hospitals designated for enemy wounded.

Penicillin.—Since penicillin was in constantly short supply throughout

the fighting in Europe, it was given to prisoners of war only when it was indicated to save life and limb, and not routinely, as it was given to Allied wounded

after it became available in the spring of 1944. Circular Letter No. 39 directed

that it was not to be issued to protected enemy medical personnel. It

instead, to be kept under the control of United States medical officers, and the

commanding officer of each hospital had to approve both the indication and

the dosage in every instance in which it was prescribed for prisoner of war.
67

CHAPTER VII

Representative Hospital Experiences

298th General Hospital

Pre-D-day experiences.—The 298th General Hospital, which began to

function 11 November 1942, at Frenchay Park near Bristol, was the third

general hospital to be established in England. Because it was located close

to major port on the west coast of England, it gained valuable experience

with battle casualties before D-day, which proved of great benefit in its later

work in France and Belgium, The patients first received were evacuated

from North Africa, Sicily, and Italy. During 1943, this hospital received 573

true battle casualties, over 50 percent of whom were patients with bone

and jointinjuries, chiefly fractures of the extremities requiring long-term treatment. About 80 percent of these patients were British, it being the policy

of the British to send to the 298th General Hospital the most seriously ill

patients from each hospital ship, because the proximity of the hospital to the

port eliminated the necessity of long trip by train or ambulance.

These patients required considerable attention and the exercise of keen

surgical judgment. They had been wounded on an average of to weeks

before their reception. Many had not had wound debridement within the

optimum time, and, as might be expected, the incidence of wound infection

and osteomyelitis was significantly higher than in battle casualties later treated

on the Continent. Penicillin was not then available, but all the patients had

received sulfonamide therapy. The plan of treatment, because of the timelag,

was chiefly to carry on with the closed plaster technique until the wound and

the fracture had healed. Every endeavor was made to improve the general

health of the patient during this time. Drainage operations were performed

as indicated, and the position of the bone fragments was improved whenever

that was possible. It was the opinion of the hospital staff at this time that the

closed plaster technique was of great value in the management of war wounds

and fractures and that plaster-of-paris casts served adequately for

transportation.

The nonmilitary experience of the 298th General Hospital can be taken

as typical of that of the general hospitals which served in the United Kingdom

before D-day. Before the invasion of the Continent, like most other hospitals

in Great Britain, it was performing station-hospital duty, that is, it was serving

the need of troops in training. During the year ending in May 1944, the

orthopedic section of this hospital treated approximately 2,300 patients with

civilian-type orthopedic conditions, chiefly fractures, dislocations and sprains,

arthritis, bursitis, cicatrices, osteochondritis, osteomyelitis, poliomyelitis,

synovitis, an occasional amputation, and some cases of frank psychoneurosis.
68 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

This type of work was sufficient to keep the orthopedic services of all the

hospitals busy. Aside from accidental injuries, chiefly from automobiles and

other mechanical equipment, most of the orthopedic material consisted of

patients with disability of the feet, back, and knees. The majority of these

complaints were among soldiers who were over age and who had other conditions

which made them unfit for actual combat duty. The difficulties of these

troops were for the most part problems in reassignment rather than actual

medical or surgical problems. Line officers hesitated, and often refused

outright, to reclassify them, with the result that the outpatient departments of

most hospitals had large clinics filled with soldiers who were seeking downgrading. These men really needed little treatment, though they occupied

great deal of professional time. They were referred to the clinic simply

because all combat units were endeavoring to streamline their personnel and

to obtain as physically perfect combat teams as possible.

All combat units were finally directed to follow Circular No. 96, 15 July 1943,

Headquarters, European Theater of Operations, paragraph 2, which emphasized

the necessity of trying to find places of limited duty with individual units

before men with so-called civilian-type disabilities were admitted to hospitals

for reassignment. All the hospitals in England were cluttered with such cases,

and many unwise elective operations (p. 185) were done in an endeavor to place

essentially unfit men on full-duty status. This proved an impossible task.

Post-D-day experiences.—When the 298th General Hospital was moved

to Cherbourg, France, where it operated from 27 July to 28 October 1944, it

supplied station and general hospital medical service to large numbers of troops

stationed in this port area. It also cared for many battle casualties and

acted as holding hospital for patients to be evacuated by hospital ship to

England. maximum of 30 days was allowed for the treatment of any case.

Orthopedic injuries included:

1. Acute non-combat-incurred injuries of the bone, joints, and soft tissues.

These were numerous, because many thousands of troops were working at the

port.

2. Minor battle-incurred wounds. Many lightly wounded battle casualties

were treated, with the objective of returning them directly to duty.

3. Serious battle-incurred injuries. Patients with this type of injury

were treated in large numbers before their evacuation to England.

4. Other war-connected injuries. Many patients were received who had

been wounded by mines left by the Germans or in the course of handling and

dismantling captured German ammunition.

From 20 November 1944 through May 1945, the 298th General Hospital

was stationed at Liege, in Belgium. Here the majority of patients admitted had battle-connected wounds and injuries. Most of them were received within

to days of primary debridement done in evacuation or field hospitals.

Particularly in December 1944 and January 1945, number of lightly and

See appendix A, p. 319.
REPRESENTATIVE HOSPITAL EXPERIENCES 69

moderately wounded patients were admitted because forward hospitals had

been too heavily loaded with more serious cases to receive them. The patients

required debridement as well as later, more definitive, surgery. Over the same

period, number of casualties were also received who had been wounded in

the immediate vicinity from aerial and buzz bombs (V-l type).

50th General Hospital

The 50th General Hospital, which had spent its time near Glasgow before

D-day, was moved to Utah Beach 15 July 1944 and bivouacked near Carentan,

France. At this time the front was not very far away, the beaches were close,

and the bridge into the town was being shelled by Germans. The hospital

did not become operational immediately. An orthopedic team, consisting of

the chief of the section, an assistant surgeon, surgical corpsmen, surgical

nurse, and nurse anesthetist, worked in the 41st Evacuation Hospital for

weeks, during the attack on Saint-L6, France.

When the 50th General Hospital became operational 15 August, the

orthopedic work was heavy and diversified. There were many injuries caused

by boobytraps and injuries on the beaches, as well as numerous serious automobile accidents, involving military as well as civilian personnel. German

prisoners of war with combat wounds of the extremities and long bones were

also treated. During this 3-month period, the hospital, which was 1,000-bed

installation, treated 1,206 casualties with bone and joint injuries, answered

820 orthopedic consultations, and treated 175 outpatients with bone and

joint conditions.

On 17 November 1944, the hospital moved to Commercy, France, and

second orthopedic team was placed on detached service at Morhange with the

30th Field Hospital. This installation was supporting armored units, and the

bone and joint injuries, while less numerous than previously, were extremely

severe and mutilating. When the main hospital again became operational

18 December 1944, the first patients received were about 300 Russian prisoners

of war who had been recaptured from the Germans by the Third United States

Army. They were in poor condition, and some were starving. There were

many fatalities in injuries of theknees, hips, and spine, alone or in combination,

in contrast to the usually low case fatality rate in bone and joint injuries

uncomplicated by other wounds.

217th General Hospital

When the 217th General Hospital, which was part of the 814th Hospital

Center, was in Paris, there were 590 admissions to the orthopedic service

during September 1944. At this time, the advance past Paris was moving

rapidly, and most of the injuries were the result of small-arms fire. The

percentage of untreated cases was high.
70 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

As the front moved away from Paris, patients began to be received by

hospital train and by air. There were 1,570 admissions to the orthopedic ward

in November and 2,042 in December. These numbers are exclusive of the

patients with bone and joint injuries admitted to other wards. From September through April, there were 8,211 admissions to the orthopedic section, of

which 5,172 were battle casualties. Included in this number were 408 patients

with fractures of the femur; 694 with fractures of the tibia, fibula, or both; 301

with fractures of the humerus; and 284 with fractures of the radius, the ulna, or

both. Two of the patients died, one of the uremic syndrome after blast

injury and the other of compound dislocation of the hip, with deep pelvic

infection and hemorrhage. Over the same period, 1,238 orthopedic consultations were answered. Some of the patients thus seen were later transferred to the orthopedic section for care.

Fifteenth United States Army Hospitals

The evacuation and field hospitals of the Fifteenth United States Army

functioned primarily in the role of station hospitals, serving all the troops in

the areas to which the army was assigned. This was the last Allied army to

enter the conflict with Germany. Combat work in all hospitals of the Fifteenth

Army was at minimum, because of its tactical mission. Becoming operational

on January 1945, this army, other than in April when it conducted operations

within the Ruhr and the Lorient-Saint Nazaire pockets, was initially mainly

concerned with receiving, training, and equipping organizations newly arrived

on the Continent, as well as rehabilitating, reequipping, and reenforcing various

units that had suffered heavy losses during the Ardennes campaign. Later, its

mission was primarily to occupy, organize, and administer military government

in the Rheinprovinz, Saarland, Pfalz, and portion of Hessen. In the final

stage of the war, as well as in the postwar period, the medical picture was

altered by the necessity of caring for large numbers of displaced persons,

RAMP’s (Recovered Allied Military Personnel), and German civilians who

required treatment for emergency conditions.

Because of the impossibility of evacuating eastern European displaced

persons, RAMP’s, and German civilians, orthopedic problems differed considerably from those usually encountered in hospitals at the army level. The

four main sources of orthopedic cases encountered by this army’s hospitals were

motor accidents, accidental gunshot wounds, mine accidents, and injuries and

diseases in RAMP’s and in displaced persons from German military and civilian

hospitals. The circumstances under which the injuries from general accidents

and mines were received made them different from injuries received in combat.

The timelag was considerably shorter than was usual in combat injuries, and

exposure was not the rule. Secondary shock was less, as was the preoperative

morbidity. On the other hand, inability to evacuate displaced persons rapidly

or within the regulation 10-day period required that they receive definitive

type of treatment which was not ordinarily permitted in an evacuation hospital.
PART II

CLINICAL POLICIES AND PRACTICES

Mather Cleveland M. D.

73

CHAPTER VIII

General Clinical Policies

Evolution of Clinical Policies

The North African (Mediterranean) Theater of Operations began to be

the scene of active combat in November 1942, more than year and half

before similar action began in the European theater. The experience of the

former theater with injuries of the bones and joints is related in detail elsewhere

in this series of volumes. The closed plaster technique, which was originally

employed on the basis of the successful experience with it in presumably comparable civilian injuries, proved thoroughly unsatisfactory in combat-incurred

injuries. Its use was attended with high incidence of infection, resultant

prolongation of the wound-healing time, and high incidence of deformity and

dysfunction. It was eventually learned by hard experience that the solution of

the problem of war wounds was (1) adequate debridement and (2) delayed

primary suture. By the spring of 1944, it had also been learned that by far

the best results were obtained in combat-incurred compound fractures in all

locations if they, too, were managed by these principles. After May 1944, this

plan of management was official policy in the Mediterranean theater.

Official liaison between the Mediterranean and European theaters was

poor, and it isregrettable that the vast experience of the Mediterranean theater

was not made available to the European theater through official channels.

After the invasion of Italy, in the fall of 1943, certain of the surgeons stationed

in the British Isles were able to visit the (then) North African theater. They

returned with practical, firsthand information regarding the best methods of

care of wounded soldiers, and these methods became the official policy of the

European theater.

It was inevitable, however, since the care of the wounded was of necessity

in the hands of physicians fresh from civilian practice and often with little or

no surgical experience, that the original concepts and practices in the European

theater should often be essentially those of civilian practice. As result, there

was some delay, and some false steps were taken, in setting up policies and plans

for the proper and expeditious care of battle casualties with bone and joint

injuries. These errors were of brief duration. Within to weeks after the

invasion of the Continent, the correct principles of management of battleincurred injuries were generally in effect throughout the European theater.

The existence of the senior and junior consultant systems, with repeated tours

of inspection of evacuation, station, and general hospitals, was largely responsible for this prompt transition.
74 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Studies on the management of battle-incurred compound fractures had

been conducted before D-day at various hospitals in East Anglia, England,

which were serving elements of the ArmyAir Forces, particularly the 2d Evacuation Hospital and the 49th Station Hospital. Three parallel series were

studied. In each series, surgical management was the same—debridement of

the wound and immediate primary closure. In the first series, no supplemental

chemotherapy was used. In the second, the patients received local and systemic

sulfonamide therapy. In the third series, they received local and systemic

penicillin therapy. The results in each series were essentially the same. The

incidence of wound infection was less than 10 percent, and healing was usually

prompt and satisfactory.

Not great deal of attention was paid to this study by Army medical

officers. These wounds were all in Army Air Force personnel and had been

sustained at high altitudes, under clean conditions, by officers and enlisted men

who lived in relatively sanitary surroundings and who had frequent opportunities to bathe. The circumstances somewhat resembled those which had

been encountered earlier in the war in desert areas of North Africa. These

wounds, it was thought, bore no resemblance to those which would be sustained after the invasion of the Continent, in the highly manured soil of France. It

was therefore not considered wise, on the basis of this study in Army Air Force

personnel, to make any change in the policy that war wounds should be thoroughly debrided and should be left open for several days after wounding.

It is unfortunate that more attention was not paid to this investigation,

for it served to emphasize universal truth. The results were equally satisfactory in all three series, in each of which the common factor was careful, adequate debridement of the wound. The good results were due, therefore, to

adequate surgery. They were no better in the series in which chemotherapy

and antibiotic therapy were used than they were in the series in which no

supplementary therapy was employed. Emphasis upon this fact would have

been of great practical value before the invasion, especially to medical officers

who had the mistaken notion that the new drugs had made established surgical

principles of somewhat less importance.

Establishment and Dissemination of Policies

In addition to preparation of the various circular letters which were issued

for the guidance of medical officers in the management of orthopedic and other

injuries, part of the time before D-day was spent in the preparation of Manual

of Therapy, which was issued in May 1944. It served as guide to the management of all varieties of wounds, including injuries of the bones and joints.

It soon became evident, however, that this manual, while it laid down

broad, sound surgical principles, did not meet all the needs of younger, inex- perienced surgeons who necessarily cared for great numbers of casualities and

(1) Annual Report, 2d Evacuation Hospital, 1943. (2) Annual Report, 49th Station Hospital, 1943. Manual of Therapy, European Theater of Operations, May 1944.
GENERAL CLINICAL POLICIES 75

who had had little or no experience with traumatic surgery, at least of the

kind and in the mass encountered in war wounds. Furthermore, some of the

principles laid down in the original Manual of Therapy required revision in

the light of increasing experience and more extensive observation.

As result of these necessities, circular letters revising the original methods

of management of injuries of the bones and joints and other injuries were published from the Office of the Chief Surgeon, European Theater of Operations,

at various times after D-day. The most important of these letters were Nos.

101, 30 July 1944; 131, November 1944; and 23, 17 March 1945. Among

other things, all these letters stressed that there must be close adherence to the

policies and methods of management described in them. One reason was the

usual military reason that casualties were treated in line of evacuation by

number of different surgeons, each of whom had to be able to take for granted

that the surgeons who had preceded him in the management of the particular

patient had followed the course of action specified for this particular type of

wound. The second reason was that, as the theater expanded and the number

of untrained and inexperienced surgeons increased, whatever freedom of action

might have been permissible for experienced orthopedic surgeons could not be

permitted for less experienced surgeons, and restrictions, however hampering

they might seem, had to be set up and strictly enforced.

Each of the circular letters published in the theater incorporated, and was

built upon, the accumulated previous surgical experience. After the suspension of hostilities, revised draft of the Manual of Therapy was completed

on the basis of the wartime experience. Comments on and criticisms of various methods of treatment had been collected throughout the period of combat,

and series of meetings had been held with the junior consultants in orthopedic surgery in the United Kingdom and on the Continent (p. 39). Discussions at these meetings were free and uninhibited, and detailed notes were

kept. The proposed revision of the Manual of Therapy (appendix B) therefore represents the final judgment of all the orthopedic surgeons who cared

for the bone and joint injuries sustained in the European Theater of Operations

in World War II. The final revision was the work of Lt. Col. John G. Manning,

MC, who was assisted by Lt. Col. William J. Stewart, MC, and the senior

consultant in orthopedic surgery, European Theater of Operations, Col.

Mather Cleveland, MC. It was not published officially because the war in

the Pacific ended soon after it was completed.

As an illustration of how policies of treatment formulated by the Theater

Chief Surgeon were disseminated to Army units, the following directive is

cited which was issued by Headquarters, Third United States Army, 28 January 1945, on the subject of medical policies for tactical operations. In substance, the material contained in this directive read as follows:

See appendix A—orthopedic details, circular letters. Cleveland, M.; Manning, J. Q.; and Stewart, W. J.: Care of Battle Casualties and Injuries Involving Bones and

Joints. J. Bone Joint Surg. 33-A: 517-527, April 1951. (See appendix B.)

Letter, Hq. Third U. S. Army, 28 January 1945, subject: Medical Policies for Tactical Operations, inclosure

1—Surgery.
76 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

General.—The Manual of Therapy, European Theater of Operations,

will be utilized as general guide and reference manual by all Medical Department officers and will be available in all medical installations at all times.

Fractures.—All compound fractures will be debrided, and the compounding wounds will be left open. No casualty with fracture will be transported without proper immobilization in splint or plaster cast. Neither field

nor evacuation hospitals are held responsible for the anatomic reduction of

compound fractures. The responsibility of these hospitals is to see that

patients with these fractures are prepared for early evacuation in comfort and

safety. No internal fixation or plating will be practiced in field or evacuation

hospital or any other Third United States Army medical unit.

Plaster casts.—All casts applied to the extremities must be padded.

All circular casts, after manipulation or operative procedure, must be split

through all layers down to the skin—in the lower extremity from the tips of the

toes to well above the knees and in the upper extremity from the tips of the

fingers to well above the elbow. When cast is applied to immobilize the leg,

the foot must be in neutral position, at right angles to the leg.

Fractures of the femur will be immobilized for transportation in double

circular plaster spica extending from the toes of the affected foot and from the

knee of the sound leg. The spica will be reenforced by strut placed posteriorly.

The leg should not be spread more than litter width, with the knees slightly

flexed. properly applied Tobruk splint may be substituted for the spica in

selected cases, if the fracture is below the upper third of the shaft.

Fractures of the tibia and fibula will be immobilized in circular plaster of

paris extending from the toes to the groin. Fractures of the feet and ankles will be immobilized by circular plaster boot, extending from the toes to just below

the knee.

Fractures of the humerus are to be transported in plaster spica bandage,

with the arm held forward and rotated medially, so that the forearm rests in

front of the body. The elbow should be flexed to at least 90 degrees. plaster

Velpeau bandage may be used to transport the patient to the general hospital

but is not as satisfactory. The hanging cast is not an acceptable means of

fixation for transportation and must not be used.

Fractures of the forearm and wrist will be immobilized in circular plaster,

extending to the midbrachial region, with the elbow flexed from 90 to 110 degrees to the long axis of the humerus. This cast must be cut back in the palm

of the hand to the proximal sulcus so as to permit free motion of the fingers.

Thomas splints.—The Thomas full- or half-ring splint is to be used

only as an emergency measure. If the Army traction strap or clove hitch is

left on the foot for more than to hours, skin necrosis almost invariably

results. Patients will therefore not be transferred or evacuated from evacuation

hospitals with the Thomas splint left on the limb, except as part of Tobruk

plaster. Thomas splint on the upper extremity is extremely uncomfortable

and should be discarded at the first hospital in which plaster-of-paris circular

splint can be substituted for it.
GENERAL CLINICAL POLICIES 77

External fixation.—The use of Steinmann pins incorporated in plaster

of paris or the use of metallic external fixation splints leads to gross infection or

ulceration in high percentage of cases. This method of treatment is not to be

employed in the Third Army.

Joint injuries.—Wounds of the joints should be closed at the earliest

possible moment, by delayed primary suture or skin graft. Whenever possible,

the synovial membrane should be closed at the time of debridement. Large foreign bodies overlooked in joints lead to infection and should always he removed.

If the joint surfaces are not badly damaged, early active motion should be

insisted upon. If they are so badly damaged that bony ankylosis is inevitable,

the joint should be immobilized as follows: Hip joint, 25 degrees of flexion, to

degrees of abduction; knee joint, 10 to 15 degrees of flexion; ankle joint, 10

degrees of equinus.

Joints of the upper extremity should be immobilized for evacuation in the

manner described for fractures of the same parts. The wrist should be dorsiflexed about 40 degrees. The spontaneously ankylosed elbow joint is the most

serious problem in the upper extremity, and many of these injuries may later

require amputation.

Amputations.—The technique of circular amputation and the postoperative management of the stump should follow the directions in Circular

Letter No. 101, Office of the Chief Surgeon, European Theater of Operations,

30 July 1944. These amputations are often traumatic, and the skin edges are

irregular, but in most instances traction, if it is adequately applied, will effect

closure of the stump. These techniques must be used in all amputations in the

Third United States Army.

The surgeon in the hospital in which the amputation is performed will, in

every case, explain to the patient before he is evacuated exactly why the amputation was necessary.

General Medical Policies

It was always emphasized, during the prewar training of American hospital

units, that preferential care should be given to wounded soldiers who could

return to duty, on the ground that the maintenance of fighting strength was the

first responsibility of the Medical Corps. As might have been expected, American medical officers, when it came to the actual test, maintained the civilian

concept of medical care and utilized their available facilities to save life first

and return men to combat second. The urge to save life produced the concept

by which triage was conducted, and most seriously wounded men received

preferential care for the reason that they would have died without it. Knowledge that they would receive prompt care fortified the courage of the fighting

men and improved their morale in danger.

This policy and practice meant, however, that only relatively few men

with bone and joint injuries were first-priority cases. Orthopedic casualties,
78 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

as rule, had first priority only when they also had suffered vascular injuries or

abdominal or chest wounds. Even then, the care of the bone or joint injury

usually had to be deferred until the major wound had been cared for. Orthopedic

surgeons were not assigned to field hospitals, where first-priority surgery was

done, and surgical personnel was seldom in sufficient supply in these hospitals to

permit orthopedic surgery to be conducted simultaneously with other surgery.

The timelag between wounding and the patient’s arrival in mobile or

fixed hospital depended upon the type and location of the hospital, the tactical

situation, and the conditions of transport. Sometimes man who was wounded

in combat passed through the echelons of the division and arrived in an evacuation hospital within or hours of wounding. More often the timelag was

close to hours, and sometimes it was considerably longer, depending, in

particular, upon combat conditions. In Normandy, some evacuation hospitals

received the wounded within an hour or two after they had been hurt. Later,

the timelag was lengthened to or hours. Still later, long ambulance hauls

were necessary, and sometimes patients were received as long as 72 hours

after wounding. Casualties with bone and joint injuries, unless they had

suffered associated visceral or vascular injuries, were, as just noted, seldom

treated in the field hospital located in the vicinity of the clearing station but

were taken directly to evacuation hospitals.

The timelag between wounding and arrival at general hospital for

reparative treatment also varied. During the summer months following

D-day, wounded soldiers frequently arrived in the United Kingdom within

to days after they had been removed from the frontlines. As the battlefront moved father and farther beyond the Normandy beachhead, the interval

increased from 10 to 14 days and was sometimes longer. During the winter

months, when the flow of casualties was extremely heavy and air transport

was hampered by weather conditions, intervals of weeks or more were not unusual. During the last months of hostilities, when air transport was

again possible and had reached high state of efficiency, casualties sometimes

reached the United Kingdom within to days after they had been wounded.

Evacuation Policies

The holding period on the Continent varied. At the maximum, it was

seldom over 60 days between admission and return to duty or further evacuation. This meant that fractures of the long bones to be treated by skeletal

traction almost without exception had to be managed in the United Kingdom

Base, where the holding period was 120 days.

The peak load of casualties on the Continent occurred between December

1944 and March 1945. At this time, as well as during all periods of general

offensives in France, Belgium, and Germany, evacuation in all hospitals had

to be rapid and efficient. Otherwise, there would not have been enough beds

available for the constant stream of wounded. At certain periods, the only

patients held were those who needed further care before evacuation and those
GENERAL CLINICAL POLICIES 79

who could be returned to duty within 10 days. Patients with bone and joint

injuries practically never fell into the latter group.

After March 1945, the holding period on the Continent was gradually

increased to 30, 60, 90, and finally 120 days, if it was thought that the man

could be returned to duty within this time.

The tactical situation and medical necessities always had to be reconciled.

The optimum time for delayed wound closure, for instance, was to 10 days

after debridement. Often there were mass admissions from evacuation hospitals to general hospitals of casualties who required definitive surgery.

Surgical policy required that such patients bo held for 10 to 14 days afterward.

The military situation, on the contrary, required that nontransportable patients

in general hospitals be held to minimum. Most of the candidates for closure

actually were in the militarily evacuable class and therefore subject to evacuation at any time after admission. The general policy was to close the wounds

within 12 to 48 hours after the patient had been received, unless local or general

factors prevented operation without further preparation or unless it was thought

that the tactical situation would require prompt evacuation.

These statements, of course, must not be interpreted to mean that there

was mandatory evacuation of patients who were in no condition to travel.

The commanding officer of any hospital could at any time declare particular

patient nonevacuable. For this reason, certain number of fractures of the

long bones were treated by delayed primary suture and skeletal traction in

general hospitals on the Continent. This policy was usually followed, if it

seemed unlikely that the patient could be evacuated safely to general hospital in the United Kingdom Base within an optimum period for the institution of

skeletal traction, which was to 21 days after wounding.

In some hospitals, far too much emphasis was laid upon the importance of

rapid evacuation. There was an occasional tendency to commend hospitals

for the number of patients who were passed through them, and, conversely,

to criticize hospitals in which evacuation seemed less efficient. As result,

essentials of treatment were sometimes disregarded. Patients with unreduced

fractures, improperly or inadequately immobilized fractures, or severe infections

and, very occasionally, incipient gangrene, were sometimes evacuated when

they should have been held for treatment. The need for beds was never so

urgent as to warrant these practices, and it is only fair to say that errors of this

kind were observed, for the most part, during the Battle of the Bulge, when

tactical necessities demanded the evacuation of every patient possible.

In the occasional case, the patient was evacuated because that was the

easiest way to handle him. To hold men who required treatment meant that

each individual had to be carefully appraised, and an occasional medical officer

was unwilling to take so much trouble. On the other hand, strict adherence

to evacuation policies sometimes militated against the basic objective of medical management, that is, the return of soldiers to duty as soon as possible.

Patients with minor injuries or ailments got into the line of evacuation and

continued in it until some alert medical officer took time to appraise their
80 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

condition and halt their journey to the rear. By this time, the soldier was

often well back in the communications zone, and it required weeks to get him

back into the line, although his wound would have not required him to be off

duty for more than few days.

None of these errors was inherent in the system itself. They were all to

bo attributed to personnel failure. Evacuation policies were well set up and

efficient, and they were carried out with an elasticity and coordination unknown

in previous military operations. Furthermore, casualties from the Continent

were, as rule, received in good condition in the United Kingdom Base. The}'

were received in much better condition as the war progressed, for the reason

that, as time passed, it was learned which casualties could safely be evacuated

promptly and which must be held for further observation and treatment.

While it was not always desirable, and was frequently highly undesirable,

to evacuate some patients with bone and joint injuries, it could be done, under

the stress of necessity, with one notable exception: When vascular injuries

were associated with compound fractures, the casualty had to be observed for

several days before evacuation was permitted, to be certain of his circulatory

status and to be sure that gas gangrene was not developing.
81

CHAPTER IX

The Management of Compound Fractures

Initial and Reparative Wound Surgery

Wounds of the extremities often made up as much as 70 percent of the

caseload of an evacuation hospital. Half or more of these wounds were associated with compound fractures, which means that from 35 to 40 percent of

all casualties presented this type of injury.

Col. Charles B. Odom, MC, consultant in surgery, Office of the Surgeon,

Headquarters, Third United States Army, analyzed 64,389 battle casualties

treated in Third Army hospitals from August 1944 to February 1945. Of

these injuries, 43,345 were found to involve the extremities or the buttocks.

This was 67.3 percent of the total number; it had been estimated that the

proportion would be 71 percent. The case fatality rate for wounds of the

extremities was 0.82 percent, compared with rate of 2.9 percent for all battle

casualties in this series.

Compound fractures thus constituted major part of the surgical load in

all Army hospitals. They also presented major problems, for four reasons

over and above their frequency:

1. They were often of devastating character not observed in civilian

practice.

2. The compounding wound was often so large and extensive that it

constituted another problem in itself.

3. There was frequently an accompanying nerve lesion, and less often

there was an accompanying vascular lesion.

4. The same soldier frequently presented multitude of injuries, any one

of which constituted major problem in itself. Thus It was not uncommon

to admit casualty with perforating wound of the thorax with hemothorax,

perforating wound of the abdomen for which colostomy had been necessary,

and compound fractures of two major bones, frequently associated with division of major peripheral nerve. The first objective in every such case was

naturally to save life, and it was extremely dangerous to overtreat the patient,

who might readily go into shock or go back into shock as the result of too

vigorous treatment. As result of the circumstances, the bone injury was

usually the last to be treated, and the delay was sometimes considerable.

Development of Policies

The evolution of the method of delayed primary wound closure in the

North African (Mediterranean) theater is recounted in detail elsewhere in this

Semiannual Report, Office of the Surgeon, Third U. S. Army, January-30 June 1945.

372572°—56
82 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

history. The technique was developed and generally accepted by an evolutionary process. It was not put into practice as theresult of directives from the

Theater Chief Surgeon’s Office. On the contrary, the directives finally issued

concerning it took cognizance of what had then become an established practice.

Many months were to pass, and many poor results were to be obtained by

other techniques, before delayed primary wound closure was routinely adopted

in the Mediterranean theater in the management of injuries of the soft parts.

It was not until the late spring of 1944, only few weeks before D-day in the

European theater, that delayed primary wound closure was also adopted in the

Mediterranean theater as technique of management of compound fractures,

and lack of time, as well as lack of liaison, prevented the general dissemination

of the information in the European theater.

In the European theater similar, though considerably briefer, period of

evolution occurred. The Manual of Therapy prepared before D-day emphasized, in the directions for initial wound surgery, the importance of “early

secondary closure” (delayed primary closure) or early skin grafting. Later

directives were specific that wounds were to be closed by delayed primary

closure, preferably within to days after debridement if there was no clinical

evidence of infection. Closure within 10 days or less from the date of injury

was still to be undertaken under the same circumstances.

In the rush of casualties that followed D-day there was certain inevitable

confusion, and the method was unevenly and improperly applied in some cases.

Some wounds were closed with strict regard to the regulation about the time of

closure but with too little attention to the requirement that they be clinically

free from infection. This happened chiefly because many newly arrived hospitals became swamped with casualties, and their medical officers, who were

inexperienced and who had not been in the theater long enough to have any

thorough training, closed some wounds regardless of their appearance. When

cases began to be properly selected and the method was properly applied results

were excellent.

It was only in occasional cases that the principles of delayed primary

closure of clean wounds or days after debridement was not accepted for

soft-tissue wounds. There was reluctance, however, to accept the same

principles of management for compound fractures. When this method is

successful, as it is in large proportion of the cases in which it is properly employed, it converts compound fracture into simple fracture, but it took some

time to convince many medical officers of the possibilities of the technique.

Indeed, it was with reluctance and trepidation that many orthopedic surgeons

in the European theater finally proceeded with delayed primary closure of compound fractures. They clung to the routine of removing the plaster, redressing

the wound, and putting on fresh cast, with, in selected cases, closure of the

wound at later date. In most cases in which this method was used, healing

was permitted to occur by granulation. It was not satisfactory technique.

Infection was frequent overseas, and while it was not possible to determine the

Manual of Therapy, European Theater of Operations, May 44.
WOUND SURGERY IN COMPOUND FRACTURES 83

end results, because the pat ients were evacuated to the Zone ofInterior, the impression was general that function was often not as good as it might have been.

When it was demonstrated in the cases in which the technique was employed that delayed primary closure of compound fractures was safe and

satisfactory method, the situation changed. After persuasion and perhaps

some browbeating by the consultants, orthopedic surgeons began to use this

technique. In late June of 1944, it began to be employed in trickle of cases, out of many later shown to be entirely appropriate for its use. By mid-July,

the number had become torrent. By September 1944, the situation in respect

to wound closure was well stabilized, and delayed primary closure was being

used routinely in all compound fractures in which it was justified. By the end of the war, almost the only wounds left to heal without delayed primary

closure were very small wounds which had already begun to close by granulation

when the casualties were received in the general and station hospitals to the

rear. At this time it was exceptional to find surgeons who were not carrying

out the prescribed techniques and who had not greatly improved their original

technique.

The full story of the success or failure of delayed primary suture of compound fractures could not, of course, be ascertained in the European theater.

Most patients with these injuries were returned to the Zone of Interior in

plaster, and final results were evaluated there. There was no question, however, in the minds of orthopedic surgeons in the theater as to the value of this

method. The practice of delayed primary wound closure had the same

advantages in the European Theater of Operations as had already been demonstrated in the Mediterranean Theater of Operations. Prolonged drainage

incidental to healing of the wound by scar tissue from the depths to the surface

was obviated. The percentage of infection was minimal as compared to the

high percentage of infection which had accompanied the closed plaster method.

Underlying exposed bone was conserved and bone healing was expedited along

with soft-tissue healing. Convalescence was shorter and far more satisfactory.

Finally, repair of divided peripheral nerves, open reduction of such fractures

as required this procedure, the application of bone grafts, and similar surgery

could all be performed much earlier, with relative ease and with generally good

results, whenever delayed primary wound closure had been practiced.

Debridement

The principles of debridement as it was practiced ideally in the European

theater did not differ from the principles by which it was practiced in other

theaters. The cardinal consideration in all initial wound surgery was thoroughness. If the debridement was adequate, the patient was almost always

received at the general hospital in the communications zone with the wound

healthy and ready for primary closure or for skin grafting as necessary. If

debridement was not adequate, frank infection or dirty wound prevented

closure at the optimum time. Frequently, in these cases, secondary debride-
84 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

mont or even drainage operation was necessary. Paradoxically, therefore, the surgeon who was most radical in the debridement of war wounds was

really practicing conservatism.

correct debridement was carried out according to thefollowing principles:

1. The incision was preferably longitudinal and was always generous

enough to permit complete exposure of the wound to its depths. It was made

through the original wound when possible. If for any reason this was not

practical, new incision was employed.

2. Damaged and devitalized tissue was excised until cleanly bleeding

surfaces were reached. Fascial planes were widely opened to relieve tension.

The tissue removed consisted, for the most part, of muscle whose fibers had

been destroyed by the enormous expansile force of modern high-velocity

projectiles.

3. All accessible foreign bodies, particularly bits of clothing, were removed.

4. As much skin as possible was conserved. Intact skin is essential for

proper healing of underlying tissues.

5. It was also the rule to conserve bone fragments, especially if they were

large. Even bone chips could serve, in effect, as bone grafts and thus provide

additional support for the injured extremity.

6. Severed nerves were loosely approximated by single wire suture. If this could not be accomplished, an identifying suture, which was demonstrable

by X-ray, was put in each end. Primary nerve suture was never attempted.

7. Hemostasis was complete and precise.

8. The wound was always left open for drainage at the initial operation.

Drainage or counterdrainage was sometimes instituted through another incision

also. Provision for drainage was particularly important in wounds in the thigh

and buttocks, and failure to institute it accounted for number of fatalities

in patients with bone and joint injuries, as well as for number of serious

infections.

9. The wound was well irrigated at the conclusion of the operation. It

was then held open withfine-mesh gauze which was placed loosely in the wound,

no more being used than was necessary to accomplish this purpose. Tightly

packed gauze prevented drainage, and the damming back of secretions by this

means could give rise to serious infections. Vaseline-impregnated gauze was

frequently used early in the European theater experience, but as time passed

it was found to be open to many of the same objections as tightly packed gauze,

and fine-mesh dry gauze was used routinely thereafter.

10. Finally, pressure dressings were applied and the wounded extremity

was encased in plaster-of-paris splint which was well padded and which had

been selected with view to the necessities of the particular case. This splint

was merely for transportation purposes. Forward hospitals were not concerned with the anatomic reduction of fractures. The splint was split or

bivalved through both plaster and padding before the patient was taken off

the operating table. The assumption was that it would be removed within

to days for delayed wound closure.
WOUND SURGERY IN COMPOUND FRACTURES 85

11. If penicillin had not already been administered, it was begun at the conclusion of the initial operation. In any event, it was continued until days

or more after delayed wound closure.

The policy of early, complete debridement, with the establishment of

adequate drainage, preferably through the open wound, was the policy set up

in the European Theater of Operations for every wound of the extremities, regardless of its type and size. On the whole, as already noted, it was carried

out fairly consistently, even in the early days of the theater.

Common errors in initial wound surgery.—The availability of the sulfonamides and, more particularly, of penicillin induced an occasional inexperienced surgeon to eliminate debridement, especially in small, perforating wounds. This was not safe or wise policy, chiefly because it was impossible to determine by external inspection of an injury what the state of the

deeper tissues might be. The burden of responsibility was always placed

squarely upon the surgeons who failed to adhere to theater policy in this regard.

The senior consultant in orthopedic surgery and the junior consultants lost

no opportunity, on their visits to the various hospitals, to stress the point

that adequate debridement was the only acceptable policy in battle wound,

and that every surgeon must adhere to this policy, regardless of the size of

the wound. In addition to inadequate debridement, the chief errors made

in the initial surgery of combat-incurred compound fractures may be stated

as follows;

1. Circumcision rather than excision of wounds. Debridement through

linear incision provided the only satisfactory exposure of the deeper tissues.

Operation by circular, coning-out technique was completely ineffective, one

reason being that satisfactory closure of the wound was impossible when circular incision had been made at initial surgery. This type of incision was

particularly undesirable in compound fractures, regardless of their location.

2. Failure to expose and examine adequately wounds which also involved

vessels and nerves. Nerve injuries were sometimes overlooked in both the

upper and lower extremities, though this error, for obvious reasons, was seldom

made in vascular injuries.

3. Too free removal of bone chips in comminuted compound fractures.

4. Failure to split all transportation casts and underlying wadding down

to the skin.

5. Holding patients too long in forward hospitals and thus delaying primary closure unduly.

6. Using penicillin too frequently and in too large amounts, merely because

it happened to be available.

Strict adherence to directives would have prevented all of these errors.

The fact that they continued to be made throughout the war is an indication

of the extreme difficulty which civilian surgeons experienced in changing over

from civilian to military practice. It is also an indication of inability to

recognize the difference in the function and responsibility of surgeons in

forward and in fixed hospital. If all orthopedic surgeons could have had
86 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

some instruction and orientation before they wore sent to evacuation hospitals,

many of these errors would probably not have occurred.

report to the surgical consultant of the Third United States Army

from Maj. Dudley W. Smith, MC, of the 4th Auxiliary Surgical Group, on

detached service at the 94th General Hospital, is an interesting, instructive, and practical commentary on the errors which had to be combated at forward

hospitals. His observations were based on 500 cases collected from the First,

Third, and Ninth United States Armies. The mission of this hospital was

chiefly the delayed primary closure of compounding wounds after debridement and the establishment of skeletal traction. The most important of

Major Smith’s observations were as follows:

1. Valuable time could be saved and the patient could be spared considerable discomfort if it were prominently marked on both the plaster splint and

the field record that the patient had nerve lesion, and if the extent of the

skin loss were also noted. Some patients did bear these notations on their

splints and their records, but they were in the minority. patient with

diagnosed or suspected nerve lesion which was thus identified could be transferred to neurosurgical center without the necessity for removal of the cast and examination of the wound.

2. Far too many wounds could not be closed for two reasons: (1) Many

contained dead muscle and damaged fascia which were actually sloughing when

the cast was removed and the wound was inspected. This was because

sufficiently long longitudinal incision had not been made at debridement, which was inadequate because exposure was inadequate; (2) many wounds

were actually blocked by heavy vaseline-gauze wicks or Penrose drains which

had been inserted deep into them. When these were removed, well-circumscribed tract was left, which was sloughing and contained more or less exudate.

The wounds in perfect condition for closure were those in which sufficiently

long incision had been made for complete excision of damaged tissue and which contained only two flat strips of vaseline gauze on each side, with the flat

edges extending into the depths of the wound. These wounds were clean

and healthy looking and almost invariably healed well after delayed primary

suture.

3. Enough attention was not paid to extremities in which vascular injuries

were associated with bone and joint injuries. In such case the popliteal vein

had been ligated days before. The leg was enormously enlarged, the foot

was cold, and the limb was not supported in any way. The patient was in

great pain, and the process was obviously not going to subside. This result might have been prevented if the leg had been put up in long leg split cast with large lettering on it to warn all concerned to keep the extremity elevated.

Surgeons at forward hospitals should have been warned that patients with

vascular injuries, whether or not the bone was involved, would not be comfortable without some kind of adequate support to the leg. These surgeons

should also have been warned that limbs might be lost by failure to observe

this precaution.
WOUND SURGERY IN COMPOUND FRACTURES 87

4. In number of instances, casts had been incompletely split, while in

some instances the sheet wadding had not been split at all.

5. In the occasional case, foreign bodies in joints had not been completely

removed. As general rule, however, the results of removal of shell fragments from the joint, followed by the instillation of penicillin and closure of

the synovial membrane, had been excellent.

6. Some patients who had been subjected to amputation were grossly

anemic and needed massive transfusions, though they had stood the trip well.

The care of amputations and stumps was generally excellent.

All these observations attested the paramount importance of adequate

initial surgery in the combat zone. If surgery there was inadequate, the

mission of the general hospital in the communications zone was complicated

and the end results of treatment were jeopardized. It was always valuable

when, as in this case, surgeon from the army area was able to make observations in the communications zone and report to his colleagues the results of

failure to carry out precisely the policies of management laid down by the

Theater Chief Surgeon.

Anesthesia.—Almost without exception, debridement was carried out

under general anesthesia. Only brief experience was necessary to prove that

it could not be satisfactorily performed under local analgesia. For one thing,

this technique would have introduced further contamination into an already

contaminated and possibly infected field. Furthermore, battle wounds were

seldom in the category of inconsequential injuries. Even the smallest wounds,

as just pointed out, were likely to be associated with severe damage to the

underlying tissues, as well as gross contamination by foreign material. In

this kind of injury, an adequate debridement could not possibly be performed

except under general anesthesia.

Wounds debrided under local anesthesia in forward hospitals were often

frankly infected when patients were received at the general hospitals. Primary

closure was not possible in these cases until secondary debridement had been

performed. This necessity delayed closure of the wound beyond the optimum

period, and healing was never quite as satisfactory as in the cases in which

closure could be accomplished more promptly. Even when frank infection

did not occur, wound healing was likely to be delayed, and the delay could

often be attributed to the original error of not using general anesthetic for

debridement.

Delayed Wound Closure

The management of compound fractures in general hospitals began with

an examination of the wound as soon as possible after the patient was admitted.

If the cast was merely split and was not bivalved, it was bivalvcd at this time

and the upper portion was lifted off. It was thus possible to inspect the area

without contaminating the wound. The operating list was made up after all

the casualties had been inspected, priority being given to patients whose
88 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

wounds were of longest duration and to those who had fractures which would

require traction.

Plaster and dressings were removed completely in the preparation room

or the operating room, and the surgical field was prepared with soap, water,

and ether or tincture of Metaphen (nitromersol).

The wound was carefully inspected to be certain it was clinically clean

throughout, but the depths were disturbed only if secondary debridement

seemed necessary. If the wound was clean, closure was proceeded with at

once. If secondary debridement was necessary, the surgeon had to use his

judgment to determine whether he might safely proceed with closure at this

time or whether it would be better to defer the procedure until later date.

If closure was undertaken within maximum of 10 days after wounding,

the skin edges were mobile and it was necessary to free them only slightly.

The wound was then approximated with vertical mattress sutures of silk or

cotton, preferably rather widely spaced. Buried sutures were avoided. If

closure without tension was not possible, undermining incisions were employed

or split-thickness skin grafts were used on part of the wound or, if necessary,

on the whole wound. The directives issued before D-day required the sprinkling of sulfonamide crystals into the wound before closure, but this practice

was forbidden by directive several months later.

Rubber-tissue drains were used for 48 to 72 hours in all deep wounds.

Small stab wounds were occasionally used for counterdrainage if dead spaces

had not been entirely obliterated.

When, for any reason, 10 days or more had elapsed from the time of wounding to wound closure, mobilization of the skin edges, which by this time had

become fixed and rigid, was practically always necessary at the reparative

operation. Secondary debridement was sometimes necessary also. The

criterion of wound closure at this time was the same as the criterion for earlier

closure, that is, clinically clean wound. The preferable technique was the

use of interrupted sutures, widely spaced and loosely tied. drain was placed

in the wound for 48 hours, and pressure dressings were kept in place for 10

to 14 days. At the end of this time, the sutures were removed.

Split-thickness skin grafts.—When there had been an extensive loss of

tissue, particularly of the skin, it was frequently impossible to close wounds

completely by suture, and sometimes they could not be closed at all. In such

cases, split-thickness skin grafts were employed to complete the partial closure

or to accomplish total closure. By this means the objective of converting

compound fracture into simple fracture was attained, tension on the wound

edges was avoided, and scar-tissue formation was prevented. Any surgeon,

even with no great amount of training, readily learned the technique of splitthickness skin grafting and the results were practically always

If it was found, later, that additional plastic surgery was necessary, the splitthickness graft could be excised and full-thickness graft applied with little

risk of infection.
WOUND SURGERY IN COMPOUND FRACTURES 89

The cases in which complete wound closure would be impossible without

skin grafting could usually be determined before operation, and the donor

site, which was on the thigh whenever possible, was prepared on the ward.

Many hospitals eventually adopted the practice of preparing donor site

before operation in any case in which there was severe compound fracture

of the lower extremity. The operating room was always set up with equipment

for skin grafting, and, even if the procedure had not been planned previously,

there was no delay if it was decided upon during the course of the operation.

Massive pressure dressings were always used after skin grafting.

The results of split-thickness grafts applied to fresh, clean wounds were

usually good (figs. 17 and 18). Many surgeons obtained takes of 100 percent.

Results were less good in old, previously infected, granulating wounds, but if the

granulations were shaved down to the base, takes of 40 to 50 percent were

readily obtained. The least successful results were obtained in prisoners of

war with neglected wounds, in which successes usually did not exceed 35

percent.

If split-thickness grafts were not successful, the use of pedicle graft often

gave excellent results (fig. 19). In certain selected cases, in which closure by

other means was impossible, pedicle grafts were used at reparative surgery,

without any trial of other techniques (figs. 20 and 21) or were applied later

(fig. 22).

Infected wounds.—In the first days of fighting on the Continent, when debridement was frequently inadequate, distressing number of patients were

received in the United Kingdom with infected wounds. Later, it was found

that treatment by wet compresses for few days, sometimes supplemented by secondary debridement, made wound closure possible in many of these cases.

In others, closure was not attempted; instead, the wounds were dressed with

vaseline gauze, which was then being used by directive. Many wounds treated

in this manner were frankly infected when the patients were evacuated to the

Zone of Interior.

Management of Fractures

Skeletal traction or, better, balanced suspension with skeletal traction

(p. 113) was the method of choice in the management of most fractures of the

long bones. It was the policy to reduce the fracture with the use of skeletal

traction on the operating table, then check the position and alinement by X-ray.

It was thus possible to determine the amount of weight to be used for traction

and to determine the cases in which sling or other supplementary equipment

was needed to prevent angulation. The original time spent in careful reduction

saved many hours in manipulation and many roentgenologic examinations later, and also avoided distraction.

Open reduction (p. 116) was performed with high degree of success provided that care was taken to select cases in which there had never been any

gross evidence of infection and in which the wounds had been healed for 17 to 21
90 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 17.—Compound fractures of humerus and radius, lacerated wound of arm

and forearm, sustained 25 June 1944. Initial surgery was done at Royal Air Force

Hospital, and the patient was received at the 91st General Hospital 29 June. He was

returned to the Zone of Interior August. A. Appearance of wound when reparative

surgery was undertaken. B. Roentgenogram showing compound fractures of radius and

humerus. C, D. Wound closure by suture and split-thickness skin graft after secondary,

more extensive debridement.
WOUND SURGERY IN COMPOUND FRACTURES 91

Figure 17.—Continued. E. Stage of wound healing 18 July, weeks after reparative

surgery.

days. Penicillin was used intramuscularly for minimum of after operation.

Results of Delayed Primary Wound Closure

in Compound Fractures Overseas Theaters

Results of the policy of delayed wound closure were generally good in the

European Theater of Operations. report by Maj. (later Lt. Col.) John A.

Grove, MC, on the work at the 15th Hospital Center is typical of both the

material handled and the results of the policy. At this center, the policy of

closing all soft-tissue wounds over compound fractures was immediately established and was continued throughout the war. At first, patients were received

promptly, and delayed primary wound closure was possible within to days

after wounding. In the later stages of the fighting in Europe, when patients

had to be evacuated after deep penetration of their units into Germany, wounds

were closed on an average of 14 days after wounding. It was the impression

of the hospital staff that the results then were somewhat less good than they

had been when closure was accomplished on the third orfourth day after wounding, as had frequently been possible in the first weeks of the early European

fighting.

During the whole period from D-day to V-E Day, 60.3 percent of all

compound fractures managed in this hospital center were treated by delayed

wound closure. In another 25 percent, suture was omitted because the wounds

were small and of the puncture type; in practically all of these cases, the wounds

were well healed or were well on the way to healing when the patients were

ready for evacuation. In the remaining cases, the wounds were severely infected and two policies of management were followed, (1) partial closure, and

(2) evacuation of the patients to the Zone of Interior with open wounds.
92 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 18.—Compound fracture of right femur, lacerated wounds of posterior thigh

and buttock, sustained 16 June 1944. Debridement was done 14 hours after injury, and the

patient was admitted to the 91st General Hospital 20 June. Here secondary debridement

was done and skeletal traction was applied. The wound was closed 16 July and by 22

August was well healed. The fracture was also satisfactorily alined. A. Appearance of

wounds when patient was first seen in the 91st General Hospital. B. Roentgenogram

showing compound fracture of femur. C. Appearance of wound when reparative surgery

was undertaken approximately weeks after wounding.
WOUND SURGERY IN COMPOUND FRACTURES 93

Figure 18.—Continued. D. Wound closure by suture and split-thickness skin graft.

E. Roentgenogram showing femoral fracture in satisfactory alinement months after

wounding. F. Appearance of healed wound weeks after reparative surgery.
94 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 19.—Compound fractures of tibia and fibula sustained August 1944. Debridement was done at the 104th Evacuation Hospital the same day. Closure of the softtissue wound was attempted at the 82d General Hospital 14 August but was not successful.

On October, split-thickness skin graft was applied but did not take. On 21 October

direct cross-leg pedicle graft was applied at the 129th General Hospital. It was divided

15 November and the patient was returned to the Zone of Interior shortly afterward. A.

Roentgenogram showing compound fractures of tibia and fibula. B. Appearance of wound

21 October just before delayed primary wound closure by pedicle graft. C. Appearance of

cross-leg pedicle graft 15 November just before division.
WOUND SURGERY IN COMPOUND FRACTURES 95

Figure 19.—Continued. D. Appearance of wound after separation of pedicle graft.

Two somewhat more detailed statistical surveys of wound closure at the

15th Hospital Center were also made by Major Grove. The first included the

period from D-day to November 1944. The second covered the period from

December 1944 to March 1945.

First series.—During the 5-month period ending November 1944,

the 15th Hospital Center received and treated 5,042 compound fractures, excluding fractures of the bones of the face and the skull, and fractures of the

spine with associated spinal-cord injuries. With few exceptions, all of these

fractures were battle incurred. Bones of the lower extremities were involved in 2,614 instances and those of the upper extremities in 1,895 instances. The

remaining 533 fractures consisted, in the order stated, of fractures of the pelvis,

scapula, patella, clavicle, and vertebrae. The bones most frequently fractured

were the tibia (757), humerus (702), and femur (684).

Preparation for the reparative operation consisted of the standard routine,

including transfusions of whole blood wheneverthe patient showed any evidence

at all of anemia. Massive whole-blood replacement was frequently necessary.

Whenever operation was delayed for any reason, the extremity was suspended

in balanced suspension with skeletal traction, which reduced edema and

facilitated later closure.

Delayed primary wound closure as attempted in 2,393 of the 5,042 cases,

the average timelag between wounding and closure being 14 days. Closure

was accomplished by suture in 2,087 cases, by skin graft in 236, and by combination of suture and skin graft in 70 cases. In many large, frankly infected

wounds, partial closure of the wound was performed with free drainage at the

site of maximum infection; counterincisions were sometimes used for dependent

drainage. This technique prevented the large losses of serum, with resulting

protein deficits, which occurred from large draining surfaces. It was practically ahvays accompanied by marked improvement in the patient’s general

condition.
96 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 20. —Huge defect with massive loss of skin and other soft tissues on palmar

surface of left forearm. Management by pedicle graft. A. Appearance of defect days

after initial wound surgery. Note exposed tendons. B. Outline of large pedicle graft from

abdomen designed to fit defect on forearm. C. Application of pedicle graft to wound of

forearm. Care was taken to avoid excessive tension. D. Healed defect 4J4 weeks after

reparative surgery. It is reasonable to assume that the function of this patient’s hand was

salvaged chiefly because of the prompt application of pedicle graft. Early healing could

not have been obtained by any other method, and the several tendons exposed in the wound

would certainly have sloughed if they had not been promptly protected by skin coverage.

This patient was treated by Lt. Col. Eugene M. Bricker, MC, senior consultant in

plastic surgery, European Theater of Operations.

Healing by primary intention occurred in 1,592 of the 2,393 cases (66.5

percent) in which delayed primary wound closure was attempted. In an additional 640 cases (26.74 percent of the total number), closure was partly successful. Wounds in this category were characterized by small sinuses, stitch

abscesses, or partial loss of skin grafts. With few exceptions, these wounds

healed after secondar} suture or secondary skin grafting or, in some instances,

spontaneously. This meant, then, that total of 93 percent of the 2,393
WOUND SURGERY IN COMPOUND FRACTURES 97

wounds in which delayed primary closure had been undertaken were completely

healed when the patients left the hospital.

In the remaining 161 cases, 6.73 percent of the total, the attempt at wound

closure was complete failure. The entire wound broke down, or an osteomyelitis developed and required wide surgical opening of the wound. These

failures chiefly occurred in wounds involving the upper third of the femur or

the pelvis, with complicating wounds of the bladder or bowel. Wounds involving the lower third of the leg and foot were also represented in the group of

failures. Cultures from the wounds which failed to heal revealed mixed types

of infection, with staphylococci and bacilli of the colon group predominating.

Figure 21.—Fracture of ulna, with large compounding wound in upper half of right

forearm. Management by pedicle graft. A. Wound at reparative surgery days after

wounding. Note comminuted fragment of ulna held by tissue forceps. B. Pedicle graft

from abdomen immediately after application to wound of forearm. C. Completely healed

wound weeks after reparative surgery.

This patient was treated by Lt. Col. Eugene M. Bricker, MC, senior consultant in

plastic surgery, European Theater of Operations.

372572°—56
98 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 22.—Compound fracture of right humerus, with paralysis of median, radial,

and ulnar nerves, laceration of right brachial artery, and gangrene of tips of fingers of right

hand. Wounds were sustained 22 September 1944. Skeletal traction was applied October

and pedicle graft from the chest was applied 28 October; at the same operation, the humeral

fracture was fixed with two screws. The pedicle was divided 21 November, and the patient

was returned in plaster spica to the Zone of Interior the following month. A. Roentgenogram showing compound fracture of right humerus with application of skeletal traction.

B. Wound of posterior humeral region just before application of pedicle skin graft. C.

Roentgenogram showing fixation of fracture of humerus by two screws. This procedure

was carried out when the pedicle skin graft was applied.
WOUND SURGERY IN COMPOUND FRACTURES 99

Figure 22. Continued. D. Coverage of wound by pedicle from infra-axillary region

E. Healed wound and coverage of donor site by split-thickness skin graft.

It is matter of interest that 2,152 of the wounds which were not closed surgically, approximately 42.6 percent of the total number, showed spontaneous

healing during the period the patients were hospitalized overseas. The maximum holding period in this theater was 10 to 12 weeks at this time, depending

upon the site of the fracture. The majority of the wounds which healed

spontaneously were small penetrating or perforating wounds. This means that

failure of healing occurred in only 658 wounds, 161 in which the attempt at

closure did not succeed and 497 in which no attempt at surgical closure was

made. In other words, within the holding period permitted, 87 percent of the

compound fractures were converted to simple fractures by healing of the

compounding wounds. Frank osteomyelitis occurred in 272 cases, 5.4 percent.

Second series.—Between December 1944 and March 1945, 3,053

compound fractures were received and treated at the 15th Hospital Center, the
100 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

same center from which the preceding study was made. Delayed primary

wound closure was undertaken in 2,241, approximately 75 percent of the total.

Eighty-seven percent of these wounds healed satisfactorily. The percentage

of absolute failure was only 7.6 percent, since healing occurred spontaneously

or later secondary closure was successful in another 5.4 percent of the cases,

after failure of the first attempt at suture. The incidence of osteomyelitis was

7.6 percent.

It should be noted that during the period covered by the second of these

two series, delayed primary wound closure was attempted in almost threequarters (73.4 percent) of the cases, against less than half (45.4 percent) of the

first series. The incidence of complete success on the first attempt at suture

rose from 67.6 percent to 87 percent. The incidence of osteomyelitis rose from

5.4 percent to 7.6 percent, and the small increase may fairly be taken as an

indication of how greatly the surgeons on the staff, in spite of the much bolder attack on the problem of wound closure, had increased in surgical wisdom and

judgment. If they had not, the proportion of bone infection would undoubtedly have been much higher. In all probability, the success or failure of

closure was always determined by the adequacy and boldness of the original

wound excision and debridement. The results were better in the second series

than in the first, because this lesson had been almost universally learned.

The good results in these cases can also be attributed to two other factors,

the youth and generally good condition of the casualties and the generous use

of whole-blood transfusions whenever they were indicated. much higher

percentage of good results was secured in the cases in which transfusions were

used to correct anemia of any degree. There was no proof, however, that the

incidence of serious wound infections in this series was materially reduced by

the use of either the sulfonamides or penicillin.

Zone of Interior Hospitals

The results of delayed wound closure in compound fractures of the long

bones could not, as already noted, be determined overseas. In December 1944,

therefore, an attempt was made by the Office of The Surgeon General to investigate the results of this technique at 23 named general hospitals in the Zone of

Interior. The outcome of the investigation was not particularly happy. It

was probably undertaken too soon. When the bulk of the questionnaires which

were answered were returned, less than months had elapsed since D-day, and

there had been insufficient time for the union of many major fractures. The

wording of the questionnaires, or so the replies suggested, does not seem to have

been as clear as it should have been. number of different observers prepared

the replies, and they naturally determined the results in accordance with their

individual standards, so that the personal equation made it almost impossible

to tabulate results, let alone correlate them. Finally, the reports on union of

fractures (delayed union versus nonunion) were particularly colored by individual interpretations.
WOUND SURGERY IN COMPOUND FRACTURES 101

Nineteen of the twenty-three general hospitals queried returned questionnaires covering 3,469 compound fractures. Of these, 1,180 were fractures of

the femur, 1,540 were fractures of the tibia and fibula, and 741 were fractures

of the humerus. Delayed primary wound closure had been attempted in 1,951 cases and had succeeded in 1,403. Of the 3,190 cases in which the information

was supplied, bony union had been accomplished in 2,189 cases, but 417

patients presented malunion and 584 still had no union. The tabulated results

confirmed the general impression that closure can be more readily accomplished

over femoral and humeral fractures than over fractures of the tibia and fibula.

Osteomyelitis was reported in 864 cases, but the figure is misleading since the

incidence was figured on both closed and unclosed wounds.

Data from studies of compound fractures in which delayed primary closure

had been attempted are more illuminating than the data just cited.

At Battey General Hospital, Rome, Ga., for instance, almost 90 percent

of the compounding wounds were successfully closed in fractures of the femur

and humerus, the incidence of union was high, and the incidence of osteomyelitis was low. In compound fractures of the tibia and fibula, on the other

hand, the incidence of bony union remained high, and the incidence of osteomyelitis low but closure was successful in only about 60 percent of the cases.

In the other hospitals reporting, the number of cases in which closure

had been attempted was frequently surprisingly small. Some of the results

were also frankly surprising. Thus it is difficult to reconcile the out of 10

failures in fractures of the humerus at Kennedy General Hospital, Memphis,

Tenn., with the percentage of successes reported from certain other hospitals,

particularly Battey General Hospital, where there were only unsuccessful

results in 38 attempted closures.

Unfavorable Cases

Nineteenth General Hospital.—An analysis of sample of material from

the 19th General Hospital is typical of the results obtained in delayed primary

wound closure when the circumstances were frankly unfavorable. At this

hospital, between 16 February and 31 May 1945, 881 wounds were closed

by this technique in 379 patients. About 90 percent of these wounds were

battle incurred. Almost all of them were severely comminuted compound

fractures, chiefly of the long bones of the extremities. In many instances,

extensive soft-tissue wounds were associated with the bone injuries.

Seventy-seven of the 379 patients were United States Army personnel;

298 were prisoners of war whose injuries were, almost without exception, the

most severe and extensive in the reported series.

When the patients in this series were first admitted to the 19th General

Hospital, their wounds were inspected merely by lifting off the upper layer of

the bivalved cast and the top layer of dressings. If the gauze was adherent

to the wound, as it frequently was, it was not removed. If through-andSemiannual Report, 19th GeneralHospital, European Theater of Operations, January-30 June 1945.

There were four additional patients of other nations (see footnote 3.).
102 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

through drain had been used, as it had been in few instances, it was removed

at once. If the wound was too tightly packed, the plug of gauze was also

removed. The policy at this time was minimum of wound inspection and

manipulation.

If the preliminary inspection just described could be carried out on the

ward it saved time. If, however, it was clear from the history that the wound

was extensive or if the gauze could not be readily removed, then the first complete inspection was carried out under anesthesia in the operating room.

On the whole, the wounds were inreasonably good condition, and debridement had been adequate. Most of the wounds had been kept open by dry,

fine-meshed gauze, lightly packed; only occasionally had the packing been

inserted so tightly that it was actually plugging the wound. In some cases

there had been too liberal removal of comminuted bone fragments, and the

large bony defects which were left could obviously be corrected only by bone

grafting.

All patients with wounds of any severity had immediate blood studies and

were given transfusions of whole blood before operation if the hemoglobin

level was below 12 gm. percent and the hematocrit level below 35.

The technique of delayed primary wound closure was that ordinarily

employed (p. 87).

Theresults in these 881 wounds in 379 patients were analyzed from several

different standpoints. Complete data were not always available in each

category.

In the 305 cases in which data are available on this point, wound closure

was carried out on the 2d day in cases and on the 75th day in case. The

(cumulative) figures show that 200 patients underwent reparative surgery

between the 2d and 7th after wounding; of these, 184 were operated on

between the 4th and 7th days. Two hundred and twenty-five patients were

operated on between the 2d and 8th days and 251 between the 2d and 10th

days. The other 54 were operated on between the 11th and 75th days.

While these patients were under observation in the 19th General Hospital,

59 frank wound infections occurred among them. Seven were in United States

Army personnel, and 52 in prisoners of war. Fifty-six of these 59 infections

occurred in men wounded in battle, 50 of whom were prisoners of war.

Primary healing occurred after delayed primary wound closure in 195

patients, 68 of whom were United States Army personnel.

It was observed that the highest percentage of good results in these 379

patients was obtained (1) when the hemoglobin at operation was 80 to 90 percent and the red blood cells 4,000,000 to 5,000,000 per cu. mm.; (2) when the

wounds were in the shoulder, arm, forearm, and hand rather than in the leg,

ankle, and foot (almost 100 percent versus 67 percent); and (3) when the discharge from the wound was serous but not seropurulent.

Composite studies.—In his annual report for 1944 to the Theater Chief

Surgeon, the senior consultant in orthopedic surgery commented on two other

reports dealing with delayed primary suture in prisoners of war.
WOUND SURGERY IN COMPOUND FRACTURES 103

The first of these reports concerned 97 prisoners of war who had been

caught between lines of fire. As result, the timelag between wounding and

initial wound surgery was unusually prolonged in most of these cases. Only

16 of the 97 had received penicillin or sulfonamide therapy before debridement. It is significant that only 33 of the 97 wounds (approximately third) were

considered clean enough to close at once by delayed primary suture. The second of these reports concerned 51 prisoners of war, in most of whom

the timelag was also unusually prolonged. Delayed primary wound closure

was carried out in all cases but was entirely successful in only 32 instances.

Partial healing occurred in 15 cases. In the other instances, the attempt at

closure was complete failure.

Three of the 32 patients whose wounds healed satisfactorily after delayed

primary suture had finally been performed had undergone debridement on the

day of wounding. The average timelag in the other 29 cases in this group was

32 hours. Of the 19 patients in whom delayed primary suture was only partly

successful or was completely unsuccessful, underwent debridement on the

day of wounding, but in the other 13 cases the average timelag was 72 hours.

Only of the 51 patients in this series hadreceived penicillin before debridement was done; they had had an average of 50,000 units each. Thirty-one others

received approximately 120,000 units each after debridement. Two of the

four patients whose wounds had failed to heal had received penicillin and two

did not.

The figures in this series are far too few to permit conclusions, but they

corroborate the generally accepted fact that the longer the delay between

wounding and initial wound surgery, the higher is the incidence of infection

and the less satisfactory is the healing process. These cases also demonstrate

again that basic surgical principles cannot be violated with impunity and that

adequate debridement is the keynote of success.

That the use or nonuse of supplemental antibiotic therapy was not the

most important consideration in the determination of the end results of wound

closure in this series is clearly shown in another series, which consisted of 107

compounding wounds in 73 soldiers. Sixty-three of the 73 patients had received penicillin, sulfadiazine, or both after admission to general hospital.

The largest number of complete or partial failures of wound closure occurred

in these 63 patients, although in every instance in the series the wounds had

been closed within 13 days, or less, after wounding, which is fairly early

timelag.

The figures, of course, must be interpreted with discretion. These wounds

were unfavorable for variety of reasons. When the cases are carefully analyzed, other factors, such as inadequate blood replacement, the location of the

wound, and the size of the wound obviously require consideration. NonetheAnnual Report, Professional Service Division, Orthopedic Surgery, Office of the Chief Surgeon, European

Theater of Operations, 1944.

Ibid.
104 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

less, in every failure or partial failure, the underlying reason was inadequate

debridement; the use of chemotherapeutic or antibiotic agents was no guaranty

of success when surgical principles were violated.

Combined Nerve-Bone Injuries

The exact frequency of peripheral nerve injuries in battle casualties is not

yet known. If the experience of the 45th Evacuation Hospital between 24

June 1944 and 26 April 1945 is taken as typical, it is just over percent. During this period, this hospital treated 14,891 surgical patients, all but 409 of the

number with combat injuries. These patients presented total of 20,740 separate wounds, 248 of which included damage to major peripheral nerve.

About 75 percent of the compound fractures complicated by nerve lesions

occurred in the upper extremity, with compound fractures of the humerus and

injuries to the radial nerve comprising the great majority of these. Compound

fractures of the femur, with division or other injury of the sciatic nerve, did not

form more than 10 percent of the combined nerve-bone injuries. The distribution was fortunate. The humerus is not only easier to approach surgically than

the femur but it also lends itself better to the shortening sometimes necessary in

serious associated nerve injuries. completely divided sciatic nerve which

cannot be repaired leaves an almost useless lower extremity, even if the fracture

of the femur heals in good position. In such cases, amputation occasionally

proved the solution of the problem.

Routine of management.—Several months after D-day, after joint

visit to several specialized treatment hospitals for neurosurgery by the senior

consultant in orthopedic surgery and the senior consultant in neurosurgery, the

following plan of procedure in combined bone-nerve injuries was proposed to

the Theater Chief Surgeon and after his approval became official policy:

1. All casualties with fractures associated with division of major peripheral nerve were transferred immediately to one of the seven specialized hospitals for neurosurgery in the United Kingdom Base. The same policy was

followed when it was suspected that the nerve was contused but not divided.

There was, in fact, no sure method of ascertaining, within the first weeks after

wounding, precisely how much nerve damage had been sustained.

2. Wounds of the soft tissues were closed as soon as possible, by suture, by

skin graft, or by both methods.

3. Fractures of the long bones were treated with skeletal traction and balanced suspension. No effort was made at this time to obtain anatomic length

of the bone, because the attempt was likely to defeat the objective of bringing

the nerve ends together.

4. Physical therapy was employed as extensively as possible to encourage

active motion of the unparalyzed muscles and to maintain mobilization of the

joints of the extremities. It included both diagnostic and therapeutic electric

stimulation of the injured part.

Semiannual Report, 45th Evacuation Hospital, European Theater of Operations, January-30 June 1945.
WOUND SURGERY IN COMPOUND FRACTURES 105

5. Definitive neurosurgical and orthopedic surgical procedures were performed approximately weeks after complete healing of the wound, which was

usually to weeks after wounding.

6. After operation, if circular plaster-of-paris splint was applied, windows

were cut out over the muscle bellies, to allow postoperative electric stimulation

of the paralyzed muscles. Some cases, as indicated later, were managed by

skeletal traction withbalanced suspension, without plaster.

7. booster dose of tetanus toxoid was administered before each operation.

8. Penicillin was administered for 48 hours before each operation and for

10 days afterward.

9. Evacuation to the Zone of Interior was effected as promptly as possible,

with plaster splint in place.

Technical considerations.—The first step in the management of combined nerve-bone injuries was to secure closure of the wound. If simple suture

was not sufficient, skin graft was used. If the plan for the second operation

was to approach the nerve injury through the original wound, full thickness of

skin was required, and full-thickness graft was used. Otherwise, split graft

was used.

After the wound had been completely healed for about 21 days, second

operation was done to explore the nerve injury and repair it as necessary.

About 50 percent of the nerve injuries explored in the European Theater of

Operations proved to be instances of contusion and not of division. The

nerves were found intact and only neurolysis was required, though, as already

emphasized, exploration was frequently required to establish this fact.

Whenever possible, the bone injury was cared for at the time that the

nerve injury was repaired. This was frequently practical, especially when the

neurosurgical center was part of hospital center and competent orthopedic

surgeons were immediately available. When the nerve and bone injuries could

be repaired at the same time, it was estimated that the soldier was saved at

least months of hospitalization. If the combined operation was not possible,

the nerve injury always took precedence over the bone injury.

The neurosurgeon first exposed the nerve and performed the necessary

nerve surgery. If possible, nerve suture was performed. If it was impossible

to bring the nerve ends together, no hesitancy was felt in shortening the bone,

it being regarded as more desirable to have shorter functional extremity than

to have paralyzed limb of normal length. Motion of the elbow joint was

not impeded if the humerus was shortened on an average of cm.

After the nerve repair had been accomplished, exposure of the bone offered

no difficulty. Various methods of management of the fracture were employed.

Fragments of the humerus were often held in position by one or two screws.

Screws could also be used on the femur, or it could be plated. Bone fragments

were often used as autogenous grafts, but care had to be taken to place them

in such position that they would not impinge upon the nerve.

Balanced suspension with skeletal traction was preferably used after operation. This method had two advantages; Elevation of the limb prevented
106 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

edema, which was particularly undesirable after nerve surgery; and electric

stimulation was easily carried out because the motor parts were exposed.

The percentage of shortening operations varied from hospital to hospital

but was, on the whole, larger than might have been expected in view of the

numerous injuries in which only neurolysis was necessary. Thus, in one

3-month period at the 117th General Hospital in the United Kingdom, 19

percent of the patients with combined injuries of the humerus and radial nerve

required shortening operations.

The results in 10 cases treated by this technique at this hospital are fairly

typical of the results achieved in shortening operations. The amount of

shortening varied from 2.5 to cm. and averaged cm. Within an average of

less than 11 months of hospitalization, of the 10 patients received certificates

of disability for discharge and had returned to civilian life, while others were

on furlough, in expectation of discharge under the same circumstances. No

details are known of the ninth case except that the patient was discharged.

The 10th patient had such severe nerve injury that tendon transplant was

regarded as better procedure than the cm. of shortening which would have

been required to approximate the nerve ends. Eight of these 10 patients had

well-healed fractures when they were last seen. The only one whose fracture

failed to heal satisfactorily as later treated by bone graft. In cases, radial

nerve function had ranged from 50 to 80 percent of normal when the patients

were discharged from service.

Full details of the management of nerve injuries are sot forth in the volume

of this series dealing with neurosurgery.

Combined asmlar-Bone Injuries

Most often the vascular injuries associated with bone and joint injuries

were caused by the direct effect of missiles, though occasional damage to the

popliteal artery resulted from penetration of the vessel by bone fragments in

supracondylar fractures of the femur. Vascular injuries associated with bone

or joint injuries naturally took precedence over them and required immediate

surgery. Full details are given in the volume of this series devoted to vascular

surgery.

Almost without exception, loss of the leg above the knee resulted in all

cases in which immediate ligation of the popliteal vessels was necessary. If

ligation could be deferred for as long as to days, it as sometimes possible

to perform the amputation below the knee, resecting the anterior lateral group

of muscles, which was most frequently involved, and leaving the patient with

more useful stump. Ligation of the femoral artery below the level of the

profundus was attended with little risk to the limb.

After ligation, the limb was protected from trauma and as kept cool.

In the absence of edema, the dependent position as preferred. If edema was

present, the limb was kept level with the body. Sympathetic blocks with

Novocain ere repeated as often as necessary, and in some hospitals the patients
WOUND SURGERY IN COMPOUND FRACTURES 107

were given small amounts of whisky by mouth to encourage dilatation of

peripheral vessels.

Sympathetic block was of great value in the management of vascular

spasm, which was often associated with compound fractures of the long bones

of the extremities. It was also of value in persistent edema and in causalgia,

which were other complications of bone and joint injuries. Sympathectomy

was performed in some cases after the value of repeated sympathetic blocks

had been established.

109

CHAPTER

The Management of Compound Fractures—

Techniques of Fracture Management

Plaster of Paris

Technique.—The following general instructions were issued for the

application of plaster casts for transportation in evacuation hospitals:

1. The extremity must be put up in the proper position.

2. Joints proximal and distal to the fracture must be immobilized.

3. Heavy padding must be used freely, with felt or other material applied

over bony prominences and major subcutaneous nerves.

4. Anterior and posterior plaster reinforcements must be applied smoothly;

then they must be encircled with plaster bandages, which must be applied

evenly and snugly and without tension. The turns of the plaster bandages

must be rubbed until they form homogeneous mass.

5. All circular plaster-of-paris casts must be split throughout their length

and through all layers, or must be bivalved, as soon as the plaster has set.

6. After the cast has been applied, an outline of the wound and of the fracture must be drawn on it. Data must include the nature of the fracture (simple

or compound), the date of injury, the date and hour of debridement, and the

unit which treated the patient.

7. The circulatory status and the motion and sensation of the fingers or

toes must be checked at frequent intervals after the cast has been applied. If

there is any doubt of these facts, the upper half of the cast should be removed,

or, if necessary, the entire cast, to be certain that the circulatory status of the

limb is not impaired.

8. Symptoms and signs of pressure sores must be looked for. If they

appear, window must be cut in the cast and firm padding applied over the area.

Casts applied after delayed primary suture were usually changed about 10

days later. At this time, the sutures were removed, and new circular plaster

splints were applied. No more padding was used than was absolutely necessary. Casts applied at this time, unlike the casts applied after delayed primary

suture, did not need to be split, the chief reason being that the patients were in

general hospital and under constant observation. Furthermore, swelling was

not apt to occur after reparative surgery.

Commanding officers of hospitals which evacuated patients to the Zone of

Interior were instructed to pay particular attention to the condition of plaster

casts in which they were to travel. Circular casts over open wounds were

always changed just prior to departure. If the wounds had been successfully

closed by primary suture, the same procedure was frequently followed but was
ORTHOPEDIC SURGERY IN EUROPEAN THEATER

not necessary in all cases, since the splints did not become foul-smelling and

stained with blood and discharge as they did in the open method of treatment.

The consultants in orthopedic surgery at first had some difficulty seeing that

the rule for splitting plaster casts for transportation was universally applied.

There was much less difficulty about insuring that enough padding be used.

Both of these were fundamental considerations, about which vigilance could

not be relaxed.

Other errors were also fairly frequent. Casts were sometimes unduly

heavy. Spicas were too widely abducted. The feet were put in the equinovarus position. The knees were sometimes straight and sometimes hyperextended.

Before D-day, the plan was followed of having the medical officers who had

made errors correct them immediately. Theoretically this was an excellent

plan but practically it took up great deal of time, which after the invasion

could not be spared from more important duties. Furthermore, the same officers frequently continued to make the same mistakes in spite of the demonstration to them of their errors. Eventually, most orthopedic consultants and chiefs

of sections arrived at the conclusion that as long as the basic principles of

padding the extremity and splitting or bivalving the cast were adhered to, no

permanent harm would come from minor errors which would be corrected in

few days anyway in general hospital, when definitive surgery was done.

Plaster proved useful and effective for orthopedic purposes in World War

II, though it had many obvious disadvantages. The hope is that in the future

some plastic dressing may be devised which will permit direct inspection of the

wound. If this type of material were available, it might not be necessary to

use the enormous quantities of protective sheet wadding which must be used

with plaster of paris, and direct inspection of the injury would be possible

without removal of the cast. This would permit prompt detection and immediate treatment of incipient gas gangrene and other infections.

Tobruk Splint

Although the splint used by the British in North Africa as transportation

splint for casualties with fractures of the femur was called the Tobruk splint,

the name was somewhat misleading. This splint was essentially the Thomas

splint, which had been devised in 1870, reenforced with plaster of paris to keep

it snugly on the limb while the patient was on his journey. The standard

method of application was as follows:

1. wide posterior plaster splint was applied from the level of the upper

thigh to point inches above the malleoli. Two 3- or 4-inch adhesive-plaster

strips were applied to the skin of the leg on the medial and lateral aspects from

just below the knee to the malleoli. The splint was applied with the knee in

15-degree flexion and was well molded by the use of muslin bias bandage.

Surgical meeting, 108th General Hospital, Paris, 26 May 1945.
FRACTURE MANAGEMENT IN COMPOUND FRACTURES 111

2. The popliteal space was protected by 6- by 6-inch piece of felt which

was applied before the splint was applied.

3. The splint was anchored to the full-ring Army splint by circular plaster- bandages which were applied loosely, so that they could be well crimped to

both sidebars of the Army splint.

4. The circular bandages and sheet wadding were split down to the skin.

5. The foot was supported by the device attached to the splint for this

purpose.

6. Approximately pounds of active traction was applied by the use of

elastic traction cord or plasma tubing attached to the adhesive-plaster strips

and tied over spreader to the end of the Army full-ring splint.

The Tobruk splint, according to its British advocates, was superior to the

plaster spica in two respects: It could be applied more quickly, and it required

less plaster and less water. In North Africa, where the splint was first used,

these were undeniable advantages. British hospitals in forward areas were

understaffed, at least by American standards, and supplies of plaster of paris

were sometimes inadequate, while water was often difficult to obtain.

In the light of the British experience and recommendations, the Tobruk

splint was accepted with enthusiasm by some American surgeons and training

film was produced to teach its correct application. All the orthopedic surgeons

who entered the European theater in 1942 and early 1943 were instructed in

the technique. Enthusiasm lessened, however, when the splint was observed

underbattle conditions. Members of the 3d Auxiliary Surgical Group who went

to North Africa in January 1943 returned almost unanimously condemning it

as inferior to plaster-of-paris spica.

This did not end the discussion. The relative merits of the Tobruk splint

and the plaster-of-paris spica continued to be argued. British consultants, at the meeting held with them by American Army consultants in Paris in October

1944, expressed the opinion that the United States Army Medical Corps was

unwise in failing to use the Tobruk splint more extensively. To settle the

question on the basis of facts rather than impressions, Lt. Col. John G. Manning,

MC, consultant in orthopedic surgery, Ninth United States Army, was requested to conduct controlled investigation and to report on it as soon as

possible.

Colonel Manning’s investigation, which covered the months of November

and December 1944, was carried out in five evacuation hospitals. During

this period, 202 fractures of the femur were treated. One hundred forty-three

of these were immobilized for transportation in the Tobruk splint. This

technique was not used in the remaining cases for three reasons: (1) The ring

of the splint would have caused pressure on wound of the upper thigh or

buttocks; (2) skin traction could not be applied because of wounds of the leg

Annual Report, Professional Service Division, Orthopedic Surgery, Office of the ChiefSurgeon, European Theater

of Operations, 1944.

Semiannual Report, Professional Service Division, Orthopedic Surgery, Office of the Chief Surgeon, European

Theater of Operations, January-30 June 1945.
112 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

or fractures of the tibia or fibula; and (3) full-ring leg splints wore sometimes

not available. The British technique was followed as precisely as possible

whenever the Tobruk splint was used.

questionnaire was placed in the medical records jacket which accompanied each of the 143 patients, and Colonel Manning’s report was based on the

63 which had been returned by 15 April 1945. While not all questionnaires

were complete on all points, the following summarized data were obtained

from them:

The 63 fractures of the femur included in the analysis consisted of 37

fractures of the shaft, 16 fractures of the upper third, and 10 supracondylar

fractures.

The timerequired for application of the splint ranged from 10 to 45 minutes.

Between and 12rolls of 6-inch plaster bandage were used for each application, the average being rolls.

The splint was kept in place from to 25 days. The average range for

the individual hospitals was from 4.4 days (in hospitals in Liege, Belgium)

to 18 days (in hospitals in Normandy, France), and the average for the whole

group of hospitals was 8.1 days.

The location of the fracture apparently influenced the surgeons’ opinion

of the value of the splint, though the number of cases is too small to be conclusive in any category. It was stated to be superior to the plaster spica in

of 15 fractures of the upper third and to be inferior in 14. In 36 fractures

of the shaft, the splint was stated to be superior to the plaster spica in and

inferior in 28, In 10 supracondylar fractures, it was stated to be superior in

and inferior in 7. For the 61 cases in which this information was available,

the splint was thought to be superior to the plaster spica in 12 and inferior in

49. Inconclusive as are these figures, there was no doubt of the preference of

American surgeons for the plaster-of-paris spica.

Information as to the patients’ opinion of the splint was also secured in 62

cases (table 3). At the meeting of the consultants in May 1945, at which the

report of this investigation was made, the Theater Chief Surgeon agreed

with the criticism voiced by one of the British surgeons present, that it was

rather risky to draw statistical conclusions from patient’s evaluation of his

Table 3. Patients’ opinions of Tobruk splint in 62 fractures of the femur

Opinion

Location of fracture

Total

Upper third Shaft Supracondylar

Comfortable __ 13 20

Uncomfortable ___ 10 15 38

Painful 14

Total 15 37 10 62

See footnote 1, p. 110.
FRACTURE MANAGEMENT IN COMPOUND FRACTURES 113

own comfort, and further agreed that casualty with fractured femur and compounding wound was unlikely to be very comfortable at the best. The majority of surgeons whoreported on these cases stated that the Tobruk splint could be applied more rapidly and with less effort than the plaster spica.

They agreed that patients were comfortable in it as long as they remained in

an evacuation hospital. They felt, however, that this splint was not suitable

for all fractures of the femur and that it did not supply adequate or comfortable

transportation. They therefore regarded it as inferior to the plaster spica for

transportation purposes.

number of complications were recorded in these 63 cases. In 11 instances the ring of the splint had become displaced medially, causing pressure,

pain, and discomfort in the perineal area. In instances, superficial pressure

sores resulted from pressure on the buttocks. Two of the 63 patients required amputation, but in neither instance was

the splint responsible. In case, the circulation in the leg and foot was unimpaired, but massive loss of soft tissue, bone, and sciatic-nerve tissue made it

impossible to save the limb; this patient died after transfusion reaction. In

the other case, the popliteal artery and vein had been ligated when debridement was done. Amputation was required in general hospital in the United

Kingdom days later, presumably for gangrene of circulatory origin.

This report, which was read at final meeting of British, Canadian, and

United States Army consultants in Paris in May 1945, produced vigorous

discussion but changed few minds. The British and Canadian surgeons

remained convinced of the value of the splint. American medical officers

continued to favor the plaster spica for transportation splinting in fractures

of the femur. The interesting point was made, in the concluding remarks on

the subject, that the Tobruk splint was almost the only important matter on

which all Allied medical officers were not in substantial agreement concerning the principles and techniques of orthopedic practice.

Skeletal Traction

Skeletal traction proved in World War II to be the safest and simplest

method of mass treatment of compound fractures of the long hones. Immediate results achieved overseas and followup reports from observers in hospitals

in the Zone of Interior all supported this point of view. One of the great

advantages of this technique, furthermore, was that it was readily mastered

by the general practitioners, obstetricians, pediatricians, and other medical

officers who had had no previous experience with fractures in civilian practice

but who often had to be assigned to surgical services in overseas hospitals because of shortages of trained personnel.

During active combat, the holding period on the Continentwas never sufficiently long to permit the routine treatment of fractures of long bones by skeletal

traction. This technique was, however, widely used in United Kingdom

See footnote 1, p. 110.

372572°—56
114 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

hospitals. Originally, it was chiefly employed for compound fractures of the

femur. After the visit of The Surgeon General to the European theater in

July 1944, its use was extended to fractures of the tibia and the humerus, and,

in some instances, it was also used for fractures of the forearm.

In the United Kingdom Base, the holding period for compound fractures

varied from to 10 weeks, depending upon tiie type and site of the fracture.

If patient was received within to 14 days of wounding, he could be treated

in continuous traction after the wound had been closed by delayed primary

suture. The patients were comfortable, and the results from every standpoint

were usually good. Reduction was maintained satisfactorily, and wound

healing was ordinarily prompt. Every effort was made to encourage exercises

which would prevent atrophy of the regional muscles, as well as to secure free

motion in the joints above and below the site of the fracture. If these exercises

were carried out as directed, functional results were usually good. Practically

always the explanation of poor results in cases in which the severity of the

original injury did not explain them was either failure to give proper attention

and constant supervision to the apparatus in which the patient was put up

in continuous traction or failure to carry out exercises as directed.

Patients were held in overseas hospitals until their fractures had frozen

sufficiently to assure maintenance of position in plaster cast during the period

of transfer to the Zone of Interior.

As noted elsewhere, it was interesting to observe how conveniently, when

the necessity arose, patients in traction could be cared for in tented wards,

though the necessary equipment reduced the number of beds from the usual

30 to 15. In the busiest times, some hospitals had as many as 35 or 40 patients

in traction in tents, and many had 200 or more in traction at the same time

in wards.

While skeletal traction was, generally speaking, the most universally

satisfactory technique for the mass management of compound battle-incurred

fractures, each injury required individual analysis with careful consideration

of such factors as the location and type of the fracture, the position and size

of the wound or wounds, the extent of destroyed or paralyzed muscle, the need

for ready accessibility to the wound for secondary operations and dressings, and

the necessity for skin grafts and nerve suture.

Only occasionally could traction alone be depended upon to effect satisfactory reduction. Before traction was instituted it was almost always necessary to reduce the fractures by carefully planned, gentle manipulation, which

was usually carried out under intravenous Pentothal Sodium (thiopental

sodium) anesthesia, supplemented by oxygen and nitrous oxide. Exploration,

wound closure, and suspension of the fractures constituted major surgical

procedure, which often occupied several hours. Both before and after operation, blood replacement, maintenance of the fluid balance, and the administration ofantibiotics and of dietary supplements were matters of great importance.

The Kirschner wire was almost always used for skeletal traction, with the

Steinmann pin reserved for special cases. In many instances, the greater
FRACTURE MANAGEMENT IN COMPOUND FRACTURES 115

surface area of the heavier Steinmann pin might have provided theoretic

advantage, but the Kirschner wire was better tolerated. Experience soon

showed that, for optimum results, the wire must be inserted with the limb in

its final position in traction. If, for instance, the knee was flexed after wire

had been inserted transversely in the supracondylar area of the femur with the

leg in extension, the skin and subcutaneous soft tissues would be folded against

or stretched around the wire, and, within few days, there would be an infected

conical cavity extending down to the bone.

It was perfectly practical, however, to use the wire and tautener as handle

for manipulation. When this was intended, the limb was placed in its final position, the wire was inserted, and the necessary manipulations were then

carried out.

Whenever possible, the wire was inserted at right angles to the long axis

of the bone. The skin was punctured directly by the wire at the point of

entrance. On the opposite side, the wire was allowed to create its own aperture

for exit. Because of the normal process of bone resorption, even correctly

inserted wires became loose to weeks after insertion. Sterile felt, cork, or

sponge rubber was inserted between the skin and the tautening bow to prevent

the wire from sliding; individual surgeons used for this purpose whatever they

happened to have available.

Wires were never inserted into bare bones or through wounds. It was

almost always possible to use adjacent areas with normal uninjured bone and

skin and to adjust the skeletal traction to compensate. When the proper

precautions were taken, infection, loosening, and drifting of pins or wires, and

even ring sequestra appeared far less often than might have been expected.

Chronic osteomyelitis practically never occurred.

The amount of weight required to maintain reduction was, on the whole,

less than was required in similar fractures in civilian life. The explanation was

the large volume of destroyed or paralyzed muscle in battle-incurred fractures.

When this factor was borne in mind, distraction was readily avoided.

As rule, patients were put up in permanent traction immediately after

delayed primary wound closure, preferably while they were still underanesthesia.

In an occasional hospital, this practice was not followed. Instead, the patient

was put up in temporary traction and taken to the recovery ward for 24 to 48

hours. This was bad practice as well as an unnecessary precaution; properly

managed patient almost never went into shock after delayed primary wound

closure. On the other hand, when he was placed in traction twice, he sometimes

went into shock after the movement and manipulations required by the

secondary procedure. From the standpoint of the injury itself, this practice

was also undesirable, particularly in fractures of the femur. The continued

manipulation of fragments frequently meant loss of position, as well as considerable discomfort to the patient.

In some hospitals, skeletal traction was used so extensively that, as in the

22d General Hospital, medical corpsman was designated as the traction

technician. His only duties were to make continuous rounds torefresh traction
116 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

slings and adjust apparatus. Once daily, he applied 70-percent alcohol to the

skin dressings around the pins. The value of the antiseptic application was

open to question, but this was simple and certain way to assure that the technician carried out his major duties on every patient. The morale factor was

also important. The maintenance of skeletal traction was matter of teamwork, and the application of the alcohol, it was found, helped to make the

technician feel that he was an important member of the team.

External Fixation

Some of the compound fractures which occurred at Pearl Harbor the opening day of the war were treated by external skeletal fixation. Unfortunately,

the reports which described the experience not only concerned too small series

of cases for objective evaluation of this method but wore also published prematurely, before the followup was sufficiently long for fair estimate of results.

The enthusiasm of the first reports, however, was contagious, and before it

could bo shown to be unjustified the Army had invested heavily in various

forms of apparatus for external fixation, and inexperienced young Army

surgeons had used the method in fairly large number of cases.

External fixation soon proved itself to be method totally unsuited to the

general management of military casualties. It had an extremely restricted

field of usefulness, and, unless the patients were selected with the greatest care,

its use in both simple and compound fractures was inevitably associated with

high percentage of both infection and delayed union. In the relatively small

number of cases in which the method was used in the European theater, with

pins incorporated in circular plaster casts, distraction of the fractures and

pinhole osteomyelitis occurred very frequently. The use of the method was

therefore forbidden, and the apparatus was removed from the hospitals,

Internal Fixation

In certain simple fractures, open reduction and internal fixation sometimes

seemed to be the only way to secure union with proper alinement. In compound fractures, anatomic replacement of the fractured hones with maintenance of their position by internal fixation was also sometimes indicated.

Fractures of the long bones adjacent to joint surfaces often could not be

managed in any other way.

In simple fractures, in which internal fixation is seldom indicated, this

technique was probably used more often than it should have been. In compound fractures, it proved useful method in certain carefully selected cases

but one that was completely unsuited for general use. Often it was an extremely formidable procedure.

Internal fixation had to bo performed with number of precautions, one

of the most important being strict attention to the preoperative blood level.

Circular Letter No. 131, Office of the Chief Surgeon, Headquarters, European Theater of Operations, November 1944, Care of Battle Casualties, Treatment of Wounds of Bonesand Joints. (See appendix A, p. 325.)
FRACTURE MANAGEMENT IN COMPOUND FRACTURES 117

The hematocrit had to be raised to at least 40. Surgeons rapidly learned that

in this operation, as in many others, there was no substitute for whole blood in

the preoperative preparation of patients.

After penicillin became available, in the spring of 1944, it was administered

routinely before all internal-fixation operations. It was given, as rule, in

25,000-unit doses at 3-hour intervals before surgery and as long thereafter as it

was indicated. As time passed, it was found that the postoperative period of

administration could be shortened considerably over what had previously been

thought necessary.

Minimal traction was used until the wound was healed. No comparative

figures are available, but the clinical impression was that this practice, in

addition to adding to the patient’s comfort after operation, shortened the

hospital stay and improved the anatomic and functional results.

One other consideration was extremely important in the use of internal

fixation: This method could be used with safety and with relative frequency

before D-day, when the general and station hospitals were staffed with qualified

surgeons experienced in this technique. As newer hospitals began to arrive

staffed with officers who were less adequately trained in bone and joint surgery,

its use had to be considerably curtailed, even for noncombat injuries. With

the great majority of surgeons who were treating military casualties both undertrained and inexperienced, disaster would have been inevitable if permission

had been given for the general employment of this method. For this reason,

and for the reasons already stated, internal fixation was forbidden as primary

procedure.

Reports from special hospitals in which internal fixation was correctly

used, with discretion and in properly selected cases, show both the possibilities

of the method and its extremely limited field. It was used, for instance, in only

71 cases at the 46th General Hospital. These included 30 fractures of the femur,

14 of the tibia, 13 of the humerus, of the ulna, of the radius, of the patella,

and of the clavicle. The distribution of cases indicates the relative usefulness

of the method in various regional fractures. Examinations of therecords showed

that without exception these patients did well in the hospital. There was not

single serious postoperative infection. Dependent drainage was often necessary

in femoral fractures, and posterolateral incision was used. Healing usually

occurred promptly.

The 23d General Hospital had similar experience. Internal fixation was

used only 55 times in 1,628 bone and joint injuries observed over 2-month

period while the hospital was operational in Italy, and the proportion of operations in the European theater was roughly the same.

On the other hand, it is doubtful that the end results of internal fixation

were as good as the immediate results seemed. In communications between

The Surgeon General’s Office and theTheater ChiefSurgeon during the winter of

1944-45, it was pointed out that review of patients treated in the MediterCircular Letter No. 23, Office of the Chief Surgeon, Headquarters, European Theater of Operations, 17 March

1945, Care of Battle Casualties, Orthopedic Surgery. (See appendix A, p. 330.)
118 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

ranean theater by internal fixation had revealed several disturbing facts. One

was that it was necessary to remove the metal in from 25 to 40 percent of all

cases in order to end drainage and permit healing. It also seemed that this

method had been used in numerous cases in which the indications were doubtful.

The Surgeon General therefore proposed that this method be reserved strictly

for cases in which there was no doubt of the indications. He also proposed that

two series of compound fractures, one treated by the usual method and the other

by internal fixation, be studied from the standpoint of wound healing and

fracture healing, with particular reference to the position of fragments and the

incidence of osteomyelitis. An incidence of infection of 25 to 40 percent was so

far in excess of the incidence in patients treated by delayed primary suture and

skeletal traction that it seemed essential to know whether the increased accuracy

secured in reduction offractures by internal fixation compensated for the higher

rate of infection. The fighting in Europe ended before this study could be made.
119

CHAPTER XI

Regional Injuries

The amount of mechanized equipment used by the United States Army

in World War II accounted for the extreme frequency of noncombat injuries

both before and after D-day. Traffic injuries were also distressingly frequent.

At the 801st Hospital Center, for instance, it was startling to learn that of 150

consecutive compound fractures treated immediately after D-day, 30 were

caused by accidents which had nothing at all to do with fighting. Simple

fractures were much more frequent in noncombat than in combat injuries, in

which compound fractures, often with serious comminution, were the general

rule.

It will be observed that in this chapter distinction is made between the

management of noncombat and combat injuries of the bones and joints, as well

as between the management of injuries before and after D-day. Before D-day

there was time—though perhaps not always justification—for techniques of

management which would have been completely unwarranted when hospitals

had become crowded with battle casualties whose need for treatment was urgent.

Forearm

Many of the fractures of the forearm treated before D-day were of the type

usually encountered in civilian practice and were managed in much the same

way as similar fractures would be managed in civilian life. Special types of

fractures, especially fractures of the radial head and of the carpal scaphoid,

were frequent and will be discussed in detail later in this chapter. large

number of Monteggia’s fractures were handled at the 803d Hospital Center,

whose staff believed that the best results were accomplished by early surgery

on the ulna, through an incision which gave complete exposure of both the

fracture and the elbow joint. The procedure consisted of internal fixation of

the ulnar fracture, reduction of the head of the radius, and suture of the orbicular ligaments.

Wounds of the forearm of combat origin usually healed well after delayed

primary suture. Special methods of reduction were, however, often necessary

to establish bony continuity, in order to speed healing and improve functional

results. The difficulty in fractures of the radius and ulna was to effect and

maintain reduction. They were preferably put up in plaster of paris in moderate pronation. decided tendency was noted on the part of some surgeons

who had had no special orthopedic training to put them up in full supination.

Cross union was inevitable in most cases in which this position was maintained

for any length of time. If the patient was caught in the chain of evacuation

for or weeks, as could readily happen, the initial bad position was likely to

become permanent.
120 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Skeletal traction.—When simple reduction of fractures of the bones of

the forearm was not sufficient and open reduction was contraindicated because

of the seriousness of compounding wounds, infection, extensive bleb formation

or other complications, unstable fractures of the shaft of the radius and ulna

were sometimes managed by the use of heavy Kirschner wires to maintain reduction. At the 298th General Hospital, the practice was to insert one wire

through the bases of the second, third, fourth, and fifth metacarpals and

second wire through the olecranon process, after which spreaders were applied

and the fragments were manipulated into good alinement. The wires were then

incorporated in long arm plaster-of-paris cast, the spreaders being removed

after the plaster had set firmly. The wires were withdrawn at the end of

weeks, but immobilization was continued until firm union had occurred.

Careful selection of cases was essential. No serious complications were encountered in the fractures in which this method was used, and it served as

satisfactory alternative to open reduction in some of the cases in which the

latter method was contraindicated.

At the 802d Hospital Center skeletal traction was used in 30 fractures of

the bones of the forearm, as follows:

Wires through the olecranon process and distal radius were used in 20

fractures of the proximal radius and ulna. The ulna could usually be controlled

very well, but satisfactory realinement of the proximal third of the radius was

much more difficult to achieve.

Traction through the metacarpals was used in 10 fractures of the distal

radius and ulna. nice adjustment of ulnar or radial deviation was necessary, and particular care was required to insert the wire and preserve the palmar

curve of the hand. The wire did not always transect all four metacarpals,

and the method was extremely difficult to apply, even when an experienced

technician was in charge of the case. This particular technique also had other

disadvantages, such as the following:

Patients were reluctant to exercise the fingers because movement was

painful and because even the slightest fixation of the carpometacarpal joints

interfered with the rotation, gliding, and interaction of the complicated, highly

flexible joints of the hand. When the fracture was in the distal or middle third

of the radius, traction through the metacarpal of the thumb or the styloid

process of the radius, with the hand put up in ulnar deviation, proved satisfactory method of management. At this hospital center, traction was practically never used in fractures involving only the ulna.

When fractures of the radius were associated with extreme shattering of

the fragments, the collapse of the bone was often enough to causeradial shortening. Radial deviation was then the end result, even when the cast had been

carefully applied in ulnar deviation. One alternative, the application of

traction through the carpus or the first metacarpal, was not viewed with particular favor, since traction had to be maintained at least weeks to obtain solid

union. Many surgeons thought that more satisfactory function of the hand

and wrist could be obtained by technique which permitted earlier removal of
REGIONAL INJURIES 121

the cast, even though later resection of the ulna might be necessary to correct

radial deviation. The relative end results of the two techniques are not known, since wartime exigencies made followup of most patients entirely impractical.

Internal fixation.—Internal fixation was the preferred method of management of compound fractures of the radius and ulna which could not be handled

by more conventional methods. In many cases, however, in which comminution of the radius was considerable, it appeared, regardless of the technique

employed overseas, that osteotomy and bone grafting would eventually bo

necessary in Zone of Interior hospitals.

Fractures of the Radial Head

In the early orthopedic literature, fractures of the head of the radius,

although they were always recognized as important because of the disability

they caused, were regarded as rather uncommon. The increasing use of

roentgenograms helped to overturn that impression, though many incomplete

vertical fractures, and even some complete fractures, continued to be diagnosed

as sprains of the elbow.

This civilian type of injury assumed considerable importance in World

War II not only in training areas but also overseas, where it accounted for

considerable loss of days from duty. For that reason, two typical series of

cases are presented in some detail.

The 168th Station Hospital, according to report by Maj. Nathaniel

Gould, MC, treated 49 of these injuries in England in 1943 and 1944. The 65th

General Hospital, according to report by Maj. Julian E. Jacobs, MC, and

Capt. Harold B. Kernodle, MC, treated 42, also in England, in the course of 10

months. The latter hospital, over the same period, treated 10 simple fractures

of the radial neck, Colies’ fractures, Smith’s fractures of the distal radius,

and 100 simple fractures of the scaphoid bone.

Nature of the injury.—The history of the injury in fractures of the radial

head is sometimes that of direct, forceful blow upon the elbow, or fall upon

the elbow. Much more often, and much more typically, the story is of minor

accident, fall from bicycle or ladder, or merely fall, with the attempt,

whether the fall is forward or backward, to break its effect against the outstretched hand, with the forearm partly pronated and the elbow slightly flexed.

In the fractures under consideration in the two overseas hospitals these stories,

which are typical of injuries in civilian life, were frequently heard, but the

histories also included falls from the wings of planes, or simple falls during the

blackout.

The regional anatomy (fig. 23) serves to explain the result of such accidents.

Grossly, the head of the radius is of the same bony composition as the patella,

with the columnar type of dense cancellous bone running lengthwise. That is

why the plane of the fracture is so often longitudinal. The head, which is

rounded on its lateral aspect and somewhat hollowed on its proximal end, to

permit articulation with the capitellum of the humerus, is entirely covered by

articular cartilage. Unless the articulation is almost anatomically perfect, full
122 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 23.—Lateral view of partly dissected joint of right elbow, showing relationship

of radial nerve to annular ligament. Insert shows ligamentum capitulum radii as continuation of quadrate ligament. Note relationship of biceps tubercle to fracture with forearm

pronated (from dissected specimen, Cambridge University Medical School).

supination and pronation of the forearm will not be possible. As result of

the fall or other accident which causes the fracture, and the effort to break its

force, an abduction force is transmitted through the head of the radius to the

capitellum. The degree of leverage and the resulting angle at which the pronated radial head is driven into the capitellum determine both the degree of

comminution and the degree of displacement whichresult. Unless the coronary

ligament, by which the radial head is strongly bound to the ulna, should rupture,

the general contour of the radial head will be maintained, even if mushrooming

occurs.

The radial head is entirely covered by articular cartilage. The posterolateral continuation of the attachment of the quadrate ligament (ligamentum

capitulum radii) is covered by distinct fold of synovial membrane (fig. 23),

which is fact of importance in cases treated surgically.

The abduction force which damages the radial head also traumatizes the

medial capsule. This explains why, even late in the followup, some patients

may complain of discomfort about the medial aspect of the elbow joint. In

the 42 patients treated at the 65th General Hospital, of 28 with mild fractures
REGIONAL INJURIES 123

in the form of simple cracks of the bone and with comminuted or displaced

fractures complained of this type of pain. The fact that patients with much

more severe injuries did not complain of it was explained in those cases by

dissipation of the abduction force by collapse of the radial head.

Classification.—All 49 fractures of the radial head observed at the

168th Station Hospital were classified as simple. The 42 fractures treated at

the 65th General Hospital were divided into three groups:

1. Twenty-eight fractures, two-thirds, were simple cracks, in the form of

single longitudinal cleft across the head, without depression (fig. 24) or with

slight depression (fig. 25). In this type of fracture, there was no actual increase

in the circumference of the head. The abduction force had been applied briefly

to the anterolateral segment of the head against the capitellurn (fig. 26). All

fractures in this group could be treated conservatively.

2. Five fractures in which the circumference of the head had been increased

moderately by comminution or had been disturbed by marginal displacement of

the anterolateral segment (fig. 27). All cases were treated conservatively,

though the question of surgical excision was raised in one or two.

3. Nine fractures in which there was marked displacement of one or more

bony fragments (figs. 28 and 29). All these cases were treated surgically.

The circumstances of the accident determined the side affected. In these

42 cases, the distribution was almost equal, 22 of the fractures being on the left

side and 20 on the right.

Fkiure 24.—Cleft fracture of radial head, group 1, 10 months after patient had sustained

“sprain.” Note persistence of fracture. (See also figures 31 and 33.)
124 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 25.—Cleft fracture of radial head, group 1. Note slight depression of anterolateral segment.

Figure 26.—Fracture of radial head, group 1, with forearm in pronation (position at

time of injury), showing relationship of fractured segment to capitellum.
REGIONAL INJURIES 125

Figure 27. —Fracture of radial head, group 2, with comminution and some displacement.

Figure 28.—Fracture of radial head, group 3, with severe comminution involving

entire head.
126 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 29.—Fracture of radial head, group 3, showing severe comminution with displacement.

Diagnosis.—The diagnosis of this injury presented no difficulty in either

of these series, partly because the story was always typical and partly because

the relative frequency of the fracture made it impossible not to bear it in mind

as possibility. Usually, as already noted, there was history of fall upon the

extended hand, with the forearm also extended. Less often there was story of

direct fall or blow on the elbow. As rule, immediate discomfort was slight,

and full range of motion was possible for some hours. Then the elbow began

to feel stiff, there was pain of increasing severity even when the arm was at

rest, and there was severe pain on motion. The pain was always most severe on

attempted supination. full range of motion was impossible. The arm could

not be extended completely, and full flexion was also impossible. The limitation of motion was chiefly due to hemorrhage into the elbow joint, which is

almost invariable in this type of fracture.

An occasional patient with fracture of the radial head complains of discomfort or pain referred to the wrist. This type of pain was not observed in

any of the cases in this series. On the contrary, the absence of clinical or

radiologic evidence of trauma to the distal radio-ulnar joint was repeatedly

noted. When pain in the wrist is present with fracture of the radial head,

it is best explained as referred pain. The explanation is that the wrist joint

is innervated by the terminal branches of the deep branch of the radial nerve

which has conceivably been irritated by trauma to the radial head.
REGIONAL INJURIES 127

When the patients in this series were first seen, the position of the injured

extremity was usually typical. The forearm was supported, in neutral position,

with the elbow flexed 100 to 135 degrees. Attempted supination of the forearm by either the patient or the examiner caused great pain, especially in the

region of the radial head. Palpation over the head of the radius elicited

complaint of tenderness. An effusion, which invariably proved hemorrhagic,

could be demonstrated in the joint.

Anteroposterior and lateral roentgenograms confirmed the clinical diagnosis.

Management.—It was the practice at some hospitals in the European

theater, when fractures of the radial head were encountered, to decide immediately whether the damaged head should be excised or be left in situ, on the

ground that delay in excision might end in the development of degenerative

arthritis between the radial head and the capitellum. If surgery was decided

upon, it was carried out as promptly as possible, on the ground that to delay

excision for period of months and then perform it for the relief of painful

elbow was simply tempting fate, since arthritis is almost never relieved by

delayed surgery. It was the practice at other hospitals to treat fractures of

the radial head conservatively unless the articular surface was badly damaged.

This policy was followed even if there was slight angulation at the neck.

The two series of cases upon which the foregoing discussion has been based

were chiefly treated conservatively.

At the 168th Station Hospital, 43 of the 49 fractures of the radial head

were treated conservatively but as immediate emergencies. As soon as the

nlinical diagnosis had been made and had been confirmed by roentgenograms,

the patient was taken to the operating room, where the joint was aspirated

under strict sterile conditions. The surgeon wore gloves and was masked, and

his assistants were also masked. The elbow, after it had been prepared with

iodine and alcohol, was draped with sterile towels.

After the affected area had been injected with sterile Novocain solution

(2 percent), No. 20 intravenous needle was introduced into the joint and

aspiration was continued until all the blood had been evacuated. The amount

removed ranged from to 36 cc. and averaged between 18 and 20 cc.

well-padded plaster cast was then applied from the midarm to the

base of the fingers, with the forearm in neutral position and the elbow at 90

degrees. In the early experience, the cast was kept on the arm for days.

As experience increased, it was removed on the fourth day.

As soon as it was removed, the patient was sent to physical therapy. He

kept his arm in sling for the remainder of that day but discarded the support

the following day. Exercises in the physical-therapy department consisted of

active flexion and extension exercises, at first with 2-pound weight, pulley,

and rope. On the following day, the weight was gradually increased until

maximum of 15 pounds was reached. Massage and whirlpool treatments to

The other patients, because of associated fractures of other bones, had to be transferred to general hospital for

treatment, since theater policy limited the holding period in station hospitals to 30 days.
128 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

the arm, forearm, and elbow were also used. In the laterpart of the experience,

formal exercises were supplemented by hot water soaks and by exercises on

the ward. Since pain was relieved dramatically almost as soon as the joint

was aspirated, only the occasional patient had to be persuaded to carry out

these instructions. Incidentally, no patient in this series required any sedation.

At the 65th General Hospital, 33 patients (groups and 2) were treated

conservatively and the other (group 3) by surgical measures.

The 28 (group 1) patients with simple noncomminuted or nondisplaced

fractures used slings for week or 10 days, but aspiration was employed only

if the joint was tense. It was repeated as necessary. It was preferred, when

aspiration was indicated, to delay it for 24 hours after injury, by which time

active bleeding had usually ceased.

In the cases in group 2, the same type of treatment was used, unless

comminution was considerable. Then plaster splint was applied for 10 to

14 days, with the forearm in neutral position and the elbow at right angle.

When the splint was removed sling was employed. Aspiration was carried

out in of the cases in this group but was not thought to have influenced

the end results. Heat and light massage were employed when the splint was

removed.

The patients in group were subjected to surgical excision of the entire

radial head. It was not always possible to determine, before direct inspection,

whether excision could be limited to the small fragment demonstrated roentgenologically or whether so much comminution would be found that resection

of the entire head would be necessary. Total resection was necessary in all

cases in this group. Trauma to the articular cartilage, which was not revealed

by roentgenograms, was also considerably greater in every case than had been suspected.

The technique of operation was as follows:

sphygmomanometer cuff, inflated to 200 mm. Hg, served as tourniquet.

An incision was made extending from the lateral epicondyle through the conjoined tendon of the extensor digitorum and the extensor carpi ulnaris (fig. 30).

It was usually about inches long. It extended down to, but not beyond, the

annular ligament. Care had to be taken not to cut or otherwise traumatize

the deep branch of the radial nerve by traction on the supinator muscle mass.

Adequate exposure of the joint could always be obtained by carrying the incision to, or proximal to, the epicondyle.

When the forearm was fully pronated, the triangular ligament came into

view through the incision. The relationship of this ligament to the bicipital

tubercle and the fracture (fig. 23 insert) which had been demonstrated at the

anatomy table was invariably confirmed.

The ligamentum capitulum radii was stripped with the osteotome down

to the point at which it blends with the synovial reflection, to provide flap

that could be sutured across the raw stump. The use of sharp osteotome,

held rigidly at the base of the radial head, proximal to the annular ligament,

produced smooth stump. Frequent light tapping, together with rotation of
REGIONAL INJURIES 129

Figure 30.—Lateral incision at elbow used in resection of radial head.

the forearm through 150 degrees, left smooth cut and offset the minute bony

fragments that resulted from the use of the Gigli saw. Any shredding of the

cartilage over the capitellum was then pared down. Further inspection of the

lateral joint compartment and visualization of the humeroulnar joint allowed

removal of any interposing fragments.

The ligamentum capitulum radii, which had previously been reflected, was

now sutured across the smooth radial neck, completely covering it. The incision was closed in layers, (1) the synovial membrane and capsule, (2) the split

conjoined tendon, and (3) the skin.

After the wound had been dressed and the arm covered with sterile sheet

wadding, plaster cast was applied, with the elbow flexed to 90 degrees and

the forearm in neutral position.

At the end of 14 days the cast was removed, the skin sutures were removed,

and active motion and physical therapy were begun. sling was worn for

the next 14 days.

End results.—At the 168th Station Hospital, where treatment was

entirely conservative, the hospital-stay days ranged from 12 to 26. In the

first cases, when the cast was worn for days, the stay days averaged 22. In

the later cases, when the cast was maintained for only days, the average stay

days were 15. An additional reason for the reduction in the period of hospitalization was the more intensive physical therapy in the later cases and the

372572°—56 10
130 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

self-treatment on the ward with hot water soaks and continued flexion and

extension exercises. In the cases treated later, more intensive effort was

also made to gain the confidence of the patient and to assure him that the continuous rigorous workout would help his arm and not injure it. One patient,

who was on duty in the hospital, was treated as an outpatient, with satisfactory

results. There were no readmissions after discharge.

There were three criteria for discharge, (1) freedom from pain, (2) complete pronation and supination, and (3) flexion or extension disability of no

more than degrees.

Forty of the forty-three patients treated at the 168th Station Hospital

could be followed up for months or more after their discharge. Results were

good in all 40 cases. Most patients had no disability at all at the end of the

period of observation and all of them were on full duty and had no difficulty in performing their duties. These results were attributed to the brief period of bleeding, as the result of prompt aspiration, with the resulting prevention of

adhesions or of mechanical block due to the presence of an unresolved clot. Prompt resumption of motion also played part in the good results.

At the 65th General Hospital, where an adequate followup was also possible,

only 17 of the 42 patients had entirely satisfactory results, the distribution being of 28 in group 1, of in group 2, and of in group 3, which was the

surgical group.

Of the 33 patients treated conservatively in groups and 2, 18 had 5- to

10-degree limitation of extension and supination, which was painless in 15

cases and painful in (fig. 31). The discomfort was not severe enough to

Figure 31. —Fracture of radial head, group 1, months after injury, with limitation of extension. The patient, who had been treated conservatively, complained of discomfort

on both extension and supination. (See also figures 24 and 33.)
REGIONAL INJURIES 131

Figure 32.—Fracture of radial head, group 3, months after resection of head. At

this time patient had full range of painless motion. A. Extension. B. Flexion. C. Su- pination. D. Pronation.

bring any of the patients back for treatment; the complaint in each case was

elicited on the routine followup visit. Both the discomfort and the limitation

of motion were attributed to the presence of the injured radial head. Surgical

excision, however, was not considered, partly because the pain and disability

were slight and partly because this operation, whether it is performed early

or late, does not always correct limitation of motion.

None of the nine patients who were operated on (group 3) had any complaints on their 6-month followup visit, and their range of motion (fig. 32) was

often better than in some of the nonsurgical cases. The only postoperative

complication was temporary palsy of the radial nerve, which disappeared in

weeks. It was attributed to unnecessarily tight application of the sphygmomanometer cuff.

In the cases in group in which, as already noted, aspiration of the joint

was carried out in addition to the use of sling or the application of cast,

the results were not considered any better than were accomplished in the cases

in which aspiration was omitted.
132 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 33.—Fracture of radial head, group 1, 12 months after injury, showing roughening

of capitellum and persistent bony cleft. (See also figures 24 and 31.)

In case in group 1, the fracture was still present in the roentgenograms

made at the end of 10 and of 12 months (figs. 24 and 33) and the patient had

some limitation of motion (fig. 31) and discomfort on movement. The findings

were explained by the presence of an intra-articular fracture. Trauma to the

capitellum was evident in this case.

The absence of bony spurs or myositis ossificans (fig. 34) in all the surgical

cases was considered due to the surgical technique, which included covering of

the stump left after excision of the radial head. Osteochondritis dissecans

was not observed in any case in the series.

Specimen Case Histories

The case histories which follow (the first and last in the series of 49 from

the 168th Station Hospital) are presented as typical of this kind of injury in

respect to the nature of the accident the clinical picture, including the usual

delay of several hours before symptoms became severe enough to require

medical consultation; the ease of diagnosis; the roentgenologic confirmation

of the clinical diagnosis; the prompt relief of pain and discomfort by aspiration;

and the excellent end results, which permitted prompt return to full duty.

It is interesting to note that the patient described in case was treated on an

ambulatory basis and was returned to full duty in 13 days, while the patient

described in case was hospitalized for 18 days.
REGIONAL INJURIES 133

Figure 34.—Fracture of radial head, group 3, months after resection of head. Note

absence of any bony reaction.

Case 1.—A 21-year-old soldier fell from his bicycle on his right elbow October 1943,

hours before admission to the hospital. Clinical examination suggested fracture of the

radial head, with hemarthrosis of the joint. X-ray examination revealed vertical, incomplete fracture of the radial head, without displacement. Aspiration of the joint yielded

16 cc. of blood. Upon his discharge 18 days later, the patient had full function and no

pain. One month later, he was entirely symptom free and was performing all his required

duties as an airplane mechanic.

Case 2.—A technician, from the hospital’s medical detachment, fell from his bicycle on

his extended left hand and forearm 30 August 1944, and was seen in the outpatient department hours later. The clinical diagnosis of fracture of the radial head with hemarthrosis

was confirmed by roentgenograms, which revealed transverse impacted fracture of the

radial head. Aspiration of the joint yielded 22 cc. of blood. The cast was removed 48

hours later and physical therapy was begun. This patient, who was treated on an ambulatory status, was returned to full duty as cook 13 days after injury, with no limitation of

motion and no pain. He had no difficulty in performing any of his duties during the several

months he was under observation.

Fractures of the Carpal Scaphoid

Fractures of the carpal scaphoid, civilian type of injury, were even more

frequent in the Army than in civilian life. Diagnostic errors are more common

in fractures of this bone than in fractures of any other bone in the body; this

was as true in the Army as it is in civilian life. The situation is strange, since,

without exception, all these fractures are produced in the same manner—by
134 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

force transmitted through the proximal palmar surface of the hand—and the

history is the key to the diagnosis. When the same type of trauma occurs in

the middle-aged person, whose muscles are flabby and whose reaction time is

longer, the result is the Colics fracture, which was seldom encountered in

soldiers.

The data which follow were collected by Lt. Col. Marcus J. Stewart, MC,

at the orthopedic service at the 826th and 827th Convalescent Centers. The

436 injuries which were observed at these centers between September 1942 and

September 1945 consisted of 433 fractures of the carpal scaphoid bone and

sprains of bipartite scaphoids. The 433 fractures fell into groups:

Eleven incomplete fractures of the distal third of the carpal scaphoid, all

of which healed promptly and without definitive treatment.

Three hundred and twenty-three fresh or acute injuries, which were

diagnosed within month of the accident.

Ninety-nine old fractures which had occurred, on the average, 38 weeks

before the diagnosis was made.

Fresh fractures. —Of the 323 patients with fresh fractures, 320 were

treated by immobilization in plaster, and 3, all of whom had good results, by

early excision of the proximal fragment.

Immobilization was accomplished in position of maximum relaxation of

the carpus, the so-called grasping pose (fig. 35). The wrist was placed in extension of approximately 30 degrees, with midulnar and radial deviation.

Figure 35.—Type of plaster cast used for immobilization in fractures of carpal scaphoid

bone. Note so-called grasping pose. Note also possible range of motion of metacarpophalangeal joints.
REGIONAL INJURIES 135

The first metacarpal was abducted and the metacarpophalangeal and inter- phalangeal joints of the thumb were flexed toward the palm. circular plaster cast, which was skintight except for single layer of stockinet, was applied from inch below the elbow to the metacarpophalangeal joints and the base of the thumbnail on the dorsal aspect, and to the distal end of the proximal flexion

crease on the palmar side. This position usually permitted the hand to pass

through the sleeve of the shirt or the coat. The practice of having the patient

clench his fist during the period the plaster was setting was avoided, on the ground that in this movement the flexor muscles recede proximally and the

circumference of the wrist is correspondingly reduced. If the plaster hardens

in this position, the patient has considerable difficulty in extending the fingers

and opening the hand.

Movement of the interphalangcal joint of the thumb was permitted during

immobilization, provided that the plaster did not weaken and allow movement

of the metacarpophalangeal joint. The latter motion, since the middle fibers

of the abductor of the thumb are attached to the tubercle of the scaphoid,

would permit movement of the fracture. In the position in which the fracture

was put up, the thumb was relaxed and the metacarpophalangeal joints of the fingers were completely free. This meant that the patients, who were seen

at rehabilitation center, could carry on an active program of work or play.

They were encouraged to participate in such activities as rope climbing,

tumbling, chinning exercises, and even baseball.

The cast was changed and the fracture studied by roentgenograms at the

end of to weeks. When the cast was removed, the patient was instructed

not to move the thumb or wrist until he was told expressly that he might.

When necessary, immobilization was reinstituted immediately after the

roentgenographic examination. Routine roentgenograms included true

anteroposterior view, lateral view, and oblique views, in pronation of 45

degrees and the other in supination of 45 degrees (fig. 36, through D).

Of the 320 patients treated by immobilization according to this technique,

258 obtained solid bony union, with restoration of full function in the wrist and

hand, an excellent range of painless motion, normal grip, and normal strength

in the wrist. The other 62 patients were transferred to other hospitals or to

the Zone of Interior, and the end results are not known. At the time of

transfer, 45 were progressing satisfactorily, and union was expected. Three

had definite signs of persistent nonunion, and 14 had been treated too recently

to permit any conclusions. It may be considered, however, that 303 of the

320 patients, about 95 percent, had good to excellent results.

When these results were analyzed, number of factors were found to

have influenced healing.

1. Location of the fracture. This was most important consideration, as

it always is in this type of fracture. As matter of fact, fractures in various

portions of the carpal scaphoid should be considered as if they were different

bones in different parts of the body.
136 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 36.—Routine roentgenographic studies in fractures of carpal scaphoid bone.

A. Anteroposterior view. B. Lateral view. C. Oblique view in pronation of 45 degrees.

D. Oblique view in supination of 45 degrees.

Of the 258 patients who obtained bony union under conservative treatment, 44 (17 percent) had fractures of the distal third of the scaphoid, which

required immobilization in plaster for to 20 weeks and for an average of

weeks; 207 (80 percent) had fractures of the waist or middle third, which were

immobilized in plaster for to 35 weeks and for an average of 12 weeks; and

(3 percent) had fractures of the proximal third of the bone, which were immobilized from 12 to 32 weeks and for an average of 23 weeks.
REGIONAL INJURIES 137

Figure 37.—Serial roentgenogram showing fracture of carpal scaphoid bone through

waist. A. Development of sclerosis in proximal fragment in spite of early and adequate immobilization. B. Excellent end result, after 30 weeks of immobilization in plaster before

union and revascularization occurred.

The average period of immobilization for the entire group of 258 patients

was 12 weeks. The reconditioning period necessary after removal of the

plaster was encouragingly short, the average time required for complete recovery of function being only 3.5 weeks. Activity of the fingers while the

plaster was in situ apparently maintained good tissue turgor, stimulated the

blood supply, and kept the tendons freely movable.

2. Reduction. The accuracy of reduction proved of paramount importance in the healing process. This is shown by the necessary duration of immobilization. In of the 258 patients, reduction was fair, and an average of

16 weeks in plaster was required. In 129, good reduction was obtained, and

an average of 14 weeks in plaster was required. In 120, anatomic reduction

was obtained, and an average of 10 weeks in plaster was required.

3. Vascular changes. It is well known that fractures through the proximal

third of the carpal scaphoid and those through the waist may result in deprivation of the blood supply to the proximal fragment in certain proportion of

cases, with resulting necrosis. This development was observed in this series:

In 41 patients, mild to marked vacuolation or cystic changes were observed

at the site of the fracture. Immobilization in plaster was maintained for an

average of 16 weeks. In spite of early diagnosis and adequate immobilization,

avascular necrosis developed in 22 (8.5 percent) of the 258 patients who obtained bony union and excellent results.

In 10 cases, increased density or sclerosis was observed at the site of the

fracture. Plaster immobilization was maintained from 11 to 35 weeks, the

average being 21 weeks.

In 12 cases, avascularity of the proximal fragment occurred. These

patients (fig. 37) spent an average of 21 weeks in plaster. Before they left
138 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

the hospital, all of them were able to negotiate an obstacle race and participate

in vigorous sports, and all returned to full duty with normal function of the

hand and wrist. In such cases, however, there is always the possibility that

degenerative arthritis may develop later.

Old fractures.—Of the 99 patients in this series with old fractures,

90 were treated only by immobilization. Fifty-one of the 90 were returned to

full duty. All had obtained solid bony union, as shown by roentgenograms,

and all had an excellent range of motion in the wrist and hand, without tenderness, and with normal grip and strength.

Thirty-nine patients were returned to the United States or discharged to

other hospitals before the conclusion of treatment. In 15 cases, healing was

progressing satisfactorily at the time of transfer, but in cases nonunion was

evident. In the other 21 cases, treatment was too recent to permit any evaluation ofresults. There was, however, solid bony union or reasonable expectation

of union in 66 of the 90 patients (73.3 percent). These results are to be compared with the approximately 95 percent of good results secured in the 320

cases in which treatment was instituted while the fractures were still fresh.

The same factors influenced healing in the old fractures as in the fresh

fractures:

1. Location. The fractures which involved the distal third of the carpal

scaphoid remained undiagnosed for 16 weeks and 34 weeks, respectively.

Immobilization in plaster was maintained for 22 weeks and weeks, respectively, an average of 15 weeks.

The 43 fractures through the waist of the bone remained undiagnosed

for from to 82 weeks, an average of 22 weeks. Immobilization in plaster

was maintained for to 59 weeks, an average of weeks. Prolonged immobilization in these cases did no harm, since daily exercise and activity of

the fingers was systematically practiced.

The fractures of the proximal third remained undiagnosed for from 10 to

56 weeks, an average of 23 weeks. Immobilization in plaster was maintained

for 12 to 60 weeks, an average of 24 weeks.

The period of immobilization required in these 51 old fractures in which

return to full duty was possible averaged 20 weeks, as compared with an average period of 12 weeks for fresh fractures. Aside from any other consideration,

the delay in diagnosis caused an average of additional weeks in plaster.

2. Reduction. As in fresh fractures, the character of the reduction

obtained influenced the duration of immobilization. In cases in which reduction was excellent, immobilization was necessary for an average of 10.9 weeks.

In 38 cases in which it was good, immobilization was necessary for an average

of 22.9 weeks. In cases in which it was fair to poor, immobilization was

necessary for an average of 23.1 weeks.

3. Vascular changes. Mild to marked cystic changes were observed in

42 cases, in which immobilization was necessary for an average of 19.3 weeks.

Sclerosis at the fracture site was observed in cases, in which immobilization

was necessary for an average of 21.4 weeks. Six of the nine patients showed
REGIONAL INJURIES 139

arthritic changes, but none of them complained of pain or weakness, and all

had full range of motion.

The presence or development of cystic changes or sclerosis, as these cases

show, does not preclude the use of prolonged immobilization in fractures of the

carpal scaphoid. The sclerotic area present in many fractures when the cast

was applied looked worse after to weeks in plaster, but improvement became

evident (figs. 38 and 39) as immobilization was continued. The freedom and

activity of the fingers, as already noted, contributed materially to the success

of the treatment.

Figure 38.—Serial roentgenograms showing fracture of carpal scaphoid bone which

was not diagnosed for 10 weeks. A. Cystic changes at fracture site. B. Appearance after

immobilization in plaster for weeks. C. Appearance after immobilization for 22 weeks.

This was an excellent result, with solid union.
140 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 39.—Serial roentgenograms showing fracture of carpal scaphoid bone which

was not diagnosed for 56 weeks. A. Roentgenogram taken when patient was first seen.

B. Appearance of bone after immobilization in plaster for weeks. C. Appearance of

bone after immobilization for 12 weeks. Fracture union was solid, but mild osteoporosis

developed.

Nine patients with old fractures were treated by surgery, as follows:

Five patients were treated by autogenous bone grafts. In of these

cases, the graft was resorbed and the fracture failed to unite; the patient was

then transferred to theZone of Interior for further treatment. Another patient

had marked stiffness of the wrist, with 50-percent disability after operation;

he was returned to limited duty. The other patients were returned to full

duty. In the light ofpresent knowledge, and on review of the roentgenograms,

there is every reason to believe that at least of these fractures would have

healed just as satisfactorily and rapidly if they had been treated by immobilization alone.
REGIONAL INJURIES 141

Figure 40.—Serial roentgenograms showing fracture of carpal scaphoid bone which

was not diagnosed for weeks. A. Roentgenogram taken when patient was first seen.

B. Roentgenogram taken after immobilization in plaster for 25 weeks. At this time there

was still no evidence of progress toward union. An inlay type of cancellous-bone grafting

was done. Postoperative immobilization was maintained for weeks, and weeks’ reconditioning was required. C. Roentgenogram taken months after patient had returned to

full duty as truck driver.

One of the patients treated by bone graft (fig. 40) had fracture which

was not diagnosed for weeks. No improvement was evident after immobilization for months. Solid union was secured weeks after excision of the

fibrocartilage at the fracture site, and an inlay bone graft was performed. The

patient was returned to full duty as truck driver. This case presented the

ideal indication for grafting; namely, failure of viablefragments to show progress

toward union after months of immobilization.

Two patients were treated by excision of the proximal fragment. One

fracture, through the middle third of the scaphoid, was not diagnosed for 24

weeks; mild sclerosis was then present at the fracture site and moderate sclerosis
142 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

in the proximal fragment. The patient returned to limited duty after 10 weeks

of postoperative treatment, with pain and weakness in the wrist and an estimated 40-percent disability. The other patient in this group had fracture of

the proximal third of the scaphoid which had remained undiagnosed for 40

weeks (fig. 41). The proximal fragment was greatly displaced. The fragment

was excised and the patient, who was paratrooper, was returned to full duty

after weeks of postoperative reconditioning.

Figure 41.—Roentgenogram

showing fracture of carpal

scaphoid bone with marked displacement of small proximal fragment. The fracture was not

diagnosed for 40 weeks. After

excision of fragment and weeks

of postoperativereconditioning,

the patient could be returned to

full duty.

Two patients were treated by multiple drilling. One obtained union

within weeks but required weeks’ reconditioning before he could be returned

to full field duty. The other had no sign of union 18 weeks after drilling and

was returned to the United States.

Comment.—As this analysis shows, excellent results can be obtained,

with minimum period of immobilization, in fractures of the carpal scaphoid

bone which are promptly diagnosed and accurately reduced. The proportion

of good results obtained in fractures which are not promptly diagnosed is considerably less, and delayed union or nonunion must be expected in certain

proportion of cases. The presence of vacuolation or cystic change in delayed

cases does not, however, necessarily presage poor result when the fracture

has been properly immobilized, healing in the cystic area will include the fracture line. If the proximal fragment is viable, sclerosis at the fracture site is not

contraindication to prolonged immobilization. In most cases of avascular

sclerosis, continuation of nonsurgical therapy is warranted; protection of the

wrist is essential until revascularization is complete. Generally speaking, sur-
REGIONAL INJURIES 143

gery does not offer any better prospects of union than does nonsnrgical therapy.

Normal function of the wrist is seldom obtained following an excision operation,

though in the occasional fracture with excessive displacement of the proximal

third, early excision of the proximal fragment is the best course unless accurate

reduction can be obtained by manipulation. Plaster should be applied with

two objectives, (1) adequate immobilization and (2) free use of the hand. Immobilization may be prolonged for year or more if daily exercise and activity

of the fingers are systematically practiced. Perhaps the most significant point

of this analysis is the very large proportion of soldiers who could be returned

to full duty after an injury that, if not properly diagnosed and treated, could

have resulted in serious loss of manpower.

It should be noted that this interesting study of fractures of the carpal

scaphoid bone was begun in September 1942, 21 months before the invasion of

the Normandy beachhead. During this period, the number of hospital beds in

the European theater considerably exceeded the need for bed space. After the

invasion, with the beginning of what was to prove steady flow of battle casualties, the maximum holding time in the European theater was reduced to 120

days, or 17 weeks. Holding times of 20 weeks, the average for fractures of the

carpal scaphoid bone seen late, were no longer permissible. In many instances

in this series the holding time was considerably in excess of this average. When

battle casualties must be treated, there is no reason to consider holding in an

overseas theater patients whose treatment mayrequire as long as 60 weeks, as

happened in case in this series. Many of these patients who were seen after

the D-day invasion should have been, and doubtless were, promptly evacuated

to the Zone of Interior.

Attention is also directed to the proper treatment of recent fractures of

the carpal scaphoid, as exemplified in this series. When diagnosis is prompt

and treatment is correct, soldiers with this type of injury can usually be returned

to duty within the prescribed limits of time in an overseas theater.

Clavicle

Fractures of the clavicle encountered before D-day were satisfactorily

treated by Blake suspension traction for 12 to 21 days, followed by ambulation

in figure-of-8 plaster bandage for to 14 days. Whether the patient was in

bed or ambulatory, hospitalization was necessary. Traction was preferred by

some orthopedic surgeons because it caused the least deformity, which is always

of importance in fractures in this area.

In battle-incurred fractures of the clavicle, the emphasis was on immobilization and early evacuation. The plaster figure-of-8 dressing and the clavicular

cross were used with equal effectiveness. common error in fractures of the

clavicle treated in plaster was failure to instruct the patient in active shoulder

exercises. This omission often resulted in significant, and unnecessary, stiffness

of the shoulder joint.
144 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Humerus

Before the invasion of the Continent, simple (closed) fractures of the humerus were chiefly treated by hanging casts, as in ordinary civilian practice.

Compound fractures were also treated by the methods employed in civilian

practice.

Battle-incurred fractures required different approach. Standard treatment at some hospitals was the insertion of Kirschner wire through the

olecranon process, combined with traction and vertical or horizontal suspension.

Excellent results were also obtained after reduction and fixation by continuous

Blake traction, whether skeletal or skin traction was employed.

Severely comminuted fractures with loss of bony continuity and large

compounding wounds responded excellently to open reduction, usually by the

use of wire or screws or by combination of these methods. When there

was considerable loss of bony substance, no hesitancy was felt in shortening

the bone as much as inches to obtain good bony union and to forestall the

necessity for later bone grafting.

The most common complication of fracture of the humerus was radial

nerve injury withresulting paralysis. In such cases, management of the nerve

injury took precedence of management of the bone injury. Vascular injuries

were sometimes associated with the bone injury, and in at least instance, at

the 68th General Hospital, the vascular damage was severe enough to require

amputation.

Patients with fractures of the humerus were transported in plaster-of-paris

spicas. hanging cast was not suitable, as was proved in the few cases in

which it was employed shortly after fighting began on the Continent.

shoulder spica or plaster Velpeau was readily applied by the following

technique: An issue type of Army arm splint was stretched between two

tables, with the ring end higher than the other end. The patient was then

placed on the splint, the ring of which formed an excellent head cushion. In

this position the plaster was easily applied about the body. When it had dried,

the splint was withdrawn. metal bar or inches wide served the same

purpose.

At the 802d Hospital Center, the 1,065 compound fractures of the humerus

treated in traction fell into groups:

1. Fractures of the upper third. Traction through the olecranon process

was used in all but few of the fractures in this group. The Kirschner wire

was introduced from the medial to the lateral side, particular care being

taken to identify the ulnar nerve by palpation and to avoid it. In few

instances, temporary neuritis developed from irritation caused by the adjacent wire, but in no instance was there permanent nerve damage. The

humerus was usually held at right angles to the thorax and in midrotation

(fig. 42). Often posterior wound had to be kept from contact with the bed

or underlying apparatus. In some instances, the axis of the immobilization
REGIONAL INJURIES 145

Figure 42.—Skeletal traction applied for treatment of injury by 88-mm. shell fragment, which caused compound comminuted fractures of the radius and ulna and simple

fracture of the humerus.

apparatus was applied with the humerus at anterior flexion of 90 degrees and

with traction directed overhead.

The hanging cast was not suitable for early treatment of extensive compound fractures. After, however, good callus had developed, at to

weeks, thoracobrachial or hanging-type plaster cast could be substituted

for traction.

2. Fractures of the middle third. Traction through the olecranon process

was also found most satisfactory for this group of cases. Fractures in this

area were seldom manipulated and were often reduced by traction alone; 10

pounds of weight for 12 to 24 hours almost invariably produced satisfactory

alinement, after which the weight could usually be reduced to to pounds.

The Thomas arm splint was used only when Pierson attachment was

needed for traction on the forearm (fig. 42).

372572°—56 11
146 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Approximately 20 percent of the patients with fractures of the upper

third of the humerus exhibited radial nerve weakness or paralysis in which

recovery followed, sometimes as early as 72 hours after reduction of the fracture and institution of traction. Complete interruption of the nerve and loss

of bone substance were frequent complications. They were managed by

deliberate shortening of the bone when necessary, though not until after the

wounds were clean and covered with healthy skin. In these cases, the presence of infection and the loss of muscle, vascular, and nerve tissue directly

over the fracture site were direct threat to the function of the hand, and

correction of these defects was obviously more important than strict immobilization and purely mechanical treatment of fractures of the arm or forearm.

3. Fractures of the lower third and at the elbow. In this group of cases,

early motion of the elbow joint and hand was the primary consideration, and

anatomic reposition of fragments was not sought at the price of immobilization. Traction was instituted either through the olecranon process or at

some point in the dorsal cortex of the proximal third of the ulna. Active

motion of the hand in the traction apparatus was begun at the earliest possible

moment. In no instance did this practice appear to inhibit the formation of

callus. The functional end results obtained by these policies in fractures of

the elbow were, in fact, curiously better than might have been expected from

the deformity and displacement often evident in the roentgenograms. Results

were, however, notoriously poor after prolonged immobilization and after

open operations intended solely to obtain anatomic position.

Pelvis

Fractures of the pelvis were at least as often caused by the highly accelerated vehicles and heavy machines of modern war as by missiles, though the

latter produced shattering compound wounds which were not present in the

vehicular type of injury. In battle-incurred fractures, injuries of every organ

within the pelvic basin were seen, and treatment of the bone injury often had

to be deferred until urinary and bowel function had been reestablished by

urethrostomy, cystostomy, and colostomy as indicated. In many instances, the position of the fractures could not be changed, although manipulations of

every description were attempted.

Once reduction had been effected, the elements of traction had to be

carefully analyzed and applied with due regard both for immobilization of

the fracture and for the nursing care required by the patient. Lateral suspension of the pelvis by traction through the femoral condyles, with the hips

flexed at 90 degrees, was both useful and comfortable in properly selected

cases. Certain extensive comminuted fractures with tendency to collapse

were maintained by lateral traction through both iliac crests and distal traction through the upper tibia or lower femur. The Rouvillois or lumbofemoral suspension frame (p. 236) obtained from liberated medical depots in

France was often more comfortable and more effective apparatus from the

nursing standpoint than the conventional hammock.
REGIONAL INJURIES 147

Patients with the conventional fractures of the pelvis usually caused by

vehicular accidents, without complications to the intrapelvic soft parts, did

very well in bilateral plaster-of-paris hip spicas carried to the knee.

Spine

Fractures of the spine and injuries of the spinal cord are discussed in detail

elsewhere in this series of volumes, and only one or two points concerning

these injuries need be mentioned here.

Transportation of the patient was the major problem in fractures of the

cervical spine. No movement was attempted until conditions were favorable.

All manipulations were avoided, and the head was not raised under any circumstances. Good results were usually obtained by moving the patient on

an ordinary litter, supported with massive gauze rolls or folded blankets to

minimize lateral movement. When possible, jacket of the Minerva type

was used.

In injuries of the thoracic spine, plaster body jacket was also used to

good advantage. The patient was usually transported prone on the litter if

laminectomy was likely to be necessary.

It was standard practice to evacuate immediately all patients with neurologic involvement, so that neurosurgeon might decide whether or not laminectomy was necessary.

Femur

Genera! considerations of management.—The fractures of the femur

received in the United Kingdom from forward hospitals immediately after

D-day were not always well managed. The wounds were often firmly packed

with gauze and were sometimes in such condition that delayed primary closure

could not be performed within the optimum period. Later, as experience

increased, the state of the wounds was improved, and gauze was placed in

them lightly, as was desirable.

Delayed primary wound closure sometimes had to be deferred while the

patients were prepared for it. Fractures of the femur were often associated

with heavy blood loss, and massive transfusions were necessary before operation could be safely performed. An interesting incidental observation was

made in this connection at the 802d Hospital Center. In number of cases

in which extensive wounds of the thigh required incision and debridement

before suspension in skeletal traction could be carried out, two teams worked

in friendly competition with each other to minimize blood loss by accomplishing complete hemostasis by the use of fine ligatures and endothermy. The

amount of blood lost at operation was estimated by studies of the supernatant

fluid after all dressings, drapes, and gowns had been soaked in dilute solution

of saponin. The smallest amount lost at any operation was 600 cc. The

amount of blood lost on the field and during transportation was assumed to

be at least equal to this quantity, and probably greater.

Patients with fractures of the femur were transported to the Zone of
148 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Interior in plaster-of-paris spicas. The fact that some fractures, especially

those in the upper portion of the femur, became displaced in the plaster during transportation, after they had been regarded as frozen, made it clear that

in some injuries, at least, the designated holding period of to weeks was

too short.

Fracture management.—Two definite lessons were learned from the

more than 1,000 fractures of the femur treated at the 802d Hospital Center:

(1) In no other site in the body is the action of muscles more important in

producing deformity; and (2) in no other group of fractures is correct application of traction more important for the achievement of satisfactory alinement

of the fracture.

The general plan of management was to use the femoral condyles or the

tibia! tubercle for the site of the Kirschner wire, depending upon the nature of

the fracture and the position of the associated wounds (fig. 4,3). When the

wire was inserted through the lower end of the femur it had to be above the

attachments of the collateral ligaments and posterior to the medial and lateral

aspects of the suprapatellar pouch. If the wire was inserted with the leg fully

extended and the knee was later flexed in the splint, the skin and deep soft

Figure 43.—Roentgenogram showing method of locating approved sites of election for

insertion of Kirschner wires in lower femur and tibial tubercle. The topographic anatomy

is shown by means of barium sulfate paste applied to the skin. Iron washers show areas

for insertion of wires. This graphic method was useful, as an adjunct to the method of

palpation, in teaching skeletal landmarks and orthopedic techniques to physicians without

previous orthopedic experience.
REGIONAL INJURIES 149

parts would become folded up or stretched around it, and ischemia and infection were apt to follow. When the wire was correctly applied, damage to the

knee joint did not occur as result of traction through the tibia, even though

weight of 30 pounds was sometimes used for brief periods.

Fractures of the femur were managed according to the location of the fracture:

1. The neck and intertrochanteric region. In this group of fractures,

coxa vara deformity was invariably present by the time the patient had been

brought in from the battlefield. Reduction was effected by manual traction

and maintained by continuous skeletal traction through the lower lemur, with suspension in either an inverted Keller-Blake half-ring splint or the

French lumbofemoral splint. If the half-ring splint was used in the standard

manner, the patients were uncomfortable, dressings of the woundwere difficult, and displacement was relatively unimproved.

2. Upper third of the shaft. This group of fractures was one of the few in which displacement followed standard pattern. The proximal fragment

was almost always flexed, abducted, and externally rotated. Reduction by

manipulation was usually successfid and could be satisfactorily maintained

merely by lining up the distal fragment and the leg with the position of the

upper fragment.

3. Shaft. Sixty percent of the fractures in this group showed satisfactory

position after suspension in skeletal traction and did not require manipulation.

In the remaining 40 percent, manipulation was necessary. The minimum

acceptable position required 50-percent contact of the fracture ends in planes,

without overriding or angulation. Less than 50-percent contact of the fracture

faces was generally untenable, and every effort was made to achieve at least

75-percent contact. Displacement occurred insidiously, and roentgenograms

made to weeks after the institution of definitive traction sometimes showed

unexpected loss of position and the presence of deformity which could lead to

malunion or nonunion. Disability was greatly prolonged when massive callus

had developed to overcome inadequate apposition or muscle interposition.

The majority of fracture patterns, fortunately, were dentate, spiral, comminuted, or of the so-called blown-straw variety and therefore could be interdigitated well by manipulation. The possibility of muscle interposition was

always investigated at the time of delayed closure of the wound, as well as

when open reduction was necessary. Only occasionally were the mass and bulk

of interposed muscle sufficient to form an obstacle to normal healing. In

almost all instances, the muscle was found attached to periosteum or callus at

the fracture site and was present in soft, hemorrhagic flaps, which could easily

be pushed aside by simple manipulation.

4. Supracondylar fractures. Shattering injuries of the lower third of the

femur were the commonest of all battle-incurred fractures of this bone, though

the condylar variety of fracture caused by indirect violence is seldom seen in

civilian practice. The distal fragment varied from single condyle to the entire

lower third of the femur. The main deformityfactor was thepull of the gastroc-
150 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

nemius muscle. Lateral or forward displacement of the distal fragment was

infrequent and was easily corrected.

The insertion of Kirschner wires in both the supracondylar region of the

femur and the upper third of the tibia, followed by manipulation by manual

traction on the tautening bow at right angles, was usually successful. The

use of posterior sling in place of skeletal traction from the distal fragment

was found undesirable. It retarded wound healing and interfered with the

circulation when it was applied to swollen, edematous thigh. In few cases

treated at the 802d Hospital Center, simple suspension through the distal

fragments, with the hip and knee each flexed at 90 degrees, produced satisfactory results. This position was also often used, of necessity, for the care of

extensive soft-tissue wounds of the posterior aspect of the thigh.

The management of the so-called T-fracture of the lower femur which

extended into the knee joint was problem created by the differential pull of the

two heads of the gastrocnemius muscle. After aspiration to relieve the severe

pain in the knee joint, which was usually greatly distended with blood and bonemarrow fat, it was possible, without much difficulty, to palpate the condyles

and manipulate them into satisfactory position. Compression could be

exerted manually, and padded carpenter’s clamp or other mechanical device

was seldom necessary.

Fractures of the lower end of the femur, with large open wounds of the

knee joint, were always serious problem. They were managed by bold

policy of arthrotomy and open manipulation, followed by closure of the wound.

Infection was surprisingly infrequent. Large doses of penicillin were administered systemically and implanted locally, though, in the light of postwar

knowledge, local implantation of the antibiotic seems of doubtful efficacy.

If the compounding wound was so extensive that no site was feasible

for the insertion of phis or wires, open reduction was sometimes preferable to

trial of traction. Fractures of the neck, if there were no contraindications, were sometimes treated by the Smith-Petersen nail.

Results in prisoners of war.—An analysis of 63 compound fractures of

the femur observed at the 19th General Hospital illustrates possible results of

delayed primary closure in cases which were none too favorable, since all the

patients, including United States soldiers who had been held by the Germans,

were prisoners of war. Fractures of the femoral condyles associated with

wounds of the knee joint are not included. Seventeen of the wounds were

infected when the patients were received, the cause of the infection, in every

instance, being inadequate or late debridement. In all of these cases, extensive

secondary debridement or wound excision was necessary.

Primary healing occurred in 21 of the 39 wounds in which delayed primary

suture could be carried out shortly after these soldiers were received in general

hospital. Eight patients were evacuated too soon to permit evaluation of

results. Healing was delayed in 10 cases, but wound necrosis and suppuration

occurred in only instance.

Semiannual Report, 19th General Hospital, European Theater of Operations, January-30 June 1945.
REGIONAL INJURIES 151

Tibia and Fibula

Fractures of the fibula furnished few problems. Simple fractures of the

tibia and fibula were satisfactorily treated by traction. Reduction was obtained by the insertion of wire through the os calcis or in the supramalleolar

region of the tibia. long leg cast was applied snugly about the fracture site

and loosely about the knee and thigh. The wire was included in the cast.

Oblique fractures of the shaft of the tibia and fibula were more difficult

to handle. They tended to be unstable and required continuous traction or

open reduction with screw fixation to maintain the correct position.

In battle-incurred compound fractures of the tibia and fibula, delayed

primary wound closure was less satisfactory than it was in other fractures.

Important causes were the lack of soft tissue in this area and the greater tension

in the tissues. These difficulties were increased if the wound had caused tissue

and skin defects. Closure frequently had to be accomplished by means of

relaxing incisions and split skin grafts. The relaxing incisions themselves

sometimes required skin grafting.

In cases which could be managed by traction, wires were inserted in the os

calcis for shattering wounds of the lower leg and in the lower tibia for wounds in

the upper leg. Suspension of the limb in Thomas splint with Pierson attachment had many disadvantages. One was that the considerable structure of

pulleys and ropes necessary in this technique required daily readjustment, and

at the best the patient was likely to be uncomfortable.

The Bohler-Braun method was used in many cases but had one important

defect which outweighed all its advantages: When the lower leg was in traction

on the cradle, although the distal fragment was relatively immobile, the

proximal fragment moved with the patient.

The plaster traction splint (fig. 44) employed at the 22d General Hospital,

802d Hospital Center (p. 45) seemed to combine the best aspects of both of these

methods of traction. As already pointed out, this technique was used in 65

compound fractures of both bones of the leg, including fractures at the ankle, treated at the 22d General Hospital. It proved highly efficient. Skin grafting

was facilitated in the cases in which it was necessary, and it was even possible

for some patients to get about in wheelchairs while they were still in continuous

traction (p. 50).

Some badly comminuted fractures of the tibia and fibula were reduced by

internal fixation. Maintenance of length was more satisfactory than with

other techniques, though this method was not suitable when the compounding

wound was extremely severe. In properly selected cases, it secured anatomic

reduction, excellent fixation, and high incidence of satisfactory union, with

minimal number of complications.

Ankle

Sprains and complete tears of the external lateral ligament of the ankle

required plaster immobilization for weeks. Any other method of management left weak ankle, with recurrent luxation of the astragalus on slight
152 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 44. —Compound comminuted fractures of the leg with large avulsed wounds of

the leg by 88-mm. shell fragments in France, after immobilization in the plaster traction

splint.

inversion strain. The diagnosis of complete tear was made by anteroposterior

films, with the heel held in strong inversion while the patient was under

Pentothal anesthesia. Comparison with the normal side was necessary.

Significant displacement of the astragalus out of the mortise was considered

diagnostic of complete tear of the external lateral ligament.

Management of fractures of the posterior malleolus of the tibia before

D-day depended upon the extent of the injury. If less than fourth of the

articular surface was involved, the residual upward displacement caused little

concern. If sufficient smooth joint surface remained intact, the small fragment

was displaced out of the way, and there was no tendency for the astragalus to

displace posteriorly. If, however, the fragment comprised as much as third

of the articular surface, anatomic reduction was necessary. If closed methods

failed, open reduction was relatively easy. posterior approach was employed,

with screw, brad, or nail fixation.

In fractures of the external malleolus, if the fracture line took the usual

direction (oblique from behind, downward and forward), immobilization was

not always necessary. Treatment consisted of elevation until the swelling had

subsided, after which the ankle was strapped in neutral position and the patient

was permitted to be ambulatory in shoe.
REGIONAL INJURIES 153

In fractures of the neck of the astragalus with displacement, reduction by

manipulation was usually successful. If, however, optimum position was not

obtained, open reduction could be done, to assure optimum realinement. The

fracture line was often intra-articular, at least in part, and this technique offered

the best chance for revascularization of the body. If open reduction was

necessary, there was frequently strong indication for subastragalar arthrodesis

at the same time, to increase the chances of early revascularization of the body.

Although fracture dislocations were not always regarded as emergencies,

they should have been. Unless immediate reduction of the dislocated body is

carried out in this type of injury, necrosis of the overlying skin may result,

with conversion of the injury to compound fracture and with consequent

chances of serious infection. The displaced body may produce such severe

pressure on the posterior tibial vessels that gangrene may result, while the

vascular deficiency caused by direct pressure and swelling may also cause

Volkmann’s ischemia. Furthermore, the longer the dislocation continues, the

more difficult reduction becomes. Although these facts should be of common

knowledge, they were not always understood, nor was the emergency nature of

this kind of injury appreciated. As result, patients were sometimes not seen

until or days after such an injury, with the fracture dislocation still

unreduced.

In properly treated case of this kind, manipulative reduction was performed immediately, sometimes aided by the application of traction to the os

calcis by Kirschner wire. If closed reduction was unsuccessful, open reduction was resorted to promptly. Astragalectomy was last resort, as it did

not produce satisfactory function. The best method of management, therefore,

was to reduce the fracture dislocation and hope that avascular necrosis of

the body would be minimal. If the results were poor, later arthrodesis could

be done.

Diastasis of the inferior tibiofibular joint, which was often overlooked,

always left painful ankle if it was not treated. This possibility should have

been investigated in all injuries about the ankle. If it was diagnosed, it was

usually easily reduced by manipulation, after which plaster cast was applied

for 10 weeks. It was important that the cast be snug; displacement recurred

promptly if it was not.

After the invasion of the Continent, many of these techniques ceased to

be practical in an active theater of operations, and patients with serious injuries

about the ankle, after initial treatment, were promptly evacuated to the Zone

of Interior, since they could not be returned to duty within the holding period

permitted within the theater. Even before the invasion, it would probably

have been wiser to return many such patients to the United States rather than

hold them in the theater.

Foot

Fractures of the os calcis with no significant displacement were treated by

elevation and immobilization until the acute reaction had subsided. Then
154 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

physical therapy was begun, and the foot and ankle were actively exercised

once an hour. Weight bearing was not permitted for to 12 weeks except in

an occasional case in which, for the last to weeks, the patient was treated

in walking cast.

Fractures with significant displacement but without comminution which

caused reduction in the salient angle were also treated by elevation and immobilization until the acute reaction had subsided. Then manipulative reduction

was carried out under portable roentgenologic control. Steinmann pin was

inserted through the lower third of the tibia and the posterosuperior portion

of the os calcis, with compression clamp to reduce the medial and lateral displacement of the calcaneal fragment. Both pins were incorporated in short

leg plaster cast.

Fractures witli significant displacement and severe comminution, in which

subastragalar joint did not seem possibility, were treated by elevation

and immobilization until the acute reaction had subsided. Then manipulative

reduction of the gross displacement was carried out, with early triple arthrodesis.

The results of fractures of the tarsal bones were usually disappointing.

In addition, the patient with compression fracture of the os calcis always

had great deal of pain. Some surgeons believed that the Pridie operation,

in which the entire os calcis is removed, might be more generally useful

procedure in such cases than subastragaloid arthrodesis.

These practices were all employed before D-day, but even then prompt

evacuation to the Zone of Interior would probably often have been wiser

than the performance overseas of such definitive surgery as has been described.

Skeletal traction was advisable for small number of battle-incurred

compound fractures of the midtarsal and metatarsal regions. This technique

was used only 15 times at the 802d Hospital Center. Traction was applied

by means of vertical wire inserted through the middle of the distal phalanx

of the toes. The ends of the wires were turned back to form hooks for elastic

bands, which were attached to metal hoop incorporated in the plaster cast.

The combination of plaster cast and traction to hold the fractures in position

was effective, but only after the fractures had been reduced by correct manipulation and molded splint had been applied.

Several errors were common in management of injuries of the foot. Casts

were originally left on for too long time. It was eventually found that fractures of the tarsal bones without displacement required no immobilization in

plaster, except for short time in some cases for relief of pain. It was an error

to immobilize the foot and ankle in position of equinovarus.

In battle-incurred compound fractures of the foot, some observers came

to believe that better results would have been secured if amputations had been

done more promptly in selected cases. This was particularly true when the

entire os calcis was destroyed. great deal of time was spent in debridement

and other care, and in the end the patient was no better off functionally than

he would have been if amputation had been performed at once.
155

CHAPTER XII

Amputations

In all wars, amputation of limb has been an operation of necessity, not

procedure of choice or election. The total destruction of tissue, including

bony tissue, was the chief indication for the majority of amputations performed in the European Theater of Operations in World War II. When the

limb was irretrievably shattered and mangled or was almost completely

avulsed, the attending surgeon had no choice but to amputate it. In effect,

nearly complete traumatic amputation had already been performed, and it was

his clear duty to complete it.

Vascular damage, the second most frequent reason for amputation, was

in many instances inherent in the destruction of tissue. This was, however,

not always true. It also very often occurred in association with compound

comminuted fractures, in cases in which tissue damage was not in itself irretrievable and in which, in the absence of vascular damage, the bone injury could have been managed successfully by one technique or another.

In such cases, the decision to amputate was frequently difficult and painful. Demonstrable, complete loss of blood supply to portion of the limb,

because of destruction of the main artery or arteries, was practically always

an indication for amputation. Recoveries were occasionally recorded after

anastomosis of major artery, and from the theoretical standpoint, therefore,

there was no justification for amputation of limb in which vascular damage

had occurred without an attempt, at least, at anastomosis and period of

postoperative observation. On the other hand, with vascular surgery at the

stage at which it was in World War II there was only remote chance of

saving such limb. The operation was time consuming. For this reason, it

could lead to the neglect, or at least the delayed treatment, of other seriously

wounded men. Finally, the procedure was not justified on the basis of the

results obtained. The reports from orthopedic surgeons in the European

theater, from whose observations these data are derived, again and again state

that the writers had never seen recovery after anastomosis of the popliteal

artery.

The senior consultant in orthopedic surgery knew definitely of only

instances in which survival of the leg below the knee occurred after ligation

of the popliteal artery. In each of these instances, the indication for ligation

was secondary hemorrhage or weeks after wounding, by which time an

It should be emphasized that these observations concern only World War II. Although there will probablynever

be more than limited number of combat-incurred injuries with damageto the blood supply of the limbs in whichvascular

surgery would be justified, in selected cases this procedure now (1955) would be both practical and warranted. fairly

largenumber of successes followed conservative managementof vascular injuries in the KoreanWar, and further advances

have been made in this field in the interval since those hostilities ceased. (Author’s note.)
156 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

anastomosis of sufficient size to carry the blood to the leg beyond the knee

must have been established. At the 68th General Hospital, the chief of the

orthopedic section stated that amputation was done in oidy of cases in

which the popliteal artery had been severed but that the other patients

would have been better off if they also had been submitted to primary amputation. The surgeons who performed the two conservative operations were

misled by the condition of the superficial tissues. Eventually, the muscles of

the leg, with the exception of the gastrocnemius muscle, went on to necrosis

and had to be dissected out.

In the light of these results, which were typical of results in general,

experienced medical officers almost universally took the position that immediate

supracondylar or transcondylar amputation of the limb was indicated whenever

the popliteal artery had been divided. The chances of recovery, even when

surgery was supplemented by sympathetic block and such other adjunct

measures as were practical in frontline hospital, were seldom good enough

to warrant the risk to fife inherent in policy of conservatism. If the anastomosis failed, as it usually did, gangrene invariably and inevitably ensued,

and secondary amputation under these circumstances was fraught with far

more risk to life than primary amputation would have introduced.

The third important indication for amputation was clostridial myositis.

Fortunately, it was not very frequent. The important point was to make

the distinction between diffuse, spreading Clostridium welchii infection, in which

amputation was mandatory and in which any significant delay put the patient’s

life in jeopardy, and localized gas bacillus infection, in which conservative

therapy was warranted. The experience reported from the 804th Hospital

Center is typical. Clinical Clostridium welchii infection was observed in 10

cases. In of the 10, true clostridial myositis was present and amputation

was necessary; patient died. In the other cases, the infection was localized

and responded to wide incision and drainage, supplemented by penicillin and

sulfadiazine. In the localized type of gas bacillus infection there was, of

course, no indication whatsoever for amputation.

Similarly, the question of amputation never arose in the type of case in

which Cl. welchii organisms were cultured from the wound but in which they

gave rise to no clinical manifestations and were obviously nonpathogenic.

Any battle wound, if examined with refined bacteriologic techniques, will

probably reveal clostridial organisms, which will, however, grow and multiply

only if dead muscle tissue is left as culture medium.

Conservatism was the rule in all cases in which amputation was possible

procedure. As rule, it was entirely justified, though, as pointed out elsewhere (p. 154), many observers thought that prompt amputation of badly

shattered feet would have been wiser than the policy of conservatism employed

throughout the war.

greater degree of conservatism was both indicated and practical in the

upper extremity than in the lower. The reason for this policy was the greater

functional importance of the upper extremity. Military surgeons, properly,
AMPUTATIONS 157

went to almost any length to save even small portion of functioning hand.

The reason why this policy was practical was that Cl. welchii infection in both

military and civilian surgery is much less frequent in the upper than in the

lower extremity.

Incidence and Case Fatality Rates

The incidence of amputation in the European Theater of Operations was

not high in relation to either the total number of casualties or the devastating

character of many wounds of the extremities. The great advances in surgery

between World War and World War II permitted the salvage of many limbs

in the Second World War which would necessarily have been sacrificed in the

First. Indeed, it is an ironic fact that during the period of World War II,

the number of amputations which were performed for medical reasons or which

were of traumatic origin in civilian life exceeded by several times the number

of amputations performed for combat-incurred injuries. There was an estimated total of 17,000 major amputees as the aftermath of World War II.

The number of civilians who lost one or more of their limbs during the same

period has been estimated at about 80,000.

The case fatality rate for amputation was also not excessive. The 2d

Evacuation Hospital, for instance, which was 750-bed hospital, served from

Normandy to Naumburg, Germany, between 23 June 1944 and 18 April 1945.

During this time, it received 37,377 patients, 10,398 of whom had surgical

conditions. Orthopedic admissions included 2,243 fractures of the long bones

with 30 deaths (1.3 percent) and 388 amputations with 25 deaths (6.4 percent).

Forty-five amputations, sixteen of which were fatal, were performed for clostridial myositis, and 327, of which were fatal, were performed for trauma.

There were no deaths in the 16 amputations performed on the indication of

circulatory damage.

Col. Charles B. Odom, MC, analyzed the amputations performed in the

64,389 battle casualties treated in Third United States Army hospitals

from August 1944 to February 1945 (tables 4, 5, and 6). In this total,

there were 39,600 injuries of the extremities, and 3,245 wounds of the buttocks,

totaling 42,845. This totalrepresented proportion of 66.5 percent battle casualties, reasonably near the 71 percent which it had been estimated would

occur in these areas. The case fatality rate of all battle casualties was 2.9

percent and for wounds of the extremities (including the buttocks) 0.81 percent.

During the 6-month period covered by this survey, 1,365 amputations

were performed on 1,290 patients in 12 evacuation and field hospitals. More

than 75 percent of these amputations were of the lower extremities, the disproportionate distribution being tacit testimony to the destructive efficiency

of the land mines employed in World War II. Traumatic destruction of tissue

was the indication for about two-thirds of the amputations, vascular damage

for about fifth, and clostridial myositis for the remainder. The case fatality

rate was 9.0 percent.

Semiannual Report, Office of the Surgeon, Third U. S. Army, January-30 June 1945.
158 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table 4.—Indications for 1,365 amputations in 1,290 casualties, Third United States Army, August 1944-1 February 1945

The 1,290 casualties upon whom these 1,365 amputations were performed

included 1,012 United States Army personnel, 28 Allied soldiers, 206 German

prisoners of war, and 44 civilians.

Evolution of Techniques

From the historical standpoint, the best way to describe the change in

the point of view about techniques for amputation is to summarize the instructions given in the Manual of Therapy issued just before D-day and the

instructions in the revision of the orthopedic section of this manual which were

prepared in June 1945 but were not published because of the ending, shortly

afterward, of the fighting in the Pacific. comparison of the two sets of

instructions furnishes an illuminating reflection of how combat experience

alters the point of view.

Manual of Therapy, 1944.—Amputations, it was pointed out in the

manual issued before D-day, should not be done unless the limb was almost

Manual of Therapy, European Theater of Operations, May 1944.

Indications

Hospital

Traumatic Gas gangrene Vascular

injury Unknown

Total Deaths

Evacuation:

12th 45 16 14 75

32d 45 55

34th 53 12 44 109

35th 97 38 140 13

39th 91 20 20 131 11

101st 54 16 21 91

104th 77 25 14 116

106th 33 21 19 81

107th 72 15 32 10 129 16

109th 41 17 65

110th 38 18 62

Field:

16th 20 35

30th 27 31

59th 14 15

60th 45 47

65th 11 24

Total 763 170 253 20 1, 206 113

The 159 amputations performed at the 103d Evacuation Hospital are omitted from the tabulated data because the breakdown isIncomplete. It Is known that 21 amputations were performed for vascular injury, but data are incomplete on how many of the remaining 138 operations were performed for the original trauma and how many for subsequent gas gangrene. There were deaths in the 159 cases.
AMPUTATIONS 159

Table 5.—Site of injury in 27J+ amputations for vascular damage, Third United States Army,

August February 19j5

completely detached. Instructions for the immediate management of the

battlefield casualty who was possible candidate for amputation were to treat

complete or incomplete traumatic amputation as any other open wound; to

control active arterial bleeding; and to be certain that tourniquet, ready for

instant application, accompany the patient during his evacuation.

Further instructions in the 1944 manual were as follows;

1. Indications for amputation were (1) complete destruction of the blood

supply, which meant loss of the main blood supply and most of the collateral

blood supply; and (2) fulminating gas bacillus infection.

2. Indications for amputation of the upper extremity should be more

rigid than indications for amputation of the lower extremity because gangrene

of circulatory origin is more infrequent in the upper extremity, and because

conservation of small remnant of the hand is of far greater functional importance than conservation of small remnant of the foot.

3. Regardless of any consideration of pros theses in the future, the limb

should be amputated as low as the nature and location of the wound would

permit.

4. Two types of amputation were permissible in the 1944 manual, (1) the

guillotine amputation, in which the skin, soft tissue, and bone are all divided

Hospital

Blood vessel

Total

Axillary Brachial Iliac Femoral Popliteal Anterior

tiblal Posterior tibial

Both

tibials

Evacuation:

12th 14

32d

34th.. 15 13 44

35th 16 12 38

39th 20

101st 12 21

103d 10 21

104th_ 14

106th. 19

107th 14 32

109th

110th 10 18

Field:

16th

30th

59th

60th

65th

Total 43 96 92 13 13 274
160 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table 6. —Site of 1,365 amputations in 1,290 casualties, Third United States Army, August

1944-1 February 1945

at exactly the same level, and (2) the circular or irregular short flap amputation, in which the skin and soft tissues are left slightly longer than the bone.

5. The guillotine amputation was to be used in cases in which the amputation level was well within the site of election. This technique was always

employed with the idea that reamputation would later be necessary. The

circular or irregular flap type of amputation was to be used when the point of

bone division was at, or close to, the point of election. As much skin as

possible was thereby saved to pull over the end of the stump, and later reamputation would not be necessary. The stump was never to be sutured.

6. If the bone had to be divided at the site of election, and if skin beyond

this point could not be saved, guillotine amputation was then indicated.

The main artery and nerve were divided at the same level as the bone. The

artery should be secured with ligature, with transfixion stitch ligature distal

to it. The nerve stump was not to be treated by ligation, crushing, alcohol

injection, or any other means. It was simply left unsutured.

7. Careful hemostasis of small vessels in the stump was essential, lest later

elevation of the blood pressure of patient previously in shock should cause

bleeding in vessels which had not been identified at operation.

Hospital Upper

arm

Forearm

Si

Hand

te

Thigh Leg Foot

Total Deaths

Evacuation:

12th. 36 31 75

32d 10 23 14 55

34th- 14 28 57 109

35th 42 76 140 13

39th 27 21 34 33 13 131 11

101st 13 10 50 91

103d 24 20 24 52 32 159

104th 26 10 35 44 116

106th 25 35 81

107th 21 32 48 18 129 16

109th 11 13 16 17 65

110th 18 39 62

Field:

16th 12 12 35

30th ___

18 31

59th 15 15

60th 24 47

65th 24

Total 155 141 35 338 581 115 1, 365 116
AMPUTATIONS 161

8. After both types of amputation, the stump should be frosted with

sulfanilamide. small dressing of vaseline gauze should be applied over the

open stump, and additional dressings were to be applied after the stump had been placed in the splint.

9. Skin traction should be accomplished with adhesive tape and Thomas

splint, or plaster spica could be applied for splinting and the incorporation

of distal traction.

10. Skin traction should be maintained indefinitely or until healing took

place. The 1944 manual permitted certain exceptions to this rule, though the

exceptions were limited to irregular flap amputations with clean, granulating

wounds, without discharge or edema, or without systemic febrile reaction.

In such cases, later secondary closure was permitted, with few loose retention

sutures.

11. The 1944 manual recommended that, whenever possible, written

statement should be incorporated in the patient’s record, prepared by

second medical officer and signifying agreement with the necessity for amputation of the limb.

The instructions for amputation in the 1944 Manual of Therapy were

confusing and were definitely written without the benefit of the extensive

experience in combat-incurred wounds which was soon to occur. The chief

points of difference between these instructions and those in the 1945 revision

of the orthopedic section of the manual will be discussed in detail shortly.

Revision of orthopedic section of proposed Manual of Therapy, 1945.

The summarized instructions contained in the proposed revision of the Manual of Therapy in June 1945 were as follows:

1. Amputation was justified for only two reasons, (1) complete destruction

of the blood supply, which meant the loss of the main artery and most of the

collateral arteries, and (2) diffuse clostridial myositis.

2. Amputation should always be performed at the lowest possible level

which the nature and location of the wound would permit.

3. Experience showed that the open circular amputation is the procedure

of choice in the management of war wounds. The guillotine amputation had

proved unsatisfactory and was not to be used. In the guillotine technique the

skin, muscle, bone, and all tissues are divided at exactly the same level. In

circular amputation, each tissue layer beneath the skin is allowed to retract

before it is severed, so that, after the operation has been completed and traction

has been applied to the skin, the stump has the appearance of shallow, inverted cone or saucer. The precise technique was described step by step

(p. 162).

4. Decision to amputate was not to be made without consultation with

the chief of the surgical service or, in his absence, with whatever senior surgeon

might be available. The details of the consultation were to be noted in the

patient’s medical record.

Appendix B.

372572°—56- 12
162 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

5. Psychotherapy, it was pointed out, was of the utmost importance in

the rehabilitation of the amputee, and the surgeon, by few words of his own,

could help in the program. It was important that the operating surgeon,

himself, should inform every amputee of certain facts before he was evacuated:

a. That the amputation had been necessary as life-saving procedure.

b. That it had been decided upon only after consultation.

c. That further surgery for revision of the stump would probably be

necessary.

d. That the patient would be sent to an amputation center where he would

be fitted with an artificial limb and where other facilities would be available

for his rehabilitation.

6. disarticulation was to be performed only when there was no other

possible choice of more conservative procedure. This is not desirable

operation. The stumps are difficult to handle, and they discharge profusely.

Traction is extremely difficult to maintain. The stumps always need extensive

revisions, most of which must be performed in two stages. In view of these

considerations, disarticulation of the knee was permitted as an emergency

measure but was not to be performed routinely.

Technique of circular amputation, 1945.—The successive steps of circular

amputation were set forth as follows in the 1945 revision of the orthopedic

section of the 1944 manual:

1. The skin of the extremity is prepared as for surgical procedure,

2. tourniquet is applied.

3. The incision is made in circular fashion, down to the deep fascia, at

the lowest possible level. An oblique incision is permitted in cases in which it

would result in conservation of the skin and of the length of the extremity.

4. The skin is allowed to retract. The deep fascia is then divided at the

level to which the skin has retracted.

5. The muscle is divided in circular sweeps, about three-fourths of an inch

being included in each sweep, so that, as the muscle retracts, the next muscle

division is made at slightly higher level.

6. The periosteum is cut in circular manner at the level to which the last

muscle layer has retracted.

7. The bone is sawed through cleanly at this level. The periosteum is

not elevated or stripped, and no attempt is made to remove it at higher level

than the saw cut.

8. Nerves are severed cleanly at the level of the surrounding muscle division. They are not crushed orligated, and the ends are not injected with alcohol.

9. Precise hemostasis of the stump is essential. All large veins and arteries

are doubly ligated, separately and not en masse. Extreme care is taken not to

include large amounts of muscle in the ligation of small vessels. After all the

larger vessels have been ligated, the tourniquet isremoved, the field is inspected,

and any remaining bleeders are ligated.

10. The end of the stump is covered with dry, fine-mesh gauze. Sulfonamides are not used to dust it or frost it.
AMPUTATIONS 163

11. Skin traction is applied immediately and is maintained continuously

while the patient is being evacuated and until healing occurs. There is but one

exception to this rule; When the amputation has been performed for clostridial

myositis, skin traction is not applied for the first 24 to 48 hours. At the end of

this time it is possible to determine whether the wound is clean or infected.

No patient, however, should be evacuated from any Army installation until

skin traction has been applied.

Skin traction for transportation has been found to be most satisfactory

when it is applied in the following manner:

a. Afterthe stump has been covered with sterile, fine-mesh gauze, circular

roll of stockinet is applied to the stump and isrolled as far as possible proximally.

b. The skin is painted with tincture of benzoin.

c. After the skin has dried, an adherent is applied to it down to the cut edge

of the stump. The stockinet is then unrolled down on the stump and is allowed

to adhere to the skin. Traction is applied to the stockinet and additional

dressings are placed inside it, against the end of the stump.

d. Traction is continued by an assistant while several layers of sheet wadding are applied loosely over the stockinet. circular plaster pylon is then

applied to the stump, with an outrigger made of wire ladder splint. The end

of the stockinet is fastened to the outrigger by means of short piece of elastic

traction cord or, if the cord is not available, by means of plasma tubing.

The following types of plaster pylons are indicated for special injuries: Below the knee, below-the-knee-to-the-groin pylon, with the knee in

full extension.

Thigh, single hip spica pylon, with the hip in neutral position.

Forearm, full-arm pylon, with the elbow flexed at 90 degrees.

Arm or humerus, shoulder spica pylon, with as little abduction as possible

and the axilla well padded to avoid pressure.

Comparison of the 1944 and revised instructions for amputation.—The

revised draft of the orthopedic section of the Manual of Therapy for the most

part simply took cognizance of changes in technique that had been in effect

since shortly after D-day. Most of them were incorporated in Circular Letter

No. 101, issued 30 July 1944 from the Office of the Chief Surgeon, ETO.

Other instructions were contained in Circular Letter No. 131,issued November

1944. In that letter, secondary closure of the stump was forbidden in the

European theater, on the ground that it often led to infection and necrosis of

the skin. When the skin sleeve was inadequate for closure by traction or

when the bone ends were obviously too long and protruded, the stump was to

be revised at the lowest possible level. The skin edges were to be mobilized

by undercutting and the bone and soft tissues were rcamputated just enough

to allow closure by traction, which was promptly reapplied and maintained

continuously. Split-thickness skin grafts were prohibited in the absence of

Circular Letter No. 101, Office of the Chief Surgeon, European Theater of Operations, 30 July 1944 (appendix A.

p. 322).

Circular Letter No. 131, Office of the ChiefSurgeon, European Theaterof Operations, November 1944 (appendix A. p. 325).
164 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

unusual and sound indications, for the reason that they do not tolerate

prostheses.

The differences between the 1944 and later instructions for amputation

concerned both substance and emphasis. As has already been pointed out,

the original instructions were written without practical experience in combatincurred wounds and the later instructions after an extensive experience.

The differences in point of view and specific details may be summarized

as follows:

1. In the 1944 Manual of Therapy, both the guillotine and the circular

techniques of amputation were permitted. In the 1945 draft of the proposed

revision, circular amputation was mandatory, fact which reflects the early,

brief, and unsatisfactory experience with the guillotine technique. This

ill-named operation is almost impossible to perform without the help of an

actual guillotine. When the skin is divided in circular amputation, it

always retracts, and so does each layer of muscle. The surgeon who attempts

so-called guillotine operation usually ends by performing true circular

amputation, which is an inverted cone, with skin left long enough to pull

down over the stump to close it. It was not very long before circular amputations were routine in the European theater, and both the name and the

technique of the guillotine amputation were abandoned.

The circular amputation, which was performed at the farthest possible

distal point of the wounded extremity, was preliminary step. Usually reamputation at an elective site was expected to be performed in an amputation

center in the Zone of Interior. The amputee was always informed of this plan.

While the circular technique, with nonsuture of the stump, was the safest

procedure for combat-incurred wounds, there was some basis for the claim

that immediate flap amputation at an elective site would be equally successful

if all damaged muscle and retained foreign bodies were removed. The healing

power of young soldiers in superb physical condition, as these men were, was

remarkable. On the other hand, the majority of the surgeons who were performing these amputations were inexperienced and, at the time, closure of amputation stumps seemed an invitation to surgical disaster. The advantages

of immediate elective amputation, which would have prevented duplication of

surgery, therefore had to be foregone. There is no doubt that the technique

which was made mandatory was by far the safest under the circumstances.

2. In the draft of the proposed 1945 revision of the orthopedic section of

the manual, specific techniques were described in detail. In the 1944 manual,

instructions were very general. The greater specificity of the revision is,

again, reflection of the necessity for leaving nothing to the imagination of

inexperienced military surgeons.

3. In the 1945 revision, provision was specifically made for the use of

tourniquet at operation. tourniquet was not mentioned for this purpose in

the 1944 manual.

4. The use of sulfonamides on the stump was provided for in 1944 and

specifically prohibited in 1945. As has already been pointed out, their local
AMPUTATIONS 165

application perhaps did no harm, but it was discovered, after several months’

experience, that it also did no good, and the practice was discontinued.

5. The use of vaseline gauze was provided for in the 1944 manual, but in

the 1945 revision it was specifically directed that dry, fine-mesh gauze be used.

The use of vaseline gauze proved actually harmful because it prevented free

drainage of secretions (p. 84).

6. In the 1944 manual, the provision of traction by adhesive plaster strips

and the Thomas splint was described. In the revision, this technique was

omitted, and technique of skin traction combined with plaster was described,

again very specifically. In the revision, the only exception to the immediate

institution of traction was 24- to 48-hour delay after amputations for

clostridial myositis.

7. Consultation before amputation was permissive in 1944 and mandatory

in 1945. It was specifically directed that the situation, including the need for

second amputation at an elective site, be made clear to the amputee. It

was also to be made clear to him that the second operation, for revision of the

stump, was part of the ordinary routine.

8. Psychotherapy was also provided for in 1945. Very early in the experience of the European theater, it became evident that, when the necessities

of his special case were clearly and sympathetically explained to an amputee,

it was the exceptional patient who did not bear with remarkable fortitude the

psychologic blow inherent in the loss of limb.

Special Considerations of Traction

Orthopedic surgeons stationed in the United Kingdom Base usually found

amputation stumps of patients received from the Continent in good condition, from the standpoint of the wound. Frequently, however, the surgeons complained that traction was inadequate. For this error there were several explanations: Sometimes the circular plaster type of countertraction had been

used; this was not satisfactory technique. Sometimes the elastic cords and

rubber tubes used for purposes of traction had not been tightened en route.

Sometimes the transportation casts were not satisfactory. hip spica, with

traction incorporated in it, proved the only way to guarantee really effective

traction during transportation after amputation of lower limb.

Until the end of the war, occasional medical officers continued to prefer

the Thomas splint, as had originally been advised in the 1944 Manual of Therapy (p. 161), with fixed countertraction against the ischium. The reason for

their preference was that when this splint is used there is no tendency for the

skin to pull in the opposite direction.

Long leg casts were not always satisfactory. When patients were transported in them, traction had frequently ceased to be functional by the time

general hospital was reached. This was true whether the amputation had

been above or below the knee. The cuff always had tendency to slip down, because there was nothing to which it could be anchored. Traction hooked

up to wire ladder splints was also not entirely satisfactory in amputations of
166 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

the upper extremity, whether the amputation had been above or below the

elbow.

In fixed general hospitals, traction was easily maintained by the use of

pulley and weight over the foot of the bed. The essential consideration was

that it be continuous. The maintenance of continuous traction required

repeated inspections, with correction of the position of the equipment if it had

slipped at all.

Amputations Caused by Special Types of Missiles

Blast injuries.—Among the large number of wounds of the extremities

encountered in the hospitals in the United Kingdom Base soon after D-day

were numerous blast injuries caused by mines at sea. These injuries were

frequently presented in the form of destruction of the os calcis, fractures of

the upper tibia, and fractures at the knee joint, often with dislocation. Profound damage to the popliteal vessels was usually part of the picture, and

amputation was often the only possible procedure.

It soon became apparent that in this type of injury it was not safe to

undertake operation without particularly careful evaluation of the patient’s

status and without unusually careful preoperative preparation. When the

casualties were first seen, they were, for the most part, obviously poor risks.

Sometimes, however, they would seem to recover from the initial shock of

wounding and to be in good condition. They looked well, the pulse was of

good quality, and the blood pressure was well above the dangerous level, or,

occasionally, abnormally high. Appearances were deceptive. If the timing

of operation was not correct, these patients were likely to go into profound

secondary shock, which was difficult, and sometimes impossible, to overcome.

It was ultimately found that the best plan in all of these cases was to delay

operation several hours longer than on the surface seemed absolutely necessary,

to be certain that the appearance of well-being was genuine and not specious

and misleading.

Land mines.—Patients with wounds of the lower extremities received in

land-mine explosions often presented, in addition to multiple comminuted

compound fractures, damage to the popliteal circulation, which was frequently

total. Multiple foreign bodies had often penetrated the regional vessels.

Because of the vascular damage, amputation was practically always necessary

in such injuries, though, as in the blast injuries just described, it was best performed as delayed procedure, to be certain that the patients were completely

out of shock.

Guided missiles.—Much the same observations as those just described

for blast injuries and injuries from explosions of land mines were made on

patients who had suffered injuries of the extremities from guided missiles.

Their appearance was often misleading, and, unless this fact was recognized

and surgery was delayed, fatalities from unrecognized shock were not infrequent.
167

CHAPTER XIII

Adjunct Therapy

Resuscitative Measures

The techniques of resuscitation are described in detail in other volumes of

this history. Here it need only be said that from the standpoint of casualty

with bone or joint injury resuscitation was continuous procedure. It

began on the battlefield with the control of hemorrhage, temporary emergency

splinting, the application of dressings, and the administration of morphine in

limited doses for the control of pain. It was continued through the various

forward echelons of medical care up to the evacuation hospital, where initial

surgery was done. In the evacuation hospital it had to be carried through without delay and with full appreciation of all measures, including the position

of the patient, protection from unnecessary exposure, the use of oxygen and of

blood and plasma as indicated, emptying of the stomach before operation, and the maintenance of free, dry airway during anesthesia. Emphasis was consistently placed on adequate blood replacement and

proper timing of surgery. Even casualties whose injuries were limited to the

bones and joints were frequently in severe degrees of shock and required the

liberal administration of blood before they were fit for operation. If the patient

did not respond with reasonable promptness (preferably within hours) to

adequate measures of resuscitation, it could be assumed that some factor was

present which accounted for the situation, such as continuing hemorrhage,

massive infection, or blast concussion. Under the circumstances, it was

frequently wiser to proceed with surgery without further delay and to continue

the administration of blood on the operating table. Patients with fractures of

the long bones, particularly compound comminuted fractures of the femur,

required especially large amounts of blood for resuscitation.

Supplemental Therapy

Blood replacement.—Blood replacement was an extremely important

phase of management in all stages of bone and joint injuries. Transfusions,

as just pointed out, were lifesaving immediately after injury and were essential

in the preparation for surgery when patient reached general hospital.

Plasma was no substitute for whole blood. When casualty had suffered

large blood loss, as was particularly frequent in compound fractures of the

femur, blood transfusions were necessary to restore the blood volume, maintain

the plasma proteins, combat sepsis, prevent shock when long surgical procedures

were required, and improve the appetite and general well-being after operation.

The preferred plan was not to operate on these patients until the hematocrit
168 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

was at least 35 and preferably higher. The copper sulfate technique was

rapid and efficient method for the determination of the hematocrit in large

numbers of patients.

Transfusion reactions were remarkably few, considering the enormous

quantities of blood used. Thus, at the 216th General Hospital, 1,389 transfusions were given on the surgical service between D-day and V-E Day with

no deaths and with only two transfusion reactions of any severity; both were

instances of hemoglobinuria.

Protein replacement.—Casualties with severe wounds rapidly became

depleted of protein, though the deficit was not always precisely reflected in the

plasma protein values, since this protein was held up at the expense of the

body tissues. Instead, the deficit was chiefly manifested in the development

of wound edema, failure of wound healing, decubitus ulcers, and general wasting.

The need for protein replacement was generally realized, as was clearly

shown by study carried out on the orthopedic section of the 803d Hospital

Center. This section, for period of months, was divided into parts. Half

the patients were fed the regular hospital diet, with supplemental vitamins

but no additional proteins. The other half were given daily diet which contained 135 gm. of protein. The contrast was impressive. Edema was practically absent in the patients provided with additional amounts of protein.

Infected wounds cleared up twice as fast as in the control group. Wound

breakdowns were 33 percent less. There were no decubitus ulcers in the

treated group against two in the control series. The general physical condition

and the mental condition of the treated patients were also far superior to the

condition of the patients in the control group.

As result of this study, it was made standard operating procedure at the

803d Hospital Center that all patients with compound fractures and other

wounds be managed by so-called orthopedic diet until their wounds were

completely healed and they were in excellent condition. This daily diet included total intake of 3,500 calories, 135 gm. of protein, unit of plasma

intravenously, and multiple vitamins. Additional calcium was given in the

form of calcium gluconate and in milk and eggs, chiefly served in the form of

chocolate milk with powdered egg added.

Position.—The edema invariably present in war wounds after wounding

and debridement was particularly noted in the legs, feet, forearms, and hands.

It sometimes made delayed primary closure extremely difficult. Some general

hospitals therefore adopted the practice of suspending the injured extremity

from an overhead frame as soon as the patient was admitted. Elevation, in

the absence ofcontraindications, was maintainedfor to 14 days after operation.

Chemotherapy and Antibiotic Therapy

Until almost the end of the war, American soldiers were provided with

sulfanilamide pills and sulfa crystals in their first-aid kits. They were instructed to take the pills as soon as they were wounded and to sprinkle the
ADJUNCT THERAPY 169

crystals into their wounds if they were able to do so. If not, this was accomplished by the first-aid men. It was also rather general policy for few

months after D-day to sprinkle sulfa crystals into the wounds at surgical

closure. These practices did no good either on the battlefield or in the operating room, and both were eventually abandoned.

Penicillin became available in the European theater before D-day, and

the Mediterranean-theater policy was instituted of administering it to all but

the most lightly wounded immediately upon their arrival in the evacuation

hospital. Later, when it became more plentiful, European Theater of

Operations directive gave instructions for the first dose to be administered

in the division clearing station. Allied personnel received 20,000 to 30,000

units every hours, frequently in combination with gm. of sulfadiazine

every hours. This was the practice in all major compound fractures and

major joint injuries. In minor injuries, sulfadiazine frequently continued to

be used alone. Because of limited supplies of penicillin, prisoners of war

received only sulfa drugs, unless their wounds were considered dangerous or

their condition was serious.

The administration of penicillin was either by continuous intramuscular

injection or intermittently. It was thought that the former technique gave

more consistent drug concentrations. It was the best practice, though it was

not usually possible, to determine the sensitivity of the particular organisms

present in wound before the penicillin was given. When no sensitivity was

demonstrated, sulfonamide drug was substituted.

The local use of penicillin was discouraged except for its instillation into

wounds of the joints. It was used for this purpose in 10,000- to 25,000-unit

doses before primary or secondary closure of the joint.

Opinions differed as to the value of combined therapy. Some observers

believed that it was better to use penicillin and the sulfonamides independently.

Others considered that combined therapy was useful. Still other experiences

suggested that the substitute of one drug for another after certain period

of time was more useful practice than administering them together.

The sulfonamides and penicillin had their widest field of usefulness in

broadening the scope of surgery. Their function, from the surgical standpoint, was protective rather than prophylactic or curative. This use aided

in the debridement of wounds even after an extensive timelag. It also gave

surgeons feeling of confidence in the delayed primary closure of wounds,

even when they were associated with compound fractures. Finally, operative

procedures could be conducted through healed wounds without reactivation

of latent infection.

On the other hand, the remarkable freedom from infection which was

enjoyed in World War II, particularly in the later months of the war in the

European theater, must not be attributed chiefly to the use of these new

agents. It is primarily attributable to adequate debridement plus the liberal

Circular Letter No. 71, 15 May 1944, Office of the Chief Surgeon, European Theater of Operations. Principles

of Surgical Management in the Care of Battle Casualties.
170 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

use of whole blood to replace blood which had been lost. If these principles

were disregarded, infection was just as likely to occur with the use of penicillin

as without it.

Psychotherapy

One of the highly favorable factors in the management of patients with

injuries of the bones and joints was that, in spite of the severity of many of

these injuries, they occurred in men who were young, in excellent health,

well fed, and, for the most part, well clothed. The concurrent illnesses and

disabilities which had existed in many previous wars and had militated against

optimum results in orthopedic surgery did not exist in the European Theater

of Operations, with the single exception of trenchfoot, which was major

problem during certain periods of the winter of 1944-45. This subject is

discussed in detail in separate volume in this series.

The emotional status of the casualties was, however, another matter.

An evaluation of it was one of the first considerations of treatment, no matter

what type of wound the soldier had sustained. Most of the patients brought

into aid stations, clearing stations, and evacuation hospitals were suffering

from battle exhaustion as well as from severe physical injury, and the one

state required attention quite as much as the other. In the first weeks after

D-day, orthopedic surgeons frequently called upon the psychiatrist if the

emotional disturbances were severe. As time passed, psychiatric services became less and less necessary because the surgeons, after handling large

numbers of patients, had themselves learned the principles of management of these disturbances.

Sympathy had no place in their management. For the first or nights

spent in an evacuation hospital the patient usually received large doses of

barbiturates, to prevent him from reliving his battle experiences after the ward

quieted down. As soon as possible, the surgeon in charge of the case talked

to him. He explained to him as simply as possible the nature of his injury and the treatment already instituted and proposed, and told him, in general

way, how long the course of treatment would be. It was made clear that in

many respects the length of convalescence would depend upon the cooperation

of the patient quite as much as upon the skill of the medical officers treating

him. If he had the kind of injury which would require his return to the United

States, he was given that information at once, though never if there was the

slightest doubt that this would happen.

One of the most effective ways of raising the injured man’s morale was

placing him on ward with other men who had received the same sort of injury

and who were on the way to recovery. This was particularly true if amputation

had been performed or if it was thought it might be necessary. This plan often

had remarkably good results. Ward discipline was relaxed as much as possible.

spotless environment was regarded as of much less importance than having

man with both legs off, for instance, throw an orange peel at similarly

afflicted patient across the ward.
ADJUNCT THERAPY 171

Workers in the rehabilitation section, workers in the various special services, and Red Cross workers all helped to keep the patients occupied and leave

them with no time to brood. Red Cross workers were untiring in their efforts

to solve individual problems, which sometimes were major and sometimes only

seemed major because of the circumstances. Finally, Army chaplains were

always of the greatest assistance in the management of casualties, not only

those who were fatally injured but also those who had survived with disabilities and deformities.

Attention to such considerations as these might seem, on first glance, to be completely unnecessary in orthopedic surgery. Inexperienced surgeons

who were at first inclined to take this point of view soon learned ust how important they were and how greatly attention to them contributed to prompt

recovery and rehabilitation.

173

CHAPTER XIV

Postoperative Complications

Wound Infections

Three types of wound infections were observed in bone and joint injuries

treated in United Kingdom Base hospitals after debridement in hospitals on

the Continent:

1. In some wounds the infection was superficial; there was no localreaction

other than moderate discharge of debris, and there was no systemic reaction.

Closure was usually possible after to days of treatment by compresses of

physiologic salt solution and pressure dressings. At operation in these cases,

particular care was taken to place the sutures loosely, and drainage was always

provided for 48 hours. Penicillin by the intramuscular route was given for

at least 72 hours after operation.

2. The type of wound infection just described was sometimes complicated

by low-grade osteitis. These patients were also treated with compresses of

physiologic salt solution and pressure dressings for to days, after which

secondary debridement was done, with the removal of all obviously infected

bone. Compresses were continued for another days, after which the wound

could usually be closed loosely. Penicillin by the intramuscular route was

given during this entire period and for days following wound closure.

3. Wounds which were grossly infected usually yielded streptococcus and

many other bacteria. Retained foreign bodies were frequent. Complete

redebridement was done in these cases, under penicillin protection, and sometimes had to be repeated one or more additional times. Foreign bodies were

removed, and the wound was counterdrained. Intramuscular penicillin was

continued after operation and local penicillin drips were sometimes used also.

Draining sinuses.—Draining sinuses were frequent complication of

inadequate debridement. They were also the most frequent complication of

unwise closure of infected wounds. The best method of treatment was to cut

down on the sinus, remove the underlying dead bone, and reclose the wound.

Clostridial infection seldom occurred when this technique was employed.

Clostridial infections.—There were two chief causes of clostridial myositis,

(1) inadequate debridement and (2) destruction of the regional blood supply.

Even if debridement had been adequate, packing the wound tightly with

vaseline or other gauze or enclosing itin tight plaster cast could so completely

seal it that anaerobes could flourish in the tissues. Under these circumstances,

no amount of sulfonamides or penicillin could control the local growth of the

organisms, because there was no local blood supply to carry these agents to

them. Similarly, anti-gas-gangrene serum was ineffective.
174 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

The only deaths from clostridial myositis in the 7,500 surgical admissions

at the 803d Hospital Center are typical. Both followed compound comminuted

fractures of the femur. In both, debridement had been inadequate. In both,

the infection was established in the psoas muscle when the patients were received. Death occurred promptly in each case, from toxemia; patient died

hours after admission and the other within 16 hours.

Clostridial myositis was more frequent during the Normandy campaign

than at any other time during the war; it was especially frequent during the

fighting around Saint L6, France. At this time, debridement was inclined to

be somewhat conservative. It was necessary, however, to guard against the

other extreme of radicalism, which solved the problem by amputating the

extremity with too much haste. Acceptable standards of therapy were eventually worked out as result of bitter experience.

Local abscesses from which gas bacillus could be cultured were frequent.

They were treated by wide debridement, and penicillin therapy was given

intramuscularly and was sometimes supplemented by sulfadiazine. The results,

due to the debridement, were usually good.

Osteomyelitis

Low-grade osteomyelitis was treated by curettage of the infected bone

until normal, bleeding bone was reached. The patient was given penicillin,

and pressure dressing was kept in place for days. In some cases, compresses

of physiologic salt solution were substituted for the pressure dressing. If at the

end of week the wound appeared clean, muscle transplant was placed in the

bone defect and the wound was closed with split-thickness skin graft. Healing

usually followed promptly. The patient was then evacuated to the Zone of

Interior where, later, the muscle transplant and skin graft were excised and

the wound defect was filled with cancellous bone chips. Wound closure was

effected at this operation with full-thickness graft.

Secondary Hemorrhage

The ever-present possibility of secondary hemorrhage furnished an important argument for complete exploration and debridement of every battleincurred wound. Any wound, no matter what its size, could conceal severe

vascular damage, and this damage, in the absence of adequate examination,

could remain undiscovered until serious hemorrhage ensued.

Other causes of secondary hemorrhage included the retention of foreign

bodies; the pressure of drains and packs placed too near major vessels; and

infection which could cause erosion or damage to vessel wall, or lysis of

thrombosis which had effectively closed thelumen of lacerated vessel. Oozing

through the wall of gradually enlarging aneurysm was still another cause of

secondary hemorrhage. Whenever splinting was careless, two risks were

introduced: (1) Movement of the fractured bone during transportation, and
POSTOPERATIVE COMPLICATIONS 175

(2) the impingement of mobile bone fragments on vessel walls, with resulting

trauma to the tissue. Hemorrhage could follow in either of these circumstances. patient in whom bleeding was considered possibility was never evacuated until the risk was definitely ended. Whenever the history of previous

bleeding or the location of the wound made secondary hemorrhage possibility,

the ward personnel was warned to be on guard and was given instructions in what to do until help could arrive. It was sometimes thought best to warn the

patient also of the possibility, so that he would call for help promptly if symptoms appeared. Splints were always so adjusted as to allow for emergency

control of hemorrhage until definitive control could be effected. This was

accomplished by providing windows in the cast over pressure points proximal

to the wound, or by placing tourniquet beneath the plaster so that it could

be tightened, if necessary, for emergency control of bleeding.

It was the general experience that most major secondary hemorrhages

were preceded by oozing or by minor hemorrhage. These signs should always

have served as warnings, but they often did not because they could be controlled by packs and pressure dressings, sometimes with deceptive ease. It

was also the general experience that resort to these temporizing measures

simply postponed the severe and perhaps fatal hemorrhage likely to follow the

first minor bleeding. Failure to appreciate the gravity of the warning oozing,

no matter how slight it might seem, was an outstanding error of management in

many hospitals. The correct policy was to explore the wound at once, under

general anesthesia and under aseptic conditions, in order to find and ligate the

bleeding point. This plan sometimes resulted in unnecessary explorations, but

it also prevented many severe hemorrhages which could easily have been fatal,

particularly if the patient had been evacuated without first identifying or

excluding the source of the first bleeding.

The source and management of secondary hemorrhage are discussed in

detail in the volume on vascular surgery in this series. The subject is simply

mentioned here because hemorrhage is one of the possible complications of

combat-incurred injuries of the bones and joints.

Decubitus Ulcers

Decubitus ulcers were best managed by taking precautions to prevent their

occurrence. If they developed, as they not infrequently did in spite of these

efforts, local applications of Azochloramid (chloroazodin) with debridement

as necessary, was standard treatment. The practice of placing Kirschner

wires through the iliac crests and suspending the patient from Balkan frame,

so that the buttocks did not come into contact with the bed, hastened healing

and greatly simplified nursing care. high-protein diet was an essential part

of the treatment.

CHAPTER XV

Rehabilitation

Rehabilitation Hospitals

Rehabilitation and reconditioning were matters of considerable importance even before D-day, because an overwhelming proportion of hospital

admissions in the United Kingdom Base consisted of bone and joint injuries.

Col. Rex L. Diveley, MC, who was the first senior consultant in orthopedic

surgery, developed special interest in this field. Shortly before D-day he

was relieved of his consultant duties to become chief of the Rehabilitation

Division in the Office of the Theater Chief Surgeon. Meantime, number of

enlisted personnel from the United States Army were trained in rehabilitation

work in the Royal Army Medical Corps institutions for rehabilitation at

Kingston-on-Thames, Aldershot, Taunton, and Edinburgh.

The first American rehabilitation center was set up at Bromsgrove,

England, and was originally planned as superorthopedic center, where the

more difficult orthopedic procedures would be handled in addition to rehabilitation. The idea was sound as long as the expeditionary force remained

small. It ceased to be practical by the time that 3,065,505 troops were in

the theater and were being served by about 200 general and station hospitals.

After D-day, as the flood of casualties increased, the load became too

heavy even for the special rehabilitation hospitals which had been set up, and

the program many times had to be assumed by rehabilitation sections in

individual station and general hospitals, sometimes with distinctly inferior

results. Even in the best hospitals, the program was somewhat slow in getting under way after D-day. Then it began to improve, particularly as

cooperation between orthopedic and rehabilitation sections became closer.

Nonetheless, rehabilitation of orthopedic casualties was best handled in hospitals set up for this special purpose. Without them, there would have been

great deal of delay in getting many men back to duty because the large

hospital centers were too crowded and too busy to undertake the work properly, and on the wards rehabilitation often had to give way to more urgent

problems. maximum number of orthopedic casualties were returned to

duty, in optimum condition, from the rehabilitation hospitals. Furthermore,

as time passed, evacuation policies were improved, and one error which had

taken up much time and bed space unnecessarily, was corrected; namely,

men with relatively minor injuries were no longer sent to these units.

Strength reports of the Army, prepared by the Office of the Chief of Staff.

372572°—56 13
178 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Physical Therapy Programs

The load of rehabilitation in bone and joint injuries was chiefly carried

by the department of physical therapy. There was, however, constant

shortage of properly trained physical therapists and technicians to handle the

volume of injuries which became their responsibility. As result, the therapists were not on the ward as often as was desirable, and much of the instruction and the persuasion necessary to implement the program were necessarily

left to the ward attendants, who were constantly with the bed patients and

who could insist that the prescribed exercises be carried out.

Most orthopedic surgeons were fully conscious of the need for rehabilitation and reconditioning and regarded definite programs of exercise for both

bed and ambulatory patients with bone and joint injuries as part of their

therapeutic responsibility. One or two hospitals displayed good deal of

imagination in setting up these programs.

An elaborate program of rehabilitation was set up at the 802d Hospital

Center, where it was started as soon as the patient was admitted. It was

carefully explained to him, as soon as his condition permitted, that his recovery

depended more upon his general condition than upon any other single factor

and that his general condition depended, in turn, upon his eating, keeping all

his muscles in optimum tone, and keeping himself interested, cooperative, and

eager to live and recover. He was told that the hospital would make his

surroundings as attractive as possible, that the first few days would be difficult

but that, nonetheless, he must make himself participate in all the activities

which were prescribed and that he would soon find participation easier. It

was explained to him that healed bone was useless without functioning

muscle, and that prosthesis would be of small value without muscular function. He was also plainly informed that, once muscles were allowed to become

wasted, it was very hard to rebuild them. The physical therapist and

technician were present when the patient was given this information by the

medical officer, and they, in turn, explained and demonstrated to the patient

the remedial exercises required of him to achieve the results expected.

Early each morning all roentgenograms taken the previous day were reviewed by the chief of the orthopedic section and his entire staff, including the

physical therapist. Progress was discussed, and general review of the whole

program was undertaken. Informal rounds were made during the week, to

keep those in charge of the program fully abreast of it. On Sunday, formal

rounds were made by the chief of the orthopedic section and were attended by

everyone who had any connection with the program. At this time, the exercises for each patient were outlined for the following week.

On the ward, regularly performed remedial exercises were the basis of

rehabilitation. The wardmaster was responsible for the supervision of the

patients. Each hour was announced by him and, for the next minutes, all

other activities that could be stopped were discontinued while the prescribed

exercises were carried out. Whenever possible, new or difficult exercises
REHABILITATION 179

were checked by the physical therapist or by the physiotherapy technician to be certain that they were being carried out correctly. Three times daily, at

10, 2, and o’clock, exercises for the entire hospital were directed over the

loudspeaker system. Ward personnel were encouraged to take the exercises

with the patients.

As might have been expected the results of reconditioning and rehabilitation at this hospital center were unusually good. Time and effort were spent

on the program, which was directed with energy and imagination, and the

patients responded to the program with equal enthusiasm and interest.

Another excellent program was directed and carried out at the 129th

General Hospital. One of its features was the presentation to each patient

of booklet entitled “Fracture Facts” which had been written by Lt. Col.

Philip S. Foisie, MC, and illustrated by Sgt. William Pitney (see extracts from

booklet, pages 180 to 183). The necessity of using the arms and logs to prevent

muscular atrophy from disuse was clearly set forth, and the booklet proved of

great value in the rehabilitation of patients with bone and joint injuries.

Replacement Centers

From the standpoint of orthopedic surgery, replacement centers did not

function as well as could have been wished. Soldiers sent to them with precise

recommendations for limited duty were frequently returned to their original

units or were sent to other units in which the duties were equally arduous.

As result, they were soon on their way back to the dispensary or the hospital.

This was extremely unfortunate. There were in the theater many positions which were occupied by men who were good combat material and which

could quite well have been filled by men qualified only for limited duty. Too

frequently, until the last weeks of the war, little or no attempt was made to

substitute these men for men fitted for frontline duty. Even then, the exchange was often not entirely satisfactory. On the other hand, some of the

men designated for limited duty were in need of rehabilitation themselves, and

sometimes in need of actual hospital care. This waste of manpower in World

War II should be borne in mind in any future war. It could have been partially

avoided by having mature and experienced medical officers, preferably with

combat experience, serve on disposition boards and in replacement centers.
180 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

fm&r&mmm

ou have now arrived at GENERAL

HOSPITAL where your broken bones and

your wounds are to receive the best

possible treatment we can give. The

personnel of this hospital is eager

to do its level best to restore full

function to your injured parts.

for patIon is who

GET ALL TAt BREAKS

We will set your bones

and sew up your wounds

and give you medicine

and take care of your

needs.

|_ _J he human body is designed for

continued use. It doesn't

build up strength by resting

that is, not by COMPLETE rest or

TOTAL inactivity

But your muscles

are controlled by

your brain alone,

and WE can't move

them for you any

more than we could

breathe for you.

YOU alone have

control over those

muscles.
REHABILITATION 181

(~jr~]ou can't pull the main switch

for month or two and then

start up again. The human body

must function at least in low gear

to stay in good condition.

...and with disuse

they soften and

shrivel up. Joints

also, even uninjured

ones, become stiff if

they aren't moved.

Wounds in healing

contract or shorten

so that fingers,

knees, elbows, and

all other joints

Muscles, particularly, depend become bent.

on use to REMAIN HEALTHY. Use

develops them.

Now, broken bones have to be SPLINTED

in order to knit together

This means that for

while the adjacent

joints will not move.

We don’t like this,

but we can't avoid it.

However, we'll tie up

those joints for the

shortest possible time

consistent with healing. We'll watch the

fracture with X-rays

(and otherwise) and

remove the splints

as soon as we can.

Therefore. if you just lie in bed and

vegetate until your injuries are healed,

you will have stiffened and bent-up

joints which your disused muscles won't

be able to straighten out again. The

only way to keep your Joints and muscles

supple is to never let them get stiff.
182 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

r~D IX joints that are not tied up must be

kept moving. Move everything that

isn't tied down. This means that if your

wrist is in splint, keep on moving your

fingers and elbow and shoulder. If your

middle finger is tied up, move your thumb

and your other fingers. and your wrist,

etc.

1, (-A uring this period you can still keep

the muscles strong by "SETTING" them

even though they don't actually move the

joints. The ward personnel will show you

how to do this.

and move them not just LITTLE

WIGGLE, but over the full range of motion

ive minutes

pJ out of every

hour throughout the

day must be spent

in setting muscles

and in exercising

joints

Then when joint is removed from

fixation you are going to have to

limber it up. Don't be discouraged

when you find out that it won't

move at first, and don’t try to do

it all the first day.
REHABILITATION 183

St takes days

weeks, and

sometimes months,

to get full motion

but this

is done by constantly, hour by

hour, gaining fraction of degree at

time which adds up to full

range of motion. nJ veryone on the surgical

r* *-n service from the technician on the ward to the

Chief of Surgery on rounds

will be constantly urging

you to move those joints.

fhe test of good result

is whether you are in

BETTER shape when you are discharged from the hospital than

you were before you got hurt.

nnn want good results

/\L as much as you do

and we'll help you all

we can, but there are

some things that only

YOU can do, so

eep 'em moving and

we'll all be happy.

Text by

Lt. Col. Philip S. Foisie

Illustrations by

Sgt. William Pitney

Don't say.

"I can't...IT HURTS

ME ..." They know

that. If you do it

gradually, but constantly, it won't hurt very

much and even if it does, it has to

be done. The more you postpone it the harder

it will be to do.

185

CHAPTER XVI

Noncombat Lesions

General Considerations

If, at the outbreak of World War II, the official history of World War

had been made required reading for every newly inducted Army surgeon, in

the senior as well as in the junior grades, and if the advice of World War

surgeons had been heeded, great many elective operations, particularly on the

feet and the knee joint, would not have been performed in World War II.

Many of them were unnecessary; they were often meddlesome; and they usually failed to achieve their objective, which was to increase the number of

combat soldiers.

Elective operations done in the United Kingdom prior to D-day included

operations for hammertoes; bone grafts; operations on the spine, particularly

for herniated intervertebral disks and spondylolisthesis; operations on the

shoulder; and, most frequently, arthrotomy of the knee joint. Eventually,

after great deal of time and effort had been wasted, it was realized that most

of these operations were, for all practical purposes, complete failures. It was

the exception rather than the rule for soldier to be able to do full combat duty

after any elective procedure. Usually he could do no more than before he was

operated on, and sometimes he could not do as much.

Some of this misplaced surgical zeal could he attributed to the paucity of

surgical work in the early days of the European theater, but more of it could be

explained by lack of mature judgment. With the approach of D-day the

problem practically solved itself. There was general realization that the

performance of elective orthopedic surgery is not the function of the medical

corps of an expeditionary force and that in most instances the difficulties of the

individual soldier are better resolved by reassignment than by attempted rehabilitation by means of surgery. Thereafter, with the exception of few

carefully selected officers, whose services were of special value in the theater,

officers and enlisted men who absolutely required elective surgery were returned

to the Zone of Interior. Few of them ever came back to the theater.

Elective Surgery Shoulder

Chronic dislocations of the acromioclavicular joint were relatively frequent and always troublesome. At the 298th General Hospital, excision of

the outer inch of the clavicle was found to be an excellent reconstructive procedure, particularly when it was compared with other operations designed

for the same purpose. It was simple, the period of hospitalization was short,

and the immediate results were good. On the other hand, the end results were
186 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

not known, and there was good deal of hesitancy over performing procedure

that was irreparable until the results could be accurately assessed.

Spine

Herniation of the intervertebral disk is discussed in detail in the neurosurgical section of this history. In the early days of the European theater,

there was great deal of indiscriminate surgery for this condition. Later, the

responsibility was shared jointly by the senior consultant in orthopedic surgery and the senior consultant in neurosurgery, one or the other of whom had

to give his consent before operation could be performed. With few notable

exceptions, even this restricted policy failed to increase the number of combat

soldiers. Eventually, the great majority of the officers and enlisted men who

really required surgery appeared before disposition boards and were returned

to the United States. Few of them ever came back to the theater.

Knee Joint

Arthrotomy for internal derangements of the knee joint was performed

more often than any other elective procedure and probably accomplished more

than any other, but at that the results fell far short of what might be expected

from the same operation in civilian practice. One reason was the successive

reduction in the theater holding period. When long holding period was

possible, some soldiers were salvaged for combat duty, though details as to the

number are not available. Information is therefore lacking on what amounts

to the acid test of the value of this procedure. When the holding period was

reduced to 120 days, and later to 90 days, it became obviously impossible to

rehabilitate man after this operation, and, as had become the policy with

other elective procedures, those who clearly needed it were returned to the

Zone of Interior for surgery.

The more mature surgeons who undertook elective arthrotomy for internal

derangements of the knee joint had the best immediate results, because of thencareful selection of cases. They did not perform the operation often. Patients

were selected for it only after careful evaluation of their status on the basis of

detailed history, painstaking physical examination, and multiple excellent

roentgenograms. One thing that the experienced surgeon always realized was

that it was as necessary to evaluate the soldier’s personality as to examine his

knee. Good, stable soldiers seldom manifested prolonged postoperative disability and sometimes could return to full combat duty within 60 days after

exploration of the knee, removal of the menisci, and similar procedures. These

results, however, were exceptional, even in the hands of competent surgeons.

Disabilities of the Feet

Elective surgery in disabilities of the feet needs no extended discussion.

Numerous operations were performed on these indications, and practically

all of them were failures.
NONCOMBAT LESIONS 187

While the tendency was sometimes observed to diagnose static foot disturbances without sufficient objective evidence, there was no doubt of the

seriousness of these disabilities and of the manpower losses which resulted

from them. The experience of the 29th Infantry Division is illustrative.

The training marches undertaken by this division in the fall of 1942

resulted in complaints of pain and fatigue in the lower extremities so far exceeding expectancy that at the suggestion of the senior consultant in orthopedic

surgery, Col. Rex L. Diveley, MC, detailed investigation was undertaken.

It was carried out by Capt. (later Lt. Col.) Marcus J. Stewart, MC, with the

cooperation of the commanding officer, Maj. Gen. Leonard T. Gerow, MC,

and the division surgeon,Lt. Col. (later Col.) William H. Triplett, MC.

The mean strength of the 29th Division when the survey was undertaken

was 9,753 men and the marching strength 6,820 men. During 2-week

individual survey of all foot troops, 820 men (12 percent) presented themselves

with complaints of pain and disability referable to the feet. The survey was

not extended to the artillery battalions, which spent much of their time on the

firing range and were not subjected to the same marching program as the

remainder of the division. This program consisted of weekly or biweekly

hikes, usually for 25 miles, with field pack and equipment, over hard-surfaced

roads.

The troops in the 29th Division had been in the Army of the United

States for approximately years. large number of them had previously

been in the National Guard. They had been on active, large-scale maneuvers

twice. Their training had included frequent long hikes on dirtroads and only

small percentage of man-days had been lost because of foot injuries until

long hikes on hard-surfaced roads had been started.

Of the 820 men examined after they had complained of foot disabilities,

20 were found to have normal feet. In seven cases, the trouble could be traced

to poorly fitted shoes. In the remaining cases, there was objective evidence

for the complaints, chiefly as follows:

Congenital malformations of bony structures, 325 cases, including low

anterior arches (123 cases), low longitudinal arches (67 cases), short first

metatarsals (50 cases), and cavus foot (33 cases).

Developmental malformations of bony structures, 40 cases, including 11

instances of bunions.

Soft-tissue lesions, 199 cases, including 125 instances of tenosynovitis, in

87 of which the Achilles tendon was affected.

Acute injuries to soft tissues, 221 cases, including 17 sprains, 29 blisters,

and 172 instances of foot strain from overtraining.

As the report pointed out, in certain number of cases the deformities

were so severe and of such long standing that the soldiers should never have

been sent overseas. The error was open to two explanations: (1) Improper

Report, Capt. Marcus J. Stewart to Lt. Col. Rex L. Diveley, 28 January 1943, subject: Report on Study of the

Foot Injuries in the 29th Division.
188 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

medical examinations, and (2) the desire to retain men who were of special

value in operational clerical work or who had some other special ability. In

all, 198 soldiers were reclassified because of foot disabilities. It was thought

that the others, under less exhausting training program and with proper foot

care, might be expected to return to full duty and remain 100 percent efficient. change in the shoes worn was recommended in 16 cases, and corrections

in the shoes were recommended in 187 cases, in 54 of which the corrections

would be permanent. If these corrections were not made and if they were not

supplemented by program of foot training, it was expected that these 54 men

would also have to be reclassified.

When the situationwas again reviewed in March 1943, it was found that in

the Infantry, Engineers, and division special troops, 739 men had fallen out

of line on test marches because of trouble with their feet, against 131 who had

fallen out for all other causes. One hundred and fifty-one of the men who

complained of their feet were recommended for reclassification, against 39 of

the 131 who fell out of line for other causes. Captain Stewart noted in his

March 1943 report that no change or alteration had been made in the foot

training or marching program in line with the recommendations made in his

January report, and that only 23 of the 187 shoe corrections recommended had

been made.

Difficulties with improperly fitted shoes continued throughout the war.

Shortly before D-day, survey in replacement pools conducted by Maj.

Irvine M. Flinn, Jr., MC, of the 801st Hospital Center revealed large number of foot complaints. The men in these pools had been sent from the

Zone of Interior to serve as combat replacements after the first wave had gone

ashore on the invasion beaches. Most of them had been in the Army for only

short time. Many were in their late thirties or had done desk work all their

lives. Little could be done for their difficulties except to suggest arch supports and better fitting shoes. The impression was that the majority of the

troubles of which these men complained could be attributed to badly fitted

shoes which sometimes, the report stated, seemed to have been “given away at

random.

The situation revealed by this survey and the detailed statistics secured

in the investigation conducted in the 29th Infantry Division in 1942 and 1943

indicate clearly why surgery for foot disabilities had so little success in the

European theater and why operations to relieve these conditions promptly

fell into disfavor.

Report, Capt. Marcus J. Stewart to Lt. Ool. R. L. Diveley, 22 March 1943, subject: Test Marches in 29th Division.
PART III

SPECIAL TYPES OF BONE AND JOINT

INJURIES

Marshall R. Urist M. D., and Mather Cleveland M. D.

191

CHAPTER XYII

Complete Dislocations of the Acromioclavicular

Joint

Marshall R. Urist, M. D*

Up to the end of World War II, no single recorded series of complete dislocations of the acromioclavicular joint consisted of even dozen cases. Orthopedic surgeons of wide experience in civilian practice seldom encountered more

than or cases, if as many, in the course of their professional lives. The

mass trauma of combat altered that situation. During the war, several times

as many of these injuries were treated by single observers as would have been

ordinarily observed in lifetime of civilian practice. This chapter is based

upon the author’s personal observation of 41 instances of complete dislocation of the acromioclavicular joint while the 802d Hospital Center was stationed at

Blanford, England, during 1944-45 and while the 97th General Hospital was

stationed at Frankfurt, Germany, in 1945.

These 41 injuries (tables through 10) were all war connected, though not

all were battle incurred. few were sustained on the football field and few

more in traffic accidents. The remainder were incurred in combat, chiefly during parachute jumps and in the course of hazardous engineering operations.

All were of great violence, however they were incurred, as might be expected,

because all the casualties were strong, active, young soldiers in the same age

group.

Twenty-three of the forty-one injuries were acute and were recognized so

promptly that most of the victims received first aid immediately or shortly

after the injury. All of this group were evacuated from the combat zone as

promptly as possible. Those who were transported by air arrived in fixed

hospitals within few hours after injury. Those transported by water or by

rail arrived within 10 days.

In the other 18 cases, the injury was unrecognized or unreported, and

therefore untreated, for periods of time ranging from few weeks to 18 months

after it had been sustained.

Eleven of the 41 soldiers, in addition to complete dislocations of the acromioclavicular joint, had associated fractures of various portions of the clavicle,

the acromion process, and the coracoid process. One of these patients had

fractures. Some of them, as would be expected, were suffering from combat

fatigue or other war-related psychosomatic conditions.

’Associate clinical professor of surgery, Division of Orthopedics, University of California, Los Angeles, Caiif. Formerly major, MC, AUS.
ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

7.

—Significant

data

in

18

complete dislocations of

the

acromioclavicular joint

treated

in

author’s splint

Case No.

Type

of

joint

Associated fractures

Position at

weeks

Ballottement at

weeks

Calcification in

coraco-clavicular ligaments

Cosmetic

results

Residual symptoms

Figure refer- ences

16 10 11 12 13 14 15 16 17 18

Positive

50

do

__

do

Good

Good

Overriding,

nearly

vertical

__do

Fair

55 52

..do....

__do

-do

54 49 46

___do

do

do

___

do do___ __do______ __.do do __.do.__ Slight

subluxation ...

51 45

__do_._

Slight

pain.. do___

See

table

10

for

details

of

later

surgical

management.

Splint

applied

after

10

days

of

management

in

adhesive

strappings.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 193

Table

8.

—Significant

data

in

11

complete,

late,

untreated dislocations of

the

acromioclavicular joint

372572°—56 14

Case No.

Type

of

joint

Primary

treatment

Days

of

healing

Calcification

in

coracoclavicular ligaments

Osteoarthritis

Cosmetic results

Figure

refer- ences

19

Hun

kin

cast

56

Present

Subluxation

56

20 21

Watson

-.Tones

adhesive

58

Present

do

splint. Ho

35

Present

do

22

Jones

humeral

splint

34

Present

do

Subluxation

and

Erb23 24

Stimson

adhesive

splintVelnen.n

adhesive

snlint

395

Ho

do

Duchenne palsy.

Subluxation

270

do

do

Dislocation

57

25

None

35

do

do

do

26 27

70

do

do

do

58

None

42

do

do

47

28

do

300

Subluxation

29

mg. Ho

do

330

Present

do

Table

9.—

Significant

data

in

complete,

variously

treated,

recentdislocations of

the

acromioclavicular joint

Case

No.

Type

of

joint

Primary treatment

osmetic result

Residual

symptoms

30

Skeletal

traction

Excellent

Pain.

31

Ho

do

Slight

pain.

32 33

Phemister transarticular wire.

Slight

subluxation

do

Coracoclavicular screw

Slight

deformity

24

Thoracobrachial

spica,

degree

abduction.

90-

Excellent

This

patient

also

had

fissure

fracture

of

the

acromion

process

and

an

avulsion

fracture

of

the

coracoid

process.
ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

10.

—Significant

data

in

complete dislocations of

the

acromioclavicular joint

eventually

treated

by

excision

of

the

distal

end

of

the

clavicle

Case No.

Type

of

joint

Associated

fractures

Primary

treatment

Interval before surgery

Operative

findings

Cosmeticresults

Figurerefer- ences

Coracocla

vicular ligaments

Joint

Fibrous

adhesions

Poor

36

do

atson-J ones

strapping

weeks

Trapezoid

stretched

Interposed

capsule

and

.do

and

frayed.

fibrous

adhesions.

37

Intact

do

do

38

12

months.

do

Chronic

synovitis

or

Dislocation

fibrous

ankylosis.

39

Adhesive brachioclamonths--. 11

Ossified

Extra-articularnew

Subluxation48

vicular

sling.

bone.

40

10

months-.

do

do

do

53

shaft.

41

Clavicle,

subchondral

Interposed

fibrous

condo

nective

tissue.

10

weeks

do

Interposed

capsule

and

do

52

fibrous

adhesions.

16

do

do

do

See

table

for

details

of

primary

treatment.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 195

The material in this chapter is presented from three points of view:

1. The anatomicopathologic, which up to the end of World War II was

incompletely understood, probably because no single observer had previously

encountered large enough series of cases to permit conclusions.

2. The therapeutic, which had not previously been clarified for the same

reason. Up to the end ofWorld War II, in spite of the small number ofrecorded

cases, more than 35 conservative methods of treatment, and at least 28 surgical

methods, had been proposed for the management of these injuries. During

the course of treatment of these 41 injuries, what seemed to be an improved

method of conservative treatment was developed.

3. The prognostic. Up to the end of World War II, very few end results

of therapy by any methods had been recorded in the literature.

Anatomic Considerations

Before discussing the pathologic process in complete dislocations of the

acromioclavicular joint, certain anatomic facts must be summarized. This

joint is made up of two structures, the clavicle and the acromion process, which

are maintained inrelationship to each other by the acromioclavicular and coracoclavicular ligaments. The coracoclavicular ligaments form syndesmosis, the

term implying synostosis of special type in which the skeletal elements are

bound together by continuous band of elastic connective tissue. Whether

the coracoclavicular syndesmosis represents trend toward the development of

diarthrodial joint between the coracoid process and the inferior surface of the

clavicle or is simply metamorphosed joint is still not clear. In about percent of random roentgenograms of the shoulder, the coracoclavicular joint is

well-developed diarthrosis. The acromioclavicular joint itself is true

diarthrosis; the articular surfaces of the acromion process and the outer end of

the clavicle, which are separated by joint cavity, are surrounded by capsule

which is reinforced by ligaments. The motion of the acromioclavicular joint

is synchronous with the motion of the shoulder joint. There is, however, no

motion of the coracoacromial syndesmosis (represented by the coracoacromial

ligament), and it can be sacrificed without effect on the function of the shoulder.

Its functional significance is, therefore, not apparent.

As part of this study, 100 unselected roentgenograms of the shoulder area

were examined, to determine possible variations in the form of the acromioclavicular joint and to confirm or disprove the impression that they are frequent.

These films were all taken by the standard Army technique, and the patients

on whom they were made had no symptoms referable to the shoulder. The

only selective consideration was that such variations as existed be present

bilaterally. The clinical impression that there are numerous variations in this

joint was promptly confirmed. Only infrequently, in fact, was the roentgenogram entirely in accord with the classical anatomic description. The explanation probably is that the articulation is made up of parts which are formed at
196 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

different stages of the morphogenesis of the typical diarthrosis and that its

normal evolutionary development is frequently interrupted.

In these particular roentgenograms, the following variations from the

classic norm were observed: The articular surfaces were occasionally separated

by meniscus attached to the superior acromioclavicular ligament. Sometimes the meniscus took the form of blade of fibrocartilage which extended

halfway into the joint. Sometimes it formed complete disk which divided

the joint into two parts. In one case, no diarthrosis was present; the joint was

represented merely by pad of fibrous tissue attached to the outer end of the

clavicle, with no evidence of an articular cavity. This is not an uncommon

observation. The joint surfaces were often incongruent. The outline of the

articular surface of the acromion process sometimes corresponded to the outline

of the clavicle, but often it did not. Sometimes no part of the clavicle opposed

the end of the acromion; then the patient, for all practical purposes, had

congenital subluxation or relaxation of the acromioclavicular joint. The

clinical prominence of the acromioclavicular joint was usually determined by

the degree of overriding of the acromial end of the clavicle. Sometimes the

joint surfaces lay in vertical plane (fig. 45, case 17). Sometimes the acromion

partly overlay the clavicle (fig. 46, case 9). In the majority ofroentgenograms,

some overriding of the clavicle on the acromion was observed (fig. 47, case 27).

Figure 45 (case 17).—Roentgenogram of severe dislocation of right acromioclavicular

joint sustained in motorcycle accident. Joint is of vertical type. Interposition of capsular

ligament was suspected in this case, because joint space was greatly increased on affected

side after reduction of dislocation.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 197

Figure 46 (case 9).—Roentgenogram showing dislocation of right acromioclavicular

process, with minute fracture of distal end of inferior margin of clavicle, weeks after

injury was sustained in tank striking tree in combat. Note calcification of inferior capsular

ligament. At this time, the patient complained of pain and had limitation of abduction of

arm beyond 90 degrees. The intact jointis partly underridingat the inferior margin because

the articular surface of the clavicle is concave and the acromial surface is convex.

The shape of the distal end of the clavicle also varied, being bulbous, square,

fusiform, flattened, or cylindrical.

When the material was analyzed statistically, it was found that the articular

surface of the clavicle overrode the articular surface of the acromion process

in 29 of the 100 roentgenograms. The articular surfaces of the acromion and

clavicle were nearly vertical and lay in the same plane in 27 cases. The inferior margin of the articular surface of the clavicle overrode the superior margin

of the acromion in cases. In 21 cases, the articular surfaces were incongruent.

In the clavicle overlay the acromion. In the inferior margin of the clavicle

underrode the superior margin of the acromion. In cases, finally, the articular

surfaces were not in contact at any point.

Mechanism of Injury and Nature of Lesion

It would be far simpler matter to explain the mechanism of injury in

these 41 dislocations of the acromioclavicular joint if the soldiers had been

able to supply more information. They knew the general circumstances of
198 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 47 (case 27).—Roentgenogram showing dislocation of left acromioclavicular

joint months after injury had been sustained in fall from moving tank. Note calcification

of capsular ligament (indicated by arrow) which was associated with mild symptoms of

traumatic arthritis. This patient presented an extreme example of the overriding type of

joint with nearly horizontal articular surfaces.

injury but most of them could provide no precise details. In two cases,

ecchymoses and abrasions indicated the point of contact of external force.

One patient (case 40) had discoloration over fracture of the clavicle, and

the other (case 34) had been struck over the acromion process by falling

steel beam. In most cases, reconstruction of the injury in correlation with the

clinical and roentgenologic findings suggested that the men had been struck

(or had fallen) on the dorsum or the anterior aspect of the shoulder and that the

scapula had thus been forced downward or backward.

There were no illustrations in this series of two mechanisms of injury

which have been reported in the literature. In one, the scapula is drawn

forcibly inferiorly and anteriorly by sudden change in the position of heavy

burden that is being carried; in the other, the coracoid process comes into

contact with the clavicle, and the joint is literally pried apart by force transmitted through the arm.

Illustrations in current textbooks were of little help in dealing with complete dislocations of the acromioclavicular joint, since they were (and continue

to be) based on the concept that this injury cannot occur without tearing of

the conoid and trapezoid ligaments. Neither past experience, as derived

from the literature, nor the evidence of these 41 cases supports that point of

view. When the distance between the clavicle and the coracoid process is

greatly increased, as it may be in this type of injury, in comparison with the
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 199

distance between these structures in the uninjured shoulder, the coracoclavic- ular ligaments are correspondingly stretched and may be sprained, but it does

not follow that they must be torn. In some cases in this series, in fact, in

which force was transmitted through the arm, it was entirely conceivable that the joint capsule took the full force of the blow or fall and that the ligaments suffered no damage at all.

In unreduced dislocations of the acromioclavicular joint, the deformity was maintained by three factors, (1) gravity, (2) the pull of the trapezius on

the distal end of the clavicle, and (3) the absence of counterpull by the aponeurosis of the anterior portion of the deltoid. When the arm on the affected

side was weighted, the scapula, and with it the acromion process, was drawn

downward and forward, so that the gap in the joint was increased both anteroposteriorly and superoinferiorly. In several doubtful cases in this series, this

maneuver was used to accentuate the suspected lesions in the roentgenograms.

Pathologic Process

No fresh material was available for examination, since United States Army

Medical Department policy was to treat acromioclavicular dislocations conservatively and not to resort to surgery until the lapse of sufficient time after

injury to permit healing or to establish the existence of residual disability.

It was possible, however, to study the process of healing after complete dislocation in cases in which resection of the distal end of the clavicle was

necessary at intervals varying from weeks to year after injury.

In each of these nine specimens the coracoclavicular ligaments, while

stretched and elongated, had healed in complete continuity. The texture of

the ligaments ranged from cicatricial induration to bony hardness. Elongation

and scarification were proportional to the distance between the outer end of the

clavicle and the coracoid process, but bony tissue was not always identified.

The joint capsule, as the result of the healing process, showed an increase of

thickness in every specimen, sometimes up to mm.

Late changes were less uniform. In five cases, the articular surfaces were

obliterated and replaced by fibrous connective tissue. In two of these cases,

interposed flakes of cartilage, fibrocartilage, and necrotic hyalinized material

were regarded as remnants of capsular ligament and meniscus, presumably

separated at injury. In five cases, osteoarthritic changes, such as bony eburnation and marginal spurs, were observed. In two cases, there was evidence, which had not been present in the roentgenograms, of subchondral compression

fractures of the clavicles and acromion processes. In one case (fig. 48, case 39),

loose osteocartilaginous bodies were present.

The changes observed in these late specimens were in accord with those

observed by Gurd in fresh cases. In of his cases, complete dislocation of the

Ourd, P. B.; The Treatment of Complete Dislocation of the Outer End of the Clavicle. Hitherto Undescribed

Operation. Ann. Surg. 113: 1094-1098, June 1941.
200 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 48 (case 39).—Roentgenogram showing healed dislocation of acromioclavicular

joint 10 months after patient was kicked squarely on point of shoulder in football game.

Note loose osteocartilaginous bodies in joint (indicated by arrow) and ossification of insertions of trapezoid ligament. The patient was subjected to surgery because of annoying

crepitations, with pain, while doing heavy work, and because he had 30 degrees of limitation

of abduction.

clavicle occurred without complete rupture of the coracoclavicular ligaments.

In other cases, stretched or ruptured ligaments were found at open operation

for repair of conoid and trapezoid ligaments with fascia lata.

Experimental observations.—For further elucidation of the mechanism of

injury in complete dislocations of the acromioclavicular joint, number of observations were made on cadavers:

1. The coracoclavicular ligaments were transected through stab incision,

after which the acromial end of the clavicle was grasped with bone forceps and

tested for motion. The motion produced did not differ perceptibly from the

motion possible on the opposite, intact side, nor did subluxation occur on the

transected side when strong traction was applied to the arm.

2. The superior acromioclavicular ligament and the entire joint capsule

were transected through an incision overlying the joint. It was then possible

to produce an incomplete dislocation of approximately 50 percent. The incision

was next carried around the outer end of the clavicle in U-shaped fashion, and

the attachments of the deltoid and trapezius muscles to the clavicle wore

divided. The end of the clavicle was then drawn upward and posteriorly.

This made it possible to accomplish complete disarticulation. When, however,

the end of the clavicle was pulled straight upward, oidy incomplete disarticulation could be produced. When the coracoclavicular ligaments on the same
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 201

side were cut, as previously described, the entire outer end of the clavicle could

he disarticulated farther upward than when only the attachments of the

deltoid and trapezius muscles were divided.

3. The trapezoid ligament, the deltoid and trapezius attachments to the

clavicle, and the superior acromioclavicular ligaments were all dissected and

divided. It was then possible to move the clavicle posteriorly or superiorly

and produce complete dislocation.

4. The experiment just described was repeated, except that the conoid

ligament was sectioned instead of the trapezoid. The same results were

accomplished as in the previous experiment, except that the acromial end of

the clavicle could be dislocated farther upward.

5. The third and fourth experiments were repeated, except that the

coracoacromial ligament was sectioned, first alone and then in combination

with each of the other ligaments. There was no perceptible alteration in the

stability of the acromioclavicular joint.

Similar observations had been reported in the literature before these were

undertaken, and the same conclusions had been drawn from them, with one

exception: The observations made in World War II were thought to emphasize

the predominant role played in complete dislocation of the acromioclavicular

joint by the joint capsule and the attachments of the deltoid and trapezius

muscles. When these structures were severed, to simulate the tearing or

stretching which they undergo in dislocation of the joint, the outer end of the

clavicle could be completely dislocated without injury to the conoid or trapezoid

ligaments. Greater displacement of the clavicle was possible when the conoid

and trapezoid ligaments were sectioned, but the alteration was quantitative

not qualitative. Section of the conoid or the trapezoid ligament alone had no

perceptible effect, as might have been expected, since there is no separate excursion of the bones united by these structures. In the interpretation of these

results, however, it was necessary to bear in mind Cadenat’s warning that in

the living subject the relationships of parts in the functioning joint are probably

altered by the tone and action of surrounding muscles and that the elasticity of

individual ligaments may vary, depending upon the necessity for synchronizing

the motions of the clavicle with those of surrounding parts.

Both the pathologic and the experimental observations in this series of

dislocations suggested that the clavicle can become completely dislocated without rupture of the coracoclavicular ligaments. It was also apparent that the

trapezoid ligament is occasionally stretched in acromioclavicular dislocations

and that still more infrequently it is grossly ruptured. Microscopically, it had

to be assumed that individual fibers of both the conoid and the trapezoid

ligaments are torn during injury, but the observations made in this study indicated that the capacity of these ligaments for both healing and repair is excellent

and can be relied upon for reconstitution of the joint relationships.

Cadenat, F. M.: The Treatment of Dislocations and Fractures of the Outer End of the Clavicle. Internal. Clin.,

Series 27, 1: 145-169, 1917.
202 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Diagnosis

Diagnosis in this series of cases was made on the history of the injury, the

clinical evaluation of the symptoms, the physical findings supplemented by

certain objective tests, and the roentgenologic findings.

In the acute case, there was considerable pain. In the untreated or recurrent case, after joint effusion and periarticular swelling and tenderness had

disappeared, which was usually by the end of the third week, there was little

pain in complete dislocation with overriding if there was no contact between

the clavicle and the acromion process. Unless they were called upon to do

hard work, most soldiers with nonacute injuries tended to make light of their

symptoms.

In some cases, residual subluxation following the conservative treatment

of complete acromioclavicular dislocations gave rise to pain, annoying crepitation, and sometimes limitation of joint motion. In such cases, there was an

unsightly protrusion of bone on the shoulder. Some soldiers, like men in civil

life, were willing to disregard the deformity if the symptoms were not severe.

In other cases, the complaints were disproportionately greater than the clinical

and roentgenologic evidence indicated that they should be.

In these circumstances, number of simple tests proved useful. When

they were positive, it was assumed that there was physical basis for the

complaints.

1. When the man leaned against the wall, so that the inferior angle of the

scapula was firmly and sharply pressed into the posterior aspect of the thorax,

pain was felt in the acromioclavicular joint.

2. When the man elevated his arm and pain was experienced on the

affected side, itwas assumed that synovitis, fibrous ankylosis, or arthritis of the

injured joint was present. Full elevation of the arm was sometimes impossible.

3. When the man shrugged his shoulder, rotated the arm internally, or

carried weight, palpable crepitations or subjective grating sensations were

accentuated. 35-pound bucket of sand in each hand was used routinely to

amplify the deformity for roentgenologic purposes.

4. Crossing the elbows on the chest in the position of adduction might be

impossible because of pain in the joint or ankylosis.

Management

As in all injuries of this kind, the purpose of treatment in dislocations of

the acromioclavicular joint was twofold, to secure anatomic reposition and to

relieve symptoms. Unfortunately, although the objectives are obviously interrelated, the accomplishment of one objective did not necessarily result in the

accomplishment of the other. After perfect anatomic restoration of the joint,

symptoms sometimes persisted in these cases, as in many other reported cases,

because there was residual damage to the articular surface and joint capsule.

In other instances, there were no residual symptoms, but the anatomic result

was poor.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 203

Recurrence of the dislocation furnished the same problems that it does in

civilian practice. In number of instances, although clinically and roentgenologically the bones were in perfect position after immobilization for the accepted

length of time, the dislocation recurred as soon as the splint was removed,

showing that healing had not yet been sufficient to reestablish the continuity

of the periarticular ligaments. Subluxation recurred in of the 18 cases treated

conservatively in this series (table 7). According to tlie literature, residual

subluxation or some degree of disability occurs in 10 to 20 percent of all cases

managed by this method.

Conservative Management

The necessity for standardization of treatment underlay all Army policies,

including the policy that complete dislocations of the acromioclavicular joint

should be treated conservatively for certain period of time before it was

concluded that this method would not be effective. Some of the data in this

series suggest that there may be ways of determining in advance which cases

will, and which will not, be responsive to conservative measures. It was

found, for instance, that men who had overriding clavicles frequently were

symptomless after conservative treatment (table 7), while those with vertical

or partially overriding joints presented complications (table 9). Two patients

with this type of joint (case 5, table and case 41, table 10) had subchondral

compression fractures.

Although conservative treatment was necessarily used in fresh cases

because of Army policies, better results might have been obtained if more

flexibility had been permitted. It would probably have been wiser to resort

to surgery at once in untreated cases and neglected cases. It would also have

been wiser to resort to it without further delay, if improvement was not evident

at the end of or weeks of properly applied conservative measures. Finally,

complete dislocation of the outer end of the clavicle did not respond well to

conservative methods, and some degree of deformity was inevitable if surgery

was not done. correct evaluation of the patient was, of course, an essential

part of the decision to undertake operative measures.

Conservative management included various techniques of manipulation

and reduction, followed by various methods of immobilization.

Manipulation and reduction.—The following methods of manipulation

were employed in this series to correct the deformity and reduce the dislocation

before the application of splints:

1. Pressure was exerted with the thumb over an appropriately placed

small felt pad, in order to depress the prominent distal end of the clavicle.

2. The scapula and acromion process were elevated by elevation of the

flexed elbow.

This argument is necessarily theoretical. As long as combat conditions prevailed in the European Theater of

Operations, no elective surgical procedure was permitted unless the soldier could be returned to full field duty after it

within120 days. (Editor’s note.)
204 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

3. These two methods were used in combination in most cases to obtain

the desired position for immobilization in brachioclavicular splint. The

patient’s role in both was passive.

4. The patient, lying supine, threw his shoulders back and abducted his

arm 90 degrees or more, or hyperextended his head, to relax the pull of the

trapezius on the outer end of the clavicle.

5. The patient, standing erect, either threw his shoulders upward and

backward or abducted the injured shoulder 90 degrees or more. This maneuver,

as well as the maneuver described under heading 4, could be carried out by the

surgeon rather than performed actively by the patient, if that was more

convenient.

Reduction of the dislocated joint was, as rule, easier than maintenance

of the optimum position for the necessary weeks. In the occasional case,

however, there were several obstacles to successful reduction. Sometimes the

clavicle slid into position and rotated on its long axis (case 5, table 7). Sometimes it lay posterior to the acromion process, even when held down at the

correct level by manual pressure (case 4, table 7). As has already been intimated, it was found, when some of these patients came to surgery for excision

of the distal end of the clavicle, that the source of these difficulties was interposition of meniscus, frayed ends of capsular ligament, and flakes of articular

cartilage between the joint surfaces.

6. If the acromioclavicular joint was ruptured as well as dislocated, the

deformity could he overcorrected by pushing the clavicle down below the level

of the acromion process. In the two cases in this series (fig. 49, case 8; cases

and 18, table 7) in which immobilization was carried out in this position, both

cosmetic and functional results were excellent.

Immobilization.—Various types of splints and other techniques of immobilization were used to maintain the extremity in position until healing ocFigure 49 (case 8) —Roentgenogram [retouched] of left acromioclavicular

dislocation sustained in motorcycle accident, after reduction and overcorrection in author’s splint. Arrows indicate points of main pressure

of shoulder strap on clavicle. The clavicle has been depressed below

the level of the acromion process.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 205

curred, which was theoretically at the end of weeks, or until it was evident

that conservative management would not be successful.

One of the eleven patients seen late and not treated (case 26, table 8) had

been put up in Velpeau bandage, which had had no effect on the dislocation.

Otherwise, slings and bandages were not used in this series except immediately

after injury, for first aid. Some of the older surgeons devised complicated

bandages to be applied by complicated techniques, but modern orthopedic

surgeons had had little experience with these methods. They give very uneven results and have the additional disadvantage that if the bandages and

slings are to be effective for any length of time, they must be painfully tight.

Four of the eleven patients seen late and not treated had been put up in

various types of adhesive splints by the surgeons who first treated them, but

in no instance had the result been satisfactory (cases 20, 21, 23, and 24, table 8).

Otherwise, adhesive dressings and strappings were not used in this series for

definitive treatment. Even the use of protective felt boards, coaptation splints,

elastoplast, and other modern elastic materials does not eliminate the fundamental objection to this method, namely, that perspiration and skin irritation

make the patient extremely uncomfortable and that removal and reapplication

of the dressing, which is necessary at intervals if position is to be maintained,

are unpleasant procedures for physician as well as for patient.

Suspension of the extremity in 90 degrees or more of abduction, by means

of the Balkan frame or some similar device, is useful method in the management of incomplete dislocations in bedridden patients but of rather doubtful

value in complete dislocations. It was not indicated in any case in this series.

Harnesses and braces were also avoided. The patient must be under constant

supervision when they are used; they require considerable degree of cooperation from him, which is not always forthcoming, and better results can be secured by less complicated methods.

Plaster immobilization.—Nineteen of the patients in this series who were

seen early or relatively early (within 10 days) were treated conservatively, with

immobilization in plaster splints for approximately weeks. Another patient

(case 19, table 8) who was seen late, had also been treated by plaster immobilization, in sort of hanging (Hunkin) cast, which had left him with subluxation.

This cast is loose, plaster torso cast, suspended from webbed shoulder strap.

It has the serious disadvantage that the effort to maintain reduction is relaxed

when the patient is recumbent. The Gibben splint has the same objection.

The Gibben, hanging arm cast suspended from an elastic band over the

shoulder, functions on the same principle as the Hunkin splint—that the weight

of the plaster will depress the outer edge of the clavicle.

The thoracobrachial spica, with 90-degree abduction, recommended by

Key and Conwell, was used in one fresh case (case 34, table 9) with excellent

results.

Key, John A.,and Conwell, H. Earle; The Management of Fractures, Dislocations, and Sprains, 3d ed. St. Louis:

The C. V. Mosby Co., 1942.
206 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Case 34.—An engineer, working with crane, was struck on the left shoulder by falling

steel beam. Roentgenologic examination an hour later showed linear fracture of the

acromion process without displacement, avulsion of the coracoid process, and acromioclavicular separation. The plaster abduction splint of Key and Conwell was considered more

practical in this case, because of the swelling and ecchymosis over the dorsum of the shoulder,

than splint which required the pressure of shoulder strap to be effective. The dorsal

section of the cast was removed at the end of weeks, and massage and biceps-setting exercises were ordered. The remainder of the cast was removed weeks later, and limited exercises were undertaken. At weeks, use of the shoulder wheel was begun. Roentgenologic

examination at this time showed union of the coracoid process and the scapula, with complete healing of the fracture of the acromion process. When the man returned to duty 12

weeks after the accident, he had slight subluxation but was free of symptoms. When the

cast was first removed his shoulder had been painful and stiff.

The Key-Conwell cast only partially reduces the acromioclavicular separation, because the distal end of the clavicle is displaced slightly posteriorly, and

the distance between the clavicle and the acromion process is undesirably increased. It should therefore be employed only on special indications, such as

existed in this case. This case is an excellent illustration of the justification for

the general policy in military practice that sufficient period of conservative therapy be tried before surgery is resorted to. The dislocation was associated

with fractures of the coracoid and acromion processes, and, as in all such cases,

management was compromise, in an endeavor to secure comfortable immobilization.

number of available casts were considered and deliberately rejected for

these fresh cases. Legg, among others, devised brachioclavicular cast which

is Velpeau bandage with an elastic shoulder strap added to depress the

clavicle. The objection to the use of such casts in combination with shoulder

straps is that the pressure of the strap in brachioclavicular slings, when the scapula is not elevated, is usually too much for skin tolerance over 6-week

period. This is particularly true if techniques which utilize suspension and

gravity are employed.

The torso cast recommended by Dillehunt elevates the acromion process

until it is alined with the distal end of the clavicle, by fixation and elevation of

the arm at the side of the chest (fig. 50B). Reduction and immobilization are

accomplished with the expenditure of very little force, because the pull of the trapezius is counteracted, while at the same time the weight of the arm is

canceled out.

The author’s splint (fig. 50) was devised to incorporate the most desirable

features of the splints devised by Dillehunt and Howard. As in Dillehunt’s

splint, elevation of the scapula is maintained by anchoring the body plaster

to the iliac crests, to provide the necessary counterbalance. Neither of these

splints, however, provides for overcorrection of the deformity by depression

of the clavicle below the level of the acromion process, which is necessary for

optimum cosmetic and functional results. In the author’s modification,

broad elastic shoulder strap, made of strip of salvaged inner tube, provides

Dillehunt, R. B.: Luxation of the Acromioclavicular Joint. S. Clin. North America 7: 1307-1313, October 1927.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 207

the necessary clavicular depression, while at the same time excessive cutaneous

pressure is avoided. The main objection to this splint seems to be that it

restricts movement of the arm and chest.

This splint was used in 18 cases in this series (table 7), in 15 of which it was applied promptly after injury.

Results.—The 15 patients just referred to were evacuated promptly from

forward areas in first-aid bandages or temporary adhesive splints. They wore

the author’s splint for weeks and had had weeks of physical therapy before

the first record of results was made, though in each instance, after the splint

had been worn for to weeks, the shoulder strap was turned medially on

itself, and the mobility of the acromial end of the clavicle was determined.

In no instance did the splint cause any disability in the elbow. Twelve patients were returned to duty completely cured after period of physical

therapy and rehabilitation (table 7). Another (case 4) was left with subluxation but without significant pain or limitation of motion. He was also

returned to unrestricted military duty, and followup showed that activity had

not increased the deformity.

The two remaining patients (cases and 6) presented subluxations associated

with pain, swelling, tenderness, and deformity after several days of physical

therapy. When they were operated on later, the capsular ligaments were found

interposed between the joint structures, and interference with satisfactory

reduction of the dislocations was evident, although it had not been observed

in the anteroposterior roentgenograms. This finding, as will be pointed out

later, could have been predicted.

Twelve successes in fifteen early cases handled by the author’s splint are

about in accord with the results of other observers with newer methods of

conservative treatment. It should be emphasized, however, that this report

concerns only complete dislocations. Many successes reported with strapping

and similar obviously inadequate methods of treatment concern ordy sprains,

subluxations, or incomplete dislocations of minor degree, such as the football

type of injury sustained in blocking.

The three other patients treated by the author’s splint (cases 16, 17, and

18, table 7) were seen 10 days after injury, when they were transferred to it

from the adhesive strappings originally applied for first aid. At the end of

weeks of immobilization, all presented subluxation of some degree, but associated symptoms were neither severe nor disabling. One of these patients

(case 16) who also had an avulsion fracture of the clavicle, had more pain

than the other two patients, whose dislocations were uncomplicated, but all

three were perfectly satisfied to return to fidl duty without further treatment.

Two tests used in the course of conservative therapy seemed useful in

determining the results being accomplished:

In some patients (fig. 51, case 16; fig. 45, case 17) roentgenograms taken

week after reduction showed measurable widening or separation of the joint

space. These were cases in which the outer end of the clavicle was characteristically above and posterior to the acromion process and in which it had ap-
208 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 50 (case 1).—Application of author’s splint. A. Separateapplication of padded

arm and body plasters. B. Elastic shoulder strap, made of strip of salvaged inner tube, is

stretched tightly over clavicle. The tube ends are doubled back on themselves between

layers of plaster bandage, to maintain constant pressure.

Figure 50.—Continued. C. Elastic shoulder strap in place. Scapula elevated, as in

method of Dillehunt. Arm section of plaster fixed to body section and elevated so that

shoulder on affected side is to inches higher than shoulder on intact side. D. Continuous

pressure maintained by wide area of shoulder strap. Support of body plaster on iliac crests

furnishes countertraction and aids in maintaining elevation of arm on body.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 209

Figure 50.—Continued. E. Roentgenogram of patient shown in figure 50A through

50D, showing dislocated left clavicle before treatment. Note overriding type of joint.

F. Roentgenogram showing reduction of dislocation in Urist splint. Note slight overcorrection of dislocation, as shown by comparison of distances between coracoid process and

clavicle in reduced joint in this roentgenogram and intact right joint shown in figure 50E.

parently been possible to reduce the dislocation and obliterate the deformity.

In these cases, when both clavicles were outlined with the fingertips, it could

easily be demonstrated that, while the upward displacement of the dislocated

clavicle bad been corrected, there was still slight posterior displacement. These

were both delayed cases, in which further manipulations would not have been

effective. In earlier cases it should be possible to correct the position.

In five cases in this series, ballottement or free floating of the distal end of

the clavicle was observed after weeks or more of conservative treatment.

It was particularly striking in two cases (cases and 5), both of which were

instances of posterior displacement. In each case, ballottement was evident

when, at the end of weeks, the shoulder strap of the splint was turned back

and the distal end of the clavicle was pushed interiorly and anteriorly, in an

attempt at adjustment. When the splints were removed at the end of weeks,

the dislocation in each case was only partially corrected, and subluxation was

evident during the weeks ofrehabilitation. In both cases, pain and sense

of instability later required excision of the distal end of the clavicle. In both

cases, as already noted, the interposition between the joint surfaces of fibrous

connective tissue, capsular ligament, and torn meniscus, clearly prevented

accurate reposition and presumably accounted for the ballottement observed

earlier. In three other cases, there were similar but less conspicuous findings

at operation.

At the end of weeks, uncomplicated or well-reduced dislocations of the

acromioclavicular joint ordinarily become stable, because the capsular ligament

has healed and the attachments of the deltoid muscle are repaired. This is not

large enough number of cases to warrant conclusions, but it may well be that

the finding of free-floating clavicular end at this time indicates the unlikelihood of success with conservative measures and the necessity for an early

resort to surgery.

372572°—56 15
210 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 51 (case 16).—Roentgenogram showing severe dislocation of right acromioclavicular joint after reduction in author’s splint. The injury was sustained in fall over

fence, on dark battlefield. false impression of overcorrection of deformity may be obtained when, as in this case, the clavicle is displaced posterior to the acromion but is actually

farther from the coracoid process than on the opposite side.

The following case history is another illustration of the good results which

can follow properly applied conservative treatment:

Case 1.—A soldier who was sitting in the front seat of jeep was thrown out after

head-on collision with another vehicle, striking his left shoulder on the pavement and sustaining complete dislocation of the clavicle (fig. 50E). Velpeau bandage applied in

local dispensary did not maintain satisfactory reduction. Twenty-four hours later, the

dislocation was reduced and the shoulder put up in the author’s splint (fig. 50A, B, C, and

D), in which it was maintained for weeks. Physical therapy was carried out for 10 days,

and days later the man was discharged to full duty, with no restrictions on calisthenics or

sports. Roentgenographic examination at this time (fig. 50F) showed the structures in correct anatomic position. There was slight induration on palpation of the joint, with slight

crepitus, but the patient had no symptoms and had full range of motion.

Surgical Measures

The end results in arthrotomy, internal fixation, and other surgical measures used in acromioclavicular dislocations depend, just as the end results of

nonsurgical measures, upon healing of the ligaments and periarticular structures. In neglected and oldlacerations, goodresults are unlikely. The theoretic

advantages of management by arthrotomy include accurate fixation of the nonosseous parts of the joint by reposition and suture under direct vision, but the

literature does not suggest that the results are any better cosmetically, symptomatically, or functionally than are achieved by improved conservative measures.

Arthrodesis was fairly popular method of management in the days

when suture operations on the joint frequently resulted in ankylosis. It was

the practice in those cases to resect the articular cartilages later, to insure bony

fusion, correct deformity, and relieve pain. Limitation of motion of the shoulder, particularly abduction, was explained by experimental observations on the

cadaver, which showed that the articulations of the clavicle, scapula, and

humerus must function independently for elevation of the arm. Arthrodesis
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 211

continues to be mentioned by occasional observers as solution of the problem

of complete dislocation, but it is not an acceptable procedure in modern orthopedic surgery, and it was not performed, or even contemplated, in any case in

this series.

Syndesmoplasty and ligamentopexy were also not employed in this series.

No conclusive data on the results of syndesmoplasty had been reported up

to World War II, and there are theoretic objections to the operation, the chief

being that repair of the conoid and trapezoid ligaments is probably impossible

because they are still inaccessible after the widest possible exposure. Suture

has been accomplished by indirect methods, such as binding the clavicle to

the coracoid process with heavy silk or wire, or repairing the periarticular

ligaments by transfer of fascia or tendons at the site of the lesion.

There lias never been agreement about the value of ligamentopexy.

Reconstruction of the conoid and trapezoid ligaments with an isograft of

fascia lata is theoretically valuable in old dislocations with extreme deformity,

but if the grafts stretch, the deformity will recur and will be increased by

postoperative stiffness of the shoulder. Furthermore, the fascia or old ligaments frequently calcify, and the resulting synostosis limits abduction.

One patient in this series (case 32, table 9) was treated by open reduction

and internal fixation with Phemister’s transarticular wire. He was left with

slight luxation but no residual symptoms.

Two patients were treated by skeletal traction (cases 30 and 31, table 9).

They had excellent cosmetic results but some residual pain. This is an excellent method for patients who have sustained other injuries which require

confinement to bed, since it assures maintenance of the anatomic position

continuously for the desired length of time. It is not, however, suitable for

either industrial or military practice; it requires great skill and judgment,

and it carries the risk of infection and of injury to nerves and blood vessels.

Finally, it can be used only in fresh injuries, and even in them it is associated

with all the disadvantages inherent in the use of external skeletal fixation.

When skeletal traction is correctly employed, traction is obtained by the

use of small threaded pins; two are inserted into the outer third of the clavicle

and another is inserted into the coracoid process, all three being tied into

triangle with rubber bands. These bands serve, in effect, as second, external

set of ligaments, and reduction is obtained by continuous skeletal traction.

The patient, to relieve the tension, involuntarily elevates the shoulder on the

affected side and thus actively aids in maintaining the reduction.

One case (case 33, table 9) was managed primarily by coracoclavicular

screw. The patient was loft with slight deformity but no residual symptoms.

Because of bone resorption, however, the screw became loose weeks after it

was inserted. It had to be removed and another splint applied. This method

was introduced by Boardman M. Bosworth in 1941 and, therefore, had not

Bosworth, B. M.: Acromioclavicular Separation. New Method of Repair. Surg., Gynec. Obst. 73: 866-871,

December 1941.
212 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

had wide trial when the United States entered World War II. WatsonJones, who recommends the removal of the screw in most cases after to

weeks, considers the results better than those accomplished by conservative

methods. Since he advanced this opinion in 1943, he was presumably referring

to the use of adhesive strappings, not to the newer conservative techniques.

The coracoclavicular screw is applicable only to fresh injuries. It seems

highly doubtful that patients who do not respond to conservative therapy,

because of the interposition of soft parts between the joint structures, will be

benefited by it. Theoretically, it is open to all the objections applicable to

operative methods which do not include arthrotomy. Since the clavicle

rotates on its long axis with abduction, it is hard to see how it could move

normally when this method of fixation has been employed. The effect on

the shoulder as whole, in fact, seems the same as the effect of fusion of the

acromioclavicular joint. Fixation of the clavicle to the scapula limits abduction of the arm and causes pain if motion is attempted beyond 90 degrees.

Surgical excision of the outer end of the clavicle was used in nine cases in

this series (table 10) after conservative methods had failed. The cosmetic

results (fig. 52, case 5) were excellent in all cases, the contour of the dorsum

of the shoulder being maintained by the acromion process. Neither the function nor the appearance of the shoulder, however, could be described as normal

in any case.

Prior to World War II, this operation had frequently been used in such

conditions as osteomyelitis, arthritis, and tumors, and it had been used,

though less frequently, in both fresh and old dislocations of the acromioclavicular joint. These experiences, as well as observations on persons with partial

or complete congenital absence of the clavicle, had led to the conclusion that the

patient with this type of defect was far better off than the patient with acromioclavicular ankylosis, and that the only disability after operation is possible

slight impairment of the muscular coordination needed for forceful forward

thrusts of the arm or for acrobatics.

The results in these nine cases, while satisfactory, do not fully bear out

these observations. Careful study of these men showed that the intact clavicle

acts as kind of yardarm, which prevents the shoulder from falling anteriorly

and inferiorly onto the chest wall (fig. 52A). This is probably its most important function in man. These were all young men, and the musculature of

the shoulder girdle compensated for the stability lost with excision of the

clavicle. All of them, however, admitted to rapid fatigue or slight weakness of

the affected shoulder as compared with the intact shoulder when they engaged

in prolonged vigorous exercise, though within few weeks of surgery all had

been relieved of pain and disability.

In all nine cases, the operation consisted of resection of from to cm. of

clavicle, which excluded the clavicular stump from interference with the

motions of the scapulohumeral joint. Suture of the cut end of the clavicle to

Watson-Jones, Reginald: Fractures and Joint Injuries, 3d ed. Baltimore: Williams Wilkins Co., 1943, vol. 2,

pp. 433-435.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 213

Figure 52 (case 5).—Results of excision of outer end of clavicle in complete dislocation

of the left acromioclavicular joint, sustained in football game, after failure of management

in author’s splint. A. Photograph 10 days after operation and just after removal of sutures

from incision, through which coracoclavicular ligaments were also explored. Note that

affected shoulder is slightly lower than intact shoulder as scapula falls forward and lower

on thorax. B. Photograph 15 days after operation. Range of active abduction is 90

degrees. C. Photograph 21 days after operation. Full elevation of arm is now possible.

D. Photograph 28 days after operation. Painless crossing of elbows on the chest, which

is now possible in this case, is seldom possible with any appreciable acromioclavicular

separation.

the coracoid process with nylon sutures, as advised by Rowe, was not regarded

as an essential part of the procedure and was omitted in all cases.

The following case reports illustrate both the indications and the results

of this method of surgery:

Case 5.—This soldier was injured when, in the course of football game, he was struck

sharply over the dorsum of the shoulder by an opponent who blocked him out of line play.

Velpeau bandage was applied as first-aid measure and was replaced days later by the

author’s splint. Roentgenograms showed excellent reduction, but there was slight widening

of the acromioclavicular joint as compared with the joint on the opposite, intact side.

Examination weeks after injury showed the distal end of the clavicle to be abnormally

mobile and apparently floating free. The splint was removed at weeks, and daily exercises

were begun at the shoulder wheel. At weeks, there was 30 degrees of limitation of motion

Rowe, M. J.: Nylon Bone Suture. Surgery 18: 764-768, December 1945.
214 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 53 (case 40). A. Roentgenogram of old

dislocation of left acromioclavicular joint with linear

fracture at junction of middle and outer thirds of

clavicle. Ecchymosis and marked swelling were

present over lateral aspect of neck and dorsum of

shoulder immediately after injury. Note synostosis

(indicated by arrow) at site of fracture. B. Roentgenogram [retouched] after excision of outer third of

clavicle. Patient had complete relief of symptoms

and returned to full duty in 12 weeks. C. Superior

and inferior aspects of excised clavicle. Note new

bone formation on anteroinferior attachments of

trapezoid ligament.

when the arm was elevated, and pain and crepitus were experienced during exercises at the

shoulder wheel. When the arms were folded across the chest, the distal end of the clavicle

rose out of the joint. Ten weeks after injury, hen it as evident that the man had full

justification for his continued complaints, the distal end of the clavicle as resected. Shoulder

exercises were begun even before the sutures were removed. Three weeks after operation

there was no evidence of deformity or disability, and all symptoms had disappeared. The

soldier cheerfully returned to full duty. This case is an instance of failure to heal under

conservative therapy, even when conditions are ideal.

Case 40.—This soldier sustained fracture of the left clavicle, with separation of the

acromioclavicular joint, produced by direct blow over the shoulder in jeep accident 10

months earlier in France. The fracture healed uneventfully and in good position, and the

man was returned to combat. Nine and half months after the accident, he began to

experience pain in the left shoulder. It increased in severity and was aggravatedby exercise

in games and calisthenics. The acromioclavicular joint was painful to palpation but was

not abnormally mobile. The clavicle on the injured side was more prominent than on the

intact side. The limitation of abduction of the arm was 30 degrees. Roentgenograms

(fig. 53) showed well-healed fracture at the junction of the middle and outer thirds of the

clavicle, with synostosis between the fracture site and the coracoid process and ossification

of the conoid and trapezoid ligaments.

The operative findings clarified the pain and disability from which the patient had

suffered. mass of bone and scar tissue was found throughout the insertion of the subclavius muscle and in the area of the coracoclavicular ligaments. bridge of bone as

palpable between the coracoid process and the site of the old fracture. The distal third

of the clavicle and the ossified coracoclavicular ligaments and regional scar tissue were
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 215

removed en masse (fig. 53C), with minimum of dissection. Physical therapy was begun

as soon as the sutures had been removed. At the end of months, when the patient had

complete range of motion and was able to lift heavy weights, he was discharged to unrestricted duty.

Associated Fractures

Fractures were associated with the acromioclavicular dislocations in 11

cases in this series, there being fractures in instance (case 34, table 9). They

were distributed as follows:

Four subchondral compression fractures of the clavicle (case 5, table 7;

cases 35, 36, and 41, table 10).

Two avulsion fractures of the trapezoid ridge (cases and 16, table 7).

transverse fracture at the junction of the middle and outer thirds of the

shaft of the clavicle (case 40, table 10).

chip fracture of the acromial end of the inferior margin of the clavicle,

in partially overriding joint (case 9, table 7).

chip fracture of the acromion process (case 4, table 7).

fissure fracture of the acromion process (case 34, table 9). This patient

also had subchondral compression fracture of the clavicle.

Two avulsion fractures of the coracoid process (fig. 54, case 7; see also

case 7, table 7; case 34, table 9), one of them in patient who also had subchondral compression fracture of the clavicle.

Figure 54 (case 7).—Roentgenogram showing avulsion fracture of medial aspect of

right coracoid process sustained in jeep accident. This patient had perfect cosmetic and

functional result after immobilization for weeks in author’s splint.
216 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

As in similar traumatic dislocations in other areas of the body, the ligaments

presumably suffered less damage when their bony insertions were avulsed. In

both avulsion fractures of the coracoid process (cases and 34), healing was not

influenced adversely, and conservative treatment produced good results, though

ossification of the coracoclavicular ligaments occurred. The same course of

events was observed in the single avulsion fracture of the inferior aspect of the

clavicle. Abduction was painful in of the cases in which articular surfaces

were involved in the injury, and all patients had painful joints for varying

periods of time, though in only instance (case 5, table 7) did the pain persist

and eventually require excision of the outer third of the clavicle.

Complications and Sequelae

As this series shows, pain and limitation of motion may follow any type

of complete acromioclavicular dislocation, whether the patient is seen early or

late and whether the treatment is good, bad, or lacking altogether. Symptoms

and disability in this series were, as is usually the case, chiefly the result of the

development of arthritis, calcification, and ossification of the soft parts, and

synovitis and adhesions in the joint.

Arthritis.—Osteoarthritic changes (see fig. 47, case 27), calcifications of

the capsular ligament (fig. 55, case 4), and loose osteocartilaginous bodies (see

fig. 48, case 39) were found on the roentgenograms in 12 cases in this series.

Figure 55 (case 4). Roentgenogram showing dislocation of right acromioclavicular

joint weeks after injury in motorcycle accident. Ossification of coracoclavicular ligaments

and calcification of meniscus, with chip fracture of acromion, have been demonstrated by

soft-tissue technique. Note nearly vertical joint line.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 217

Five of the twelve were treated by excision of the distal end of the clavicle.

All had complete relief of symptoms within weeks.

Atrophy or rarefaction of the acromial end of the clavicle was apparent

in the roentgenograms in almost all the severe recent dislocations as well as

in the cases seen late. If the dislocation remained reduced and normal function was resumed, the density of the bone gradually returned to normal.

So-called avascular necrosis or osteochondritis was observed in two cases

(cases 35 and 36, table 10). In both, subchondral compression fractures were

found at operation. Gross examination and roentgenologic examination of

the excised specimens showed sclerosis of old bone, irregular areas of resorption,

and new periosteal bone formation, typical of the process of healing in crushed

spongiosa. Avascular necrosis is complication which must be expected in

certain proportion of complete acromioclavicular dislocations, especially in

severe cases, whether or not reduction is accomplished.

Only of the 12 patients who presented these various changes had genuine

pain, and only of these, as already mentioned, had pain severe enough to

require operation. There seems logic, therefore, in the position of some observers that the phenomena are not necessarily evidence of traumatic arthritis.

Calcification and ossification of soft parts.—Calcification of the conoid

and trapezoid ligaments was demonstrated by roentgenograms in 18 cases

(figs. 56, 57, and 58). (See figs. 47, 48, 53, and 55 for further examples.)

Figure 56 (case 19).—Roentgenogram showing dislocation of left acromioclavicular

joint, weeks after fall from motorcycle. Note calcification under clavicle, which had been

evident since 3% weeks after injury, but at that time did now show up clearly enough for

reproduction.
218 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

These deposits first appeared within or weeks after injury and increased in

density and extent during the several months that healing was in progress.

They varied widely in their final size. In some instances, the deposit was

mere fleck, which could be observed only in oblique roentgenograms made by

special soft-tissue technique. In other instances, it took the form of massive

ossification of the coracoclavicular ligaments and synostosis of the clavicle

and scapula. Gross and roentgenologic examination of excised specimens

containing new bone showed that in some instances the calcification appeared

as an outgrowth from the periosteum of the clavicle or the coracoid process,

while in other specimens it was completely detached body.

Until actual fusion of the clavicle and scapula occurred, these deposits,

judging by the patients’ complaints and the physical findings, were not of

clinical significance. When the synostosis was nearly complete (see case 24 in

table and fig. 57), range of motion of the coracoclavicular syndesmosis was

diminished, and the effect on function was that of ankylosis of the acromioclavicular joint. In the case just mentioned, abduction beyond 90 degrees

was painful and limited, although subluxation was only moderate. Both

symptoms and deformity were relieved by excision of the outer end of the

clavicle.

Figure 67 (case 24).—Roentgenogram showing dislocation of left acromioclavicular

joint months after injury sustained when jeep rolled down embankment under enemy

fire. Note coracoclavicular synostosis, which was associated with moderate pain and inability to abduct arm beyond 80 degrees.
DISLOCATIONS OF ACROMIOCLAVICULAR JOINT 219

Figure 58 (case 26).-—Roentgenogram showing dislocation of right acromioclavicular

joint 10 weeks after automobile accident caused by artillery blast. Note coracoclavicular

synostosis (indicated by arrow) which was associated with slight pain and limitation of

abduction.

Synovitis and joint adhesions.—When vague pains and uncomfortable

crepitations are present in complete dislocations of the acromioclavicular joint

in the absence of demonstrableroentgenologic changes in the bone or the joint,

it may be assumed that synovitis and articular adhesions are present. Swelling

over the acromioclavicular articulation is sometimes observed in such cases.

The patients may complain of instability with extreme motions of the shoulder, though this complaint usually disappears as time passes. These complications, as has already been noted, may occur whether or not the dislocation has

been successfully reduced.

In the only case (case 6, tables and 10) in this series in which these particular complications were evident, conservative treatment with the author’s

splint had apparently been successful for year after treatment. Then the

man, who was stevedore, began to be incapacitated for his duties. When

the outer end of the clavicle was eventually resected, the joint cavity was found

obliterated by intra-articular fibrous connective tissue, calcified capsular ligament, and torn meniscus.

221

CHAPTER XVIII

Battle-Incurred Compound Fractures About

the Hip Joint

Marshall R. Urist M. D.

Battle-incurred compound fractures about the hip joint have been major

problem and have been attended with almost equally unsatisfactory results

in all the recorded wars of history. This is true of the Napoleonic Wars; the

Crimean War; the War of the Rebellion; the Wild West era of American development, which had all the effect of warfare; the Anglo-Boer War; the

Spanish-American War; the Russo-Japanese War; World War I; and the

Spanish Civil War. The records show that in all of these conflicts, compound

fractures produced by war wounds in the region of the hip joint were more

often septic, were more frequently associated with systemic infection, and

healed more slowly and more unsatisfactorily than other joint injuries. They

also had the poorest functional results and had the highest case fatality rate

of all joint injuries.

The background of this chapter is detailed analysis of 29 intensively

treated, personally observed battle-incurred fractures in the region of the hip

joint (fig. 59). These 29 fractures were selected from 154 similar injuries

which occurred in total of approximately 25,000 (chiefly battle incurred)

orthopedic injuries treated in the 18 general hospitals which made up the 802d

Hospital Center in the United Kingdom Base between May 1944 and July 1945.

The reason for the selection of these 29 cases was threefold: (1) The patients

were all treated intensively; (2) they were all personally observed and, because

they were all classified as nontransportable, the period of observation was unusually long, ranging from 12 to 20 weeks; and (3) they were all followed up

for periods varying from months to years. From this selected sample, it

is possible to determine the special problems inherent in the reaction of the hip

joint to injury and to evaluate the methods of treatment employed against

methods previously employed and those recently proposed. The analysis of

these cases is shown in the following tabulation:

Classification:

Intracapsular 24

Extracapsular

Intrapelvic

Operations:

Superficial debridement 20

Debridement and arthrotomy

The intracapsular classification includes involvement of the head of the femur in 20 cases; of the neck of the femur in

cases; and destruction of articular surfaces in 18 cases.
222 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 59.—Semidiagrammatic showing of distribution of 29 battle-incurred compound

fractures of hip joint. Circles represent locations of main fractures. Numbered circles

represent fractures described in detail in case histories in text. Since each fracture was the

result of missile injury, and since missile fractures are practically always comminuted,

each circle may be considered the point from which stellate lesion radiated to involve inferior and superior segments of the bone. Circles also, however, indicate the points of

maximum displacement of the fractures.
BATTLE-INCURRED FRACTURES OF HIP JOINTS 223

Complications:

Suppurative arthritis

Incision and drainage

Excision head of femur

Bronchopneumonia

Thrombophlebitis

Pulmonary embolism

Deaths (both from homologous serum hepatitis)

Known end results 27

Less than 25-percent disability

Disability moderate or not yet determined 12

Disability more than 50 percent

Death from sepsis and undetermined other causes after years

Other bone and joint injuries 19

Septic fractures

Sciatic nerve injuries

Laceration femoral vein

Chest injuries

Intra-abdominal injuries

Gastrointestinal tract

Liver

Genitourinary tract injuries

Nonorthopedic operations 20

Laparotomy

Thoracotomy

Genitourinary

Incision-drainage septic wounds

Known end results include 15 cases in which avascular necrosis of the femoral head occurred.

Including major operations on the gastrointestinal tract.

Although the immediate results of wounds of the hip joint were no more

encouraging in the early days of World War II than they had been in any other

recent war, the situation had changed in one important respect: These wounds

are not lethal in themselves, but they are frequently associated with other

serious wounds, and in former wars the men who sustained them succumbed

in large numbers on the battlefield or in forward areas. In World War II,

many of them survived serious abdominal, thoracic, and other wounds which,

of course, took precedence of bone injuries, and the fractures about the hip

could therefore be treated. This was because of the speed of first aid; the

competent abdominal, thoracic, and other urgent surgery performed in forward hospitals soon after wounding; the liberal use of whole blood and blood substitutes; the wise use of chemotherapeutic and antibiotic agents not available

in earlier wars; and the excellent supervisory care along the whole chain of

evacuation. Orthopedic surgeons in World War II were thus confronted with

challenge of almost unique magnitude, as compared with the responsibilities

which had confronted specialists in this field in earlier wars.

Emergency Measures

Transportation of the wounded soldier from the battlefield to the hospital

was more rapid, more efficient, and more humane in World War II than in
224 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

any otherrecorded conflict. The splints provided for transportation of casualties with injuries about the hip joint were modified from those employed in

World War I. The most popular was the Keller-Blake half-ring modification of the Thomas splint, in which the leg is maintained in full extension. The

traction obtainedby this method was helpful in the control of pain, but adequate

immobilization of the hip joint was not secured unless the torso was also

bandaged to the litter. Immobilization of the torso is inherent in the use of

the Liston and Hayes splints, which do not seem to have been employed on

the battlefield in World War II, but the application of bandages, as just

mentioned, was equally effective when the Keller-Blake modification of the Thomas splint was used, as it was in 19 of these 29 patients. The other 10

were transported in improvised splints, including splints made from rifles. One

rifle was applied from the axilla to the lower extremity and the other from the groin to the foot. Both were held in place by bandages.

Patients strapped to litters for transportation in ambulances or airplanes

automatically obtained good immobilization and efficient splinting for short

periods of time between medical installations. Medical-aid men had been

thoroughly schooled in the dictum that soldier with fresh fracture should

be moved about or otherwise disturbed only when it was absolutely necessary.

This practice alone probably saved as many lives as splints saved in World

War II. Its importance was apparently not realized in World War I, when

the Thomas splint was considered to be lifesaving.

Morphine, plasma, whole blood, and careful avoidance of any measures

that would produce disturbance and pain at the fracture site reduced the

incidence of shock originating on the battlefield in injuries about the hip joint

and reduced the incidence of death from that cause before casualties reached

forward (field) hospital to level not much higher than obtains in ordinary

civilian automobile accidents. Unless very large artery had been lacerated,

pressure bandages were sufficient to control hemorrhage for several hours. During the time these particular men were treated, penicillin was available

and was used routinely, usually with sulfonamide.

With these exceptions, methods of treatment of injuries of the hip joint

were much the same as those described in American, English, and German

records of World War I. These records, unfortunately, were not made generally available in World War II, nor was their value emphasized, with the

result that many of the errors made in the First World War were repeated in

the Second. The experience in these 29 cases is typical in that respect, and

their record may prevent similar errors of omission and commission in some

future conflict.

Initial Wound Surgery

directive from The Surgeon General’s Office, based on the accumulated experiences of World War and experiences in World War II prior to D-day

War Department Technical Bulletin (TB MED) 147, March 1945.
BATTLE-INCURRED FRACTURES OF HIP JOINTS 225

in the European Theater of Operations, provided for the management of wounds

of the hip joint by debridement and early arthrotomy whenever circumstances

permitted. Because of the more destructive character of the weapons used in

World War II, extensive debridement was even more necessary than it had been

in World War I. Wounds caused by land mines, hand grenades, shell casings,

and particles of disrupted bidlets might seem insignificant on the body surface,

but underneath there would almost invariably be found extensive lacerations

of the muscles and other deep tissues, and numerous blood clots.

In the presence of these injuries, it had to be assumed that bacterial contamination had occurred. The fact that bullets and some shell fragments

had penetrated the body at white heat did not warrant the assumption that

they were sterile. The phenomenon of the ricochet and the low velocity at

which fragments of mine casings frequently entered thebody made it inevitable

that they would carry with them soil and fragments of clothing. This was not

always evident when the foreign bodies were first lifted out of the tissues.

When, however, blood clot, old fibrin, friable granulating tissue, or enshoathing

scar tissue was soaked off, it was usually possible to identify wisps of woolen

clothing, water-repellent raincoat material, and other fabrics which had not

been apparent on the first inspection. Many observers thought the explanation of the apparently greater incidence of wound infection in winter was the

greater amount of clothing worn in cold weather and the greater difficulties of

personal hygiene under combat conditions. There seems little doubt that the

original damage to soft parts, as well as the later ravages of infection, was almost

directly proportional to the volume of cold steel, stone, wood, and other foreign

material, including excreta inevitably present on clothing worn in combat,

and to theirretention in the tissues.

Fractures of the bony structures were theresult not only of the force of the

direct impact of the missile but also of its blast effect as it passed through the

limb. The disorganization and disruption of the skeletal structure which

followed, and the cutting effects of sharp fragments of bone, caused quite as

much damage to muscles, nerves, blood vessels, and viscera as did the missile

itself. Finally, foreign bodies which might have passed out of soft tissues were

frequently retained in the hip joint because this pelvifemoral structure was

powerful enough to arrest them.

All of these considerations explain why, in wounds of the hip joint as in

other combat wounds, the first principle of management, regardless of location,

was bold incision. The excision of macerated tissue and retained foreign

bodies was equally important; both served as excellent culture media for

infection.

Primary arthrotomy, which is simply an extension of debridement to the

joint, was regarded as radical measure by many observers in World War

and by some surgeons in World War II. Pool, however, in reporting to The

Pool, Eugene II.: Wounds of Joints. In The Medical Department of the United States Army in The World War.

Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1, pp. 317-341.

372572°—56 16
226 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Surgeon General on its use in World War I, termed it “conservative” operation. comparison of his report with reports by British, French, and German surgeons makes it apparent that all of them followed much the same

policies and practices and that apparent differences can usually be explained

by differences in nomenclature. The French, for instance, advocated what

they termed extensive primary resection of the joint as soon as possible after

wounding. What it amounted to was particularly extensive debridement.

The basic principles of arthrotomy and joint debridement may therefore

be said to represent the evolution of large experience, accumulated over the

same period of time by many different surgeons working under much the same

circumstances in several different theaters of war. Furthermore, the criticisms

of arthrotomy voiced by such experienced military surgeons as Jolly, Trueta,

Wheeler, and Levit were all expressed prior to the introduction of penicillin

and the subsequent decrease in the surgical risk.

Analysis of Cases

It is not evident from any report in the literature that arthrotomy, per se, has ever been responsible for the introduction of infection into the joint.

That generalization holds for the cases in this series in which it was employed.

On the other hand, sepsis is frequent when primary arthrotomy is omitted.

It was present in of the 20 cases in this series in which the joint was not

opened at operation, and Ellis 10 reported that it occurred in more than half

of the cases in his series under the same circumstances. The figures suggest

that whatever may be the merits of watching and waiting policy in some

injuries, it is not sound in wounds of the hip joint.

The only possible exception to the routine application of early debridement

and arthrotomy was the type of case described by Pool 11 in the medical history

of World War I, in which high-velocity bullet perforates the hip joint cleanly, leaving punctate wounds of entrance and exit. In such cases in this series,

arthrotomy was omitted and only debridement was done. There were no septic

complications, it is true, but it should also be pointed out that bone damage was

much less severe than in the other cases.

In all, 20 of the 29 injuries of the hip joint in this series were treated initially by so-called conservative measures, consisting of cleansing the wound with soap,

Frankau, C. H. S.: Gunshot Wounds of the Joints. In Great Britain War Office, Medical Services. General History, Surgery of The War, History of The Great WarBased on Official Documents. London: His Majesty’s Stationery Office, 1922, vol. 2, pp. 297-325.

Fruchaud, H.: Wounds of the Joints. Lancet 235-238,19 August 1944.

Franz, Carl: Lehrbuch der Kriegschirurgie. Verletzungen des Hiiftgelenks. Berlin: Springer-Verlag, 3d ed., 1942, pp.303-307.

Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941, pp. 123-128.

Trueta, Jose: The Principles and Practice ofWar Surgery With Reference to the Biological Methodof the Treatment

of WarWounds and Fractures. St. Louis: The C.V. Mosby Co., 1943, pp. 170-173; 214-226; 352-355. Wheeler, W. I. de Courcy: Wounds Involving the Hip Joint. In Bailey, Hamilton: Surgery of Modern Warfare. Edinburgh: E. and S. Livingstone, 1st ed., 1941, pp. 474-480. 3d ed., 1944, pp. 541-549.

Levit, V. C.: Concerning Gunshot Wounds of Jointsand Their Treatment. Khirurgiya 14: 3-8,1944. Abstracted in Bull. War Med. 303-304, January 1945. ifEllis, J. S.: Wounds in Region of Hip Joint. Lancet 2: 490-492, 20 October 1945. 11 See footnote 2, p. 225.
BATTLE-INCURRED FRACTURES OF HIP JOINTS 227

water, and antiseptics; more or less complete debridement of the damaged

soft parts, and final irrigation of the wound, without exposure of the joint or

arthrotomy. The other cases, as already noted, were treated within 12 hours of wounding by debridement of the soft parts, incision of the joint capsule,

and removal of readily available foreign bodies and unattached fragments of

bone and cartilage. The joint capsule was left open in of the cases, and the

soft-tissue wounds were left open in all 29 cases.

Complete debridement was recognized, theoretically, as the ideal primary

treatment for wounds of the hip joint, but there were many reasons why it

could not always be applied:

1. Patients brought off the battlefield were frequently in shock and could

not have withstood such extensive surgery as debridement and arthrotomy implied in wounds of the hip joint.

2. The injuries were often so extensive that complete debridement was

not possible. The aim of early surgical treatment was to obtain gross mechanical cleanliness. To achieve it, wide excision of tissues was frequently necessary because small fragments of wood or metal, gritty substances, or bits of

stone were so adherent that they could not be removed manually or by irrigation; sometimes their complete excision was impossible.

3. If injuries to bowel, bladder, or other structures were present and offered

an immediate threat to life, their treatment had to take priority over treatment

of wound which threatened merely the vitality of limb.

4. The tactical situation was often such that time-consuming operations

on major joint were not practical within an optimum, or even reasonable time

after wounding.

5. Surgery of the hip joint is complex, difficult, and highly specialized

procedure. Surgeons experienced in it and competent to undertake it were

always in short supply and were seldom available in forward areas. Debridement of the soft tissues could be performed by inexperienced surgeons, but

they could not undertake arthrotomy and debridement of the joint.

Nonetheless, the conservative measures employed in many cases in this

series were deliberately undertaken, preliminary to policy of so-called expectant observation or masterly inactivity. This was in direct conflict with instruc- tions from the Office of The Surgeon General. 12 With all due regard for the

difficulties of complete debridement and arthrotomy, token treatment of surface wounds in fractures of the hip joint in which thorough debridement was

impossible still could not bo condoned. The least that should have been done

was to remove accessible foreign bodies, together with fragments of tissue

crushed and deprived of circulation. When ideal therapy proved impossible,

the least that should have been done in any case in which sepsis was clearly

inevitable or seemed likely was to employ bold incision and saucerize the

wound. When infection was not present or was not thought possibility, the

local forces of nature usually proved remarkably adequate to prevent it in the

young, healthy men who made up the casualties of war. When the circulation

12 See footnote 1, p. 224.
228 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

in the hip joint and the capacity for repair seemed insufficient, debridement

should have included removal of parts whose death or loss might reasonably

have been anticipated. These simple principles were violated in number of

cases in this series.

Case Histories

Poor results did not always follow inadequate debridement, as the first

and second of the following case histories show. The poor results which may

follow an inadequate procedure are, however, well illustrated in the third case.

Case 1.—An infantryman was shot in the right hip by rifle bullet which entered the

anteromedial aspect of the joint,ripped away segment of the inferior margin of the epiphyseal line of the femoral head, and lodged in the tissues adjacent to the greater trochanter

(fig. 59). After superficial debridement of the wound in field hospital, the patient was

transported in plaster-of-paris hip spica to an evacuation hospital, which he reached days

after injury. At this time, there was considerable local tenderness, but no local or constitutional signs of infection were evident.

When the patient reached general hospital in the United Kingdom Base, skeletal traction was instituted by means of Kirschner wire at the level of the adductor tubercle of the

femur in Thomas splint with Pierson attachment, with 30-degree abduction, 150-degree

extension, and 5-degree internal rotation in Balkan frame. On the 16th day after wounding, exploration was carried out through lateral incision; the gluteus maximus was split at

right angles to the line of the skin incision. The bullet was located by palpation of the

muscle bellies and was removed. It lay in pool of purulent fluid, and the adjacent tissues

were discolored. The wound was deepened to the level of the greater trochanter and was

debrided of all contused, necrotic tissue. It was left open, and closure was not undertaken

until the 15th postoperative day. At this time, the wound was clinically clean and healing

was uneventful. smear from the fluid surrounding the bullet had showed typical purulent

exudate, but routine cultures were sterile.

At the end of weeks, the patient was removed from skeletal traction and put up in

Buck’s extension. Active exercises were carried out in it for the next weeks. Eight weeks

after wounding, roentgenograms showed no evidence of avascular necrosis. Eight weeks

later, there was moderate limitation of rotation in both directions, 15-degree abduction, 15-degree adduction, and from 18- to 60-degree flexion. The patient was in excellent condition when he was evacuated to the Zone of Interior weeks later. He was eager to begin

to walk, but weight bearing was not permitted until months after injury. At the end of

the year, there was no appreciable disability.

Case 2.—An airborne infantryman was injured by machinegun bullet which caused

compound fracture in the intertrochanteric region, with fissure fractures of the neck and

head of the femur (figs. 59 and 60). The wounds were thoroughly debrided in field hospital few hours later, and the bullet was removed from the substance of the muscular

attachments on the greater trochanter. Although the capsule was torn and frayed anteriorly

at the base of the neck of the femur, the jointwas not opened. Supportive therapy, including

transfusions, was required for days after operation.

On the 11th postoperative day the patient was transported in plaster-of-paris hip

spica to general hospital in the United Kingdom. His temperature had been normal for

the preceding days. Roentgenologic examination at this time showed an extreme coxa vara

deformity. The fracture was manipulated on the fracture table, and the wound, which was

clinically clean, was closed by delayed primary suture. The hip was suspended in skeletal

traction in Thomas splint, with the ischial half ring inverted and with Pierson attachment.

Excellent reduction was obtained.

Eight weeks after wounding, the fracture was united, and the wound was well healed.

Four weeks later the patient was evacuated to the Zone of Interior in double hip spica with
BATTLE-INCURRED FRACTURES OF HIP JOINTS 229

Figure 60 (case 2).—Roentgenogram showing compound intertrochanteric fracture.

High-velocity machinegun bullet is seen in posterior soft parts. (Unless otherwise noted,

all roentgenograms were taken within few hours of wounding. This film and those reproduced in figures 66 and 67 were made with field equipment, under difficult conditions, which

accounts for their poor quality.)

abduction, internal rotation, and flexion at the hip. At months, he was reported to be

walking in an ischial non-weight-bearing caliper brace, with 50 percent of the normal range

of motion of the hip.

Case 3.—An infantryman was wounded in the abdomen by an artillery-shell fragment

which perforated the pelvis and the right upper hip joint and emerged on the lateral aspect

of the thigh. The upper end of the femur was shattered (figs. 59 and 61). Exploration of

the abdomen at field hospital few hours later, after resuscitative measures which included

transfusion of 500 cc. of whole blood, revealed multiple lacerations of the large and small

intestine. Enteroenterostomy and jejunostomy were performed. 2-inch wound on the

lateral aspect of the right thigh, throughwhich the shell fragment had emerged, was enlarged

to inches, and debridement was done through it, but the jointwas not opened. The saucerized wound was dressed with vaseline gauze, and hip spica was applied.

Up to the 10th day, convalescence was uneventful, but in the hospital train, en route

to the coast of France, foul odor began to issue from the dressings, and the temperature

rose to 101° F.

The hip spica was removed at general hospital in England, and bilateral vertical

skeletal traction was applied (fig. 62). The wound sloughed, and purulent material drained

copiously from it. Cultures taken from the depths of the wound revealed mixture of

organisms, including both anaerobic and aerobic forms of streptococci and bacilli. In spite

of systemic and local penicillin therapy (250 units per cubic centimeter of physiologic salt

solution) drainage continued for 49 days. Closure of the wound was attempted at this

time but was only partly successful, and draining sinus persisted for several months longer.

Over this whole period, there were daily temperature elevations to 99° and 100° F.
230 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 61 (case 3).—Roentgenogram showing extensive compound fracture of hip

joint involving acetabulum and head of femur. Roentgenogram also shows shell fragments

which produced the damage. This picture was made after fractures had been reduced and

immobilized for 10 weeks in vertical skeletal traction.

Figure 62.—Vertical skeletal traction with overhead balanced suspension in compound

fracture of hip joint. Note that patient can lift himself on bedpan and that active and

passive exercise of knee joints is possible. This form of traction and suspension could

therefore be maintained for to weeks without much danger of development of contractures.
BATTLE-INCURRED FRACTURES OF HIP JOINTS 231

Although the jejunostomy functioned well, the patient lost weight steadily. Laboratory

studies showed secondary anemia and slight hypoproteinemia. Supplementary feedings

of high-protein, high-caloric, high-vitamin diet were followed by slow gain in weight.

At the end of 10 weeks, vertical skeletal traction was discontinued, and the patient

was put up in suspensionin Rouvillois splint (fig. 63), with 45-degree flexion and 20-degree

Figure 63.—A. Use of Rouvillois lumbofemoral splint with skeletal traction and

unilateral suspension in compound fracture of neck of femur. Note that patient can lift

himself from bed and exercise while in this apparatus. B. Use of Rouvillois splint with

bilateral suspension in bilateral fractures of pelvis and hips.
232 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

abduction. At this time, the fracture was in excellent position, and some motion could be

obtained in the joint under anesthesia. At the end of months, the roentgenograms showed typical picture of avascular necrosis, with ossification of the superior capsule. Clinically,

the joint was ankylosed and painful, and disability was almost complete.

Surgical Approach to the Hip Joint

In of the cases in this series in which arthrotomy was done, the approach

was by posterior (Kochcr) incision, which was merely an enlargement of the original wound. In another instance, the approach was by lateral (WatsonJones) incision. In the other cases it was by an anterior or Smith-Petersen

incision. This approach, which was widely popular in the United States even

before World War II, consists of anterior iliofemoral arthrotomy, with exarticulation of the head of the femur. In an occasional case, when the traumatic wound is very large, it is good judgment, as in this series, to use any

other standard incision, such as the Kocher or the Watson-Jones incision,

which best exploits the exposure already present. With these exceptions, the

anterior iliofemoral route is the most expeditious of all approaches.

The Smith-Petersen incision has number of advantages. It is easily

modified. In of the cases in which it was used in this series, the original

technique was followed, except for omission of tenotomy of the rectus femoris. The incision was particularly useful in both cases because it permitted debridement and irrigation of the acetabulum under direct vision, which would not

have been possible with any other approach. In both of these cases, elongation

of the wound and development of the iliac portion of the approach, as in arthroplasty, provided sufficient exposure to permit exarticulation and resection of

the head of the femur, including part of the acetabulum. In another case,

L-shaped incision of the capsule and removal of numerous fragments of the

head of the femur resulted in sufficient relaxation to permit exarticulation and

irrigation of the joint and to make excision of the anterior ligaments unnecessary. It was possible, as the next step, to close the joint and instill penicillin.

Another advantage of the Smith-Petersen approach is that the exposure can

be made to correspond with the degree of damage to the joint. In cases in

this series in which there was fracture of the neck or only minor damage to

the circumference of the head of the femur, exposure of the joint in the sulcus

between the sartorius and rectus femoris permitted thorough debridement

without exarticulation.

The following case history illustrates the advantages of the Smith-Petersen

approach:

Case 4.—When an infantryman was examined at an evacuation hospital few hours

after he had sustained perforating wound of the left hip from machinegun bullet, small

puncture wound was found on the anterior aspect of the upper portion of the injured thigh.

The wound of exit, inches long, was in the left buttock. Roentgenograms made under

field conditions showed stellate fracture of the neck of the femur which extended into the

head and split the upper portion of the greater trochanter (fig. 59). After resuscitative
BATTLE-INCURRED FRACTURES OF HIP JOINTS 233

measures, including transfusion of 500 cc. of whole blood, the joint was exposed by the

anterior iliofemoral approach and was thoroughly cleansed of all loose bone and blood clots

by debridement and irrigation. The posterior wound was enlarged to inches and was carried

down to the bone by splitting the muscle along the track of the missile. Closure of the

joint capsule could not be effected. Penicillin solution (10,000 units) was injected into and

around the articular cavity. The fractures were reduced by manipulation, and the hip

was temporarily immobilized by skin traction in Thomas splint.

Seven days later, the patient was evacuated to general hospital in the United Kingdom

in plaster hip spica, in Whitman’s position. Three days later, the wounds were closed

by delayed primary suture, and the patient was suspended in skeletal traction in lumbofemoral Rouvillois splint, in which he remained for the next weeks. At the end of this

time, there was partial union. The patient was evacuated to the Zone of Interior weeks

later (11 weeks after wounding) in Whitman’s position. There the hip was again suspended,

this time in Thomas splint with Pierson attachment. An ischial caliper non-weight-bearing

brace was fitted at 20 weeks. At 10 months, although the fracture was still incompletely

united, there was no limitation of adduction or abduction, and 90-degree flexion was possible.

McMurray osteotomy was performed at the end of year because of insufficient bone

structure in the neck of the femur.

Management of Retained Foreign Bodies

The foreign bodies encountered in these 29 injuries about the hip joint

consisted of fragments of steel from hand grenades, high-velocity bullets,

casings from high-explosive artillery shells and land mines, and similar objects.

In cases the hip joint was perforated, and in instances infection followed.

In of these cases the bullet passed through the bladder, did great damage to

the head of the femur, and left track of metallic dust behind it.

In the other 20 cases, or more fragments penetrated the hip joint and

lodged iu it or about it. In of these cases, no attempt at removal was made.

In cases, complete removal of the foreign bodies was possible; infection followed in instance. Infection also followed operations in which only partial

removal of the foreign bodies was accomplished.

Operations for removal of foreign bodies from the hip joint were undertaken

only through standard surgical approaches. These permitted sufficient visualization of vital nerves and blood vessels in the region to prevent further trauma.

Blind extraction of sharp missile from its bed was extremely dangerous and

was not attempted. In actual practice, the most efficient method of detecting

foreign bodies was found to be by digital exploration, oriented by true anteroposterior and lateral roentgenograms. Two gloves wore always worn, because

of the risk of tearing the glove on the sharp fragment.

In cases, the foreign bodies were found at operation in lakes of green,

purulent fluid. In such instances, the fluid was sterile on culture. In the

other cases, various organisms were identified, including Bacillus proteus

and Bacterium coli. One of these patients developed fulminating pyoarthrosis.

The other recovered uneventfully, and wound healing was satisfactory in

each instance.
234 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Wound Closure

Closure of the wound of the joint was always the desideratum after arthrotomy, but in most fractures of the neck or head of the femur the ligaments were

so badly damaged that complete closure of the capsule was usually impossible.

When the incision was anterior, closure of the wound of the soft tissues

offered no difficulty; the muscles fell together with remarkable ease. When

there had been considerable loss of substance in the soft parts, it was the practice

to remove various amounts of iliac crest with sharp osteotome, to obtain close

approximation of hone and soft parts, and to eliminate dead spaces or close the

incision without tension, according to the circumstances of the individual case.

Black silk, which was used for deep stay sutures, was tied loosely, so as not to

interfere with drainage of the wound along the natural anatomic planes.

Closure of the skin was delayed for to days, until the critical period of

possible infection had passed.

Delayed primary closure of the soft-tissue wound was carried out successfully in clean cases in this series and was partly successful in others. The

operations were usually done within to 10 days after wounding. Drainage

was not employed in any of these cases. Nine other clean cases which were

closed by the same plan healed by secondary intention or were treated by skin

grafting. In the remaining cases, wound closure was never seriously considered, because infection was present or was obviously impending when the

patients first came under observation. In several of these cases, multiple

foreign bodies were retained; delayed primary closure was, quite correctly,

never employed in such cases.

Adjunct Fracture Management

Postoperative transportation splinting.—Twenty-seven of the twenty-nine

casualties, after surgical treatment in the field or evacuation hospitals, were

transported to rear installations in plaster-of-paris double hip spicas, with the

plaster carried only to the knee on the uninjured side. The other patients

were moved in Tobruk splints.

The orthopedic surgeons in general hospitals who treated the 154 patients

with compound fractures of the hip joint from which these 29 cases were

selected for detailed analysis had no doubt of the relative advantages of these

splints. Almost without exception, they agreed that the men were more

comfortable and their injuries were more adequately immobilized in the properly padded full plaster spica than in the Tobruk splint or any of its modifications. It is true that the initial application of hip spica was slightly more

troublesome and somewhat more time consuming than the application of the

Tobruk splint, but the hip spica was the least difficult of all splints to maintain,

and in the end time was saved by its use. Extension in the Tobruk splint was

advantageous when there were no other wounds or when the wounds were so

located that the padded bar of the splint could be placed against the ischial
BATTLE-INCURRED FRACTURES OF HIP JOINTS 235

tuberosity, but this advantage was more than counterbalanced by the ineffectiveness of the traction thus obtained, as well as by the rapidity with which

whatever traction had been achieved was dissipated during transportation.

Ellis’ 13 suggestion that Thomas splint be incorporated in the hip spica

was made independently by several United States Army surgeons in evacuation

hospitals about the time that he advanced it. This technique was employed

in cases (not included in the 29 analyzed in this chapter) but it proved no

more effective than the original Tobruk splint.

Skeletal traction.—Two patients in this series were retained in plaster

spicas without traction. Two others were treated in extension, one by Russell’s and the other by Buck’s apparatus. The other 25 were treated by

skeletal traction. This was larger number of cases treated by this technique

than had been recorded in any other single series of combat-incurred fractures

of the hip joint up to the end of World War II. Reduction of fractures of the hip can be obtained more easily, at least by

comparison, in combat-incurred injuries than in similar civilian-type fractures,

because of the soft consistency and flexibility offractures resulting from combat.

Maintenance of fragments in position, however, requires some form of continuous traction. The proper combination of manipulation and traction is

essential for good results. Neither one of these methods is sufficient in itself.

In this series, the advantages of combined manipulation and traction were

clearly evident. The combination provided comfortable immobilization, while

at the same time it permitted maximum exposure of the wounds for dressing

and other treatment. It kept the joint surfaces separated while they were

healing. It held the reduced fractures in proper position in cases which had

originally showed extreme coxa vara. Finally, and by no means least important, it facilitated nursing care.

The advantages of traction for compound fractures of the hip joint were

recognized in World War I, just as in World War II, though not all of the

methods proposed were efficient. Wheeler 14 in 1944 and Ellis 15 in 1945 suggested that the Jones abduction frame, which Frankau 16 had recommended in

World War I, be used when patients could not tolerate countertraction on the

ischial tuberosities or about the gluteal or perineal regions. This apparatus

(an upholstered table with leg splints attached for traction) was, however,

cumbersome and not entirely efficient. It did not provide for flexion of the

hip, which is essential in bilateral injuries, or for exposure of wounds of the

buttocks or sacrum, which are frequently associated withhip injuries. Efficient

nursing care was also difficult in this apparatus. Some of these difficulties had

been solved in World War 17 by the use of the pelvic elevator, as suggested by

the United States Navy Medical Corps, but the weights and pulleys required

were also cumbersome and difficult to handle.

13 See footnote 10, p. 226. 14 See footnote 8, p. 226. 18 See footnote 10, p. 226. 16 See footnote 3, p. 226. 17 See footnote 2, p. 225.
236 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

The newer techniques of suspension used in overseas hospitals in World

War II proved far more efficient than any of the methods employed in World

War I. Among them were the following:

1. Vertical traction (fig. 62). Although this is not universally applicable method, it proved more efficient than the Thomas splint in every case

in which it could be used.

2. The hip spica. This was the most efficient method for the immediate

postoperative management of suppurating hip joints with missing bone substance. It was equally efficient as transportation splint for patients to be

returned to the Zone of Interior.

3. Pelvic suspension. Tins technique, which was devised by German

surgeons, 18 was carried out by means of wires placed through the anterior

superior spines of the pubis. It could be used alone or in combination with

vertical skeletal traction. American orthopedic surgeons did not use it widely.

4. The Rouvillois splint. 19 This splint (fig. 63), which had been introduced in 1925, was standard equipment in the French Army. Considerable

quantities were captured by the Germans at the fall of France in 1940, but

they apparently did not use it, as large numbers were found by American

forces going through France in 1944. supply was issued to the 22d General

Hospital, by the senior consultant in orthopedic surgery, for preliminary

trial, and the splint soon became very popular among the surgeons who had

access to it, though it remained unknown to other surgeons until the end of

the war. This was unfortunate, for it provided more comfort for the patient

than any other method of traction currently in use, and it also simplified

nursing care. Not single instance of sacral decubitus ulcer was observed

in any case in which this method was used.

The Rouvillois splint (fig. 63) is essentially modification of the Blake

splint. It consists of metal frame in which the leg and thigh are suspended

on slings and attached to which is another large curved metal frame which

extends anteriorly over the lower torso. This second frame holds the attachments of the supporting hammock placed under the lumbar spine. The weight

of the frame, aided by the hammock, provides the necessary countertraction.

Universal joints at the knee and hip permit any angle of flexion, abduction,

and rotation. The whole apparatus can be suspended in balanced traction,

and the region of the hip and sacrum can swing freely, without pressure on

the bed at any point. The patient can also exercise in this splint.

5. The revolving orthopedic frame. This frame, which was devised at

the 22d General Hospital in World War II, 20 is basically Bradford frame

revolved by mechanical means. One of its advantages was that it could

easily be constructed from salvage material available in any Army ordnance

depot. This frame solved many of the problems which were encountered

18 Westhues, H.: Die knooherne Halbschwebelagerung des Beckens. Chirurg. 14: 489-493, 1942.

19 Rouvillois, M. H.: Appareils universels suspension pour le traitement des fractures du membre inlericur.

Bull, et in6m. Soc. nat. dechir. 51: 846-849, 1925. 20 Urist, M. R.; Maxwell, E. A.; and Ferguson, R.; Revolving Orthopedic Frames Made From Salvaged Material.

Bull. U. 8. Army M. Dept. 6: 628-630, November 1946.
BATTLE-INCURRED FRACTURES OF HIP JOINTS 237

Figure 64.—Active exercises in bed weeks after open reduction and internal fixation

of pertrochanteric fracture of femur. Old scars of bullet wounds of entrance and exit can

be seen, as well as healed incision of lateral approach to upper femur between these wounds.

when fractures of the hip joint were associated with wounds of the intestine

which required colostomy and wounds of the bladder which required cystostomy. It greatly simplified nursing care in such cases and was particularly

useful when patients with severe, complicated injuries of the hip joint had to

be transported in plaster casts for long periods of time.

Early motion.—Moderate passive exercises could be carried out while the

patient was in suspension and were usually begun during the first weeks

after injury (fig. 64). Quadriceps-knee exercises were always supervised by

physical therapists.

Active exercises were seldom possible or practical during the first 12

weeks of healing in compound fractures of the head or neck of the femur.

They were, however, instituted guardedly and gradually in cases in this

series within this period, with very good results. One of these cases (case 1)

has been described in detail elsewhere in this chapter.

Adjunct Therapy

Supportive therapy.—The constitutional and nutritional status of many

patients in this series, especially those with pyoarthrosis, was extremely poor

and furnished extremely serious problems of management. Eight of the

septic patients became greatly emaciated within to weeks after wounding,
238 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

their weight loss being progressive. Many of the septic patients, as well as

number of others, presented serious secondary anemia, and most of the 29

patients had low plasma protein levels.

Men with extensive wounds were routinely given supplementary feedings

of high-caloric, high-protein substances in addition to their regular meals.

They also received supplementary vitamins and iron salts. The correction of

anemia in the septic patients was more of problem. Some of them had already

had so many transfusions that matching them with donors was difficult when

more blood was needed to fortify them for additional surgery on the joint. In

number of instances in which multiple small transfusions would have been

highly desirable, this plan, for thereason just stated, could not be employed.

Chemotherapy and antibiotic therapy.—Every patient in this series was

treated with penicillin and sulfadiazine for at least 10 days from the day of

injury. In many instances, chemotherapy was continued for weeks, the duration of treatment depending upon the temperature response. The early use of

chemotherapeutic agents constituted one of the essential differences between

the management of casualties with injuries of the hip joint in World War and

their management in World War II. Chemotherapy proved an effective

measure, though the reliance apparently placed upon penicillin in the early

days of its availability, when it was sometimes regarded as possible substitute

for surgery, was never justified. It should have been evident from the beginning that damaged bony tissues lack circulation to distribute drug given

systemically and lack interstices for its diffusion when itis given locally.

When therapy was systemic, as it usually was, penicillin was given in

doses of 20,000 units at 4-hour intervals and sulfadiazine in doses of gm. by

the same schedule. Chemotherapy was used locally as routine measure in the

early phases of American participation in World War II and was occasionally

employed by this route almost until the end of hostilities. Penicillin was used

locally much less frequently.

Fourteen of the twenty-nine patients in this series, chiefly those injured in

France within the first weeks after D-day, received local sulfonamide therapy,

crystalline sulfanilamide being implanted in the wound in doses of to gm.

In instances, the sulfanilamide (10 gm.) was combined with 20,000 to 50,000

units of penicillin. In other cases, penicillin solution (20,000 units) was

injected into the joint after arthrotomy.

Seven of the nine septic cases were treated by one or another of these

methods. There is no reason to believe that the infection was modified by

their use in any instance. There is also no reason to believe that local chemotherapy had anything to do with the absence of sepsis in the 20 nonseptic cases

in the series.

Complications of Hip Injuries

Suppurative Arthritis

Suppurative arthritis was major problem in wounds of the hip joint in

World War II, just as it had been in previous wars, but the incidence was much
BATTLE-INCURRED FRACTURES OF HIP JOINTS 239

lower than it had been in the War of the Rebellion 21 and in World War I.22

The fearful infections so commonly observed in military hospitals during those wars were seldom observed in World War II, probably as the result of the

almost routine use of the sulfonamides and penicillin from the time the patient

was injured until his wound was completely healed. In the 154 wounds of the hip joint observed between D-day and V-E Day at the 802d Hospital Center, there was not single instance of the type of rapidly spreading hemolytic

streptococcic or staphylococcic infection described by Frankau 23 in World

War and characterized by hyperpyrexia, tachycardia, and septicemia. Infec- tions of this sort were usually promptly fatal. The incidence of infection in this series, of 29 injuries, is slightly less

than that reported in similar series by Ellis 24 and by Franz. 25 There was

instance of infection in the fractures involving the neck of the femur and

instances in the 20 cases in which the femoral head was fractured or completely exploded. Most writers, unfortunately, have failed to specify the region of the fracture in reports of the development of infection, though this is

an important consideration. The femoral head has low vitality and high

susceptibility to infection, and injury to it alone may largely determine the

end result.

The infection was mixed in all cases in this series. Bacterium coli and

Bacillus proteus predominated in cases and could be cultured from the deep

spongiosa of the femoral head in sixth case.

Experience proved that it was extremely important to keep close watch

on the charts of patients receiving chemotherapy, to pick up low-grade fevers, anorexia, and other evidences of infection which might be masked by the

drugs being administered. In case in this group, aspiration, and later incision, revealed pyoarthrosis and gluteal abscess, and, in another, pyoarthrosis

was associated with pelvic abscess. In both cases, the clinical localizing

signs—rubor, calor, and dolor, as well as the usual systemic responses to infection—were strangely obscure. The explanation probably is that the more

virulent organisms originally present had been controlled by penicillin and

sulfadiazine, while the organisms undoubtedly introduced by fecal contamination on the buttocks and the clothing, although they did not produce the usual

acute manifestations of suppurative arthritis, were not suppressed by chemotherapy and flourished in the deep necrotic tissues.

Suppurative arthritis developed in all cases in which intestinal wounds

were also present, just as in similar cases observed by Collom and Hampton 26

in the Mediterranean theater. In cases, the anterior wounds of the hip

21 Otis, George A., and Huntington, D. L.: Wounds and Injuries of the Hip Joint. In The Medical and Surgical

Historyof the War of the Rebellion. Washington: U. S. Government Printing Office, 1883, vol. 2, pt. Ill, pp. 61-168. 22 See footnote 2, p. 225. 23 See footnote 3, p. 226.

See footnote 10, p. 226.

25 Franz, C.: Zur Frage der Oelenkresektionen. Deut. Militararzt. 7; 266-272, April 1942. Abstracted in Bull. War

Med. 3: 322-324, February 1943. 2« Collom and Hampton. Unpublished data.
240 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

joint were only few inches from the colostomy stoma, and in spite of the

utmost care in dressing the intestinal wounds, as well as repeated attempts to

isolate them with collodion gauze and adhesive tape, contamination of the

wounds of the hip joint was repeated and constant. The juxtaposition of the

intestinal wound to the hip joint was so obvious source of infection that it

was an error, as the following case shows, not to place the colostomy well up

on the abdominal wall, even if it had been necessary to create it in more

proximal portion of the bowel.

Case 5.—A paratrooper suffered lacerated wounds of the right lower abdomen and

penetrating wound of the right hip joint from high-explosive shell fragment. Debridement,

removal of large intra-articular foreign body, and cecostomy were carried out shortly

afterward at field hospital. The hip was put in spica. During the first week after

wounding, the patient received 2,000 cc. of whole blood and units of plasma. Although

every effort was made to prevent contamination from the colostomy, the hip spica became

soiled. On the seventh day, the temperature rose to 102° F., and the hip wound began to

discharge large quantities of pus with an unmistakably fecal odor.

When the patient was received by air in the United Kingdom Base on the 11th day

after wounding, the original cast was replaced by fresh, reenforced, well-padded hip spica

which was constructed with fenestrations lined with waterproofed material to permit dressing of the hip wound and the cecostomy. The temperature continued to rise daily to 102°

F., and, by the 18th day after wounding, there had been considerable and progressive

loss of weight and bedsores had appeared over the sacrum. By the 32d day, sloughing of

the wound had resulted in the loss of so much substance on the anterior aspect of the hip

joint that the fracture site was clearly exposed.

At this time, the patient was removed from the spica and put up in suspension in

skeletal traction, by means of Kirschner wire inserted through the tibial tubercle. On the

50th day, in an attempt to simplify the management of the hip wound, an abdominal surgeon

closed the colostomy and partly repaired the wound of the abdominal wall. Evacuation of

the bowels through the rectum after this operation eliminated many of the previous problems

of nursing care. Supplementary high-protein, high-caloric feedings were instituted. On

the 60th day, the hip wound was widely opened, and the entire anterior aspect of the joint

was saucerized. Drainage continued to be copious. On the 63d day, the patient became

severely jaundiced, and weight loss was even more rapid than it had been previously. Death

occurred 12 days later, on the 75th day after wounding. Homologous serum hepatitis was

regarded as the immediate cause. The necropsy also revealed, as frequently happened in

battle-incurred injuries, that the bone was damaged much more extensively than the

roentgenograms had indicated. The inferior portion of the fracture line was healing, but the

femoral head was necrotic.

The only other death in the series, also in serious infection of the hip

joint, was also attributable to homologous serum hepatitis. This patient had

been given transfusion of dried plasma immediately after wounding, months

earlier.

followup of the 29 cases in this series for minimum of months and usually for longer periods of time showed that, if joint infection were to occur, it

would become evident within 12 to 16 weeks after wounding. Suppuration

did not occur primarily in any case in this series during the period of hospitalization overseas, which usually was months, if delayed closure had been accomplished successfully, though abscess formation was reported in all kinds of

wounds as late as or months after the patient was evacuated to the United
BATTLE-INCURRED FRACTURES OF HIP JOINTS 241

States. Suppuration was probably also hazard in closed wounds of the hip

joint, but it must have been extremely infrequent, if it occurred at all. At

any rate, the possibility was not regarded as reason for disregarding the important surgical principle of delayed primary suture of war wounds.

The immediate results in these 29 cases, and the similar results in the (unpublished) series studied by Collom and Hampton, 27 show clearly what can

be expected when thorough debridement is omitted or delayed. Even when

debridement was omitted for the valid reason that men who had been submitted

to major intra-abdominal surgery appeared incapable of tolerating surgery of

the hip joint immediately afterward, the omission was followed by sepsis in

large proportion of cases.

It was not possible to determine in advance whether wound of the hip

joint wouldbe contaminated in the course of intestinal surgery. On the surface, there seemed no reason why contamination should occur at this time unless

there was direct communication, either external or intrapelvic, between the

two wounds. The difficulties of preventing contamination afterward when

colostomy had been done have already been described.

Methods of management of suppurative arthritis in World War II included

incision and drainage, resection of the femoral head, and amputation or disarticulation.

Incision and drainage.—Incision and drainage were carried out in of the

septic cases, through liberal anterior or anterolateral incision, or through both

approaches. The wound was kept open by Penrose tubing, rubber drains, or

vaseline-impregnated gauze applied to various aspects of the drainage tract.

Posterior incision, which was attempted in additional case, proved just as

inadequate in World War II, in which it was supplemented by chemotherapy,

as it had proved in World War I. In this case, the tract closed within week,

as the result of contraction of the gluteal muscles, but the joint went on to

destruction, just as in the World War experience, and second operation was

necessary to excise the head of the femur.

The following case history illustrates the stormy course which patient

with suppurative arthritis following inadequate debridement was likely to

pursue.

Case 6.—An infantryman sustainedpenetrating wounds of the pelvis and left hip (fig. 59)

from high-explosive shell. Shortly afterward, portion of the ileum was resected, with

end-to-end anastomosis; large laceration of the rectum was repaired; and Mikulicz sigmoidostomy was performed. The man was in such poor condition at the end of these procedures that the wound in the left hip was merely cleansed with soap, water, and antiseptic.

Other injuries included large lacerated wound of the left calf, fractures of the right elbow,

forearm, wrist, and hand, and minor lacerated wounds of the right upper extremity.

Roentgenograms (fig. 65) taken at the field hospital showed fragment of shell, approximately cm. in each dimension, lodged squarely in the middle of the body of the

ischium at the point at which it forms the acetabulum. The assumption was that the

fragment had penetrated the joint from the pelvis outward after lacerating the upper rectum.

Ibid.

372572°—56 17
242 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 65 (case 6).—Roentgenogram showing

fragment of 88-mm. artillery shell lodged in left

anteroinferior acetabulum after traversing lower

abdomen, penetrating rectum, and penetrating body

of ischium. Septic arthritis, necrosis of head of

femur, and luxation of hip joint followed within

months.

It was not possible at this time to determine which of four wounds of the hip and sacrum

led down to the hip joint.

At the end of weeks, the patient was nourishing well and had maintained reasonable

weight. At this time, he was evacuated to the United Kingdom, where the sigmoidostomy

was closed weeks later.

The management of the wounds of the hip had been unavoidable in the circumstances, and the results, as had been expected, were not satisfactory. There was no gross evidence

of abscess formation, but continuous discharge of seropurulent fluid occurred. After the

patient had been evacuated from the Continent, he had considerable pain in the hip, which

was intensified when he moved about in bed. The temperature rose to 101° and 102° F.

each afternoon, and he was obviously toxic. Roentgenograms showed that the joint margins

were becoming irregular and obscure. Drainage was instituted on the 33d day after wounding, through posterior incision; 100 cc. of greenish-white, purulent fluid was evacuated.

Culture revealed mixed organisms, chiefly Bacterium coli and Bacillus proteus.

Seven weeks after wounding, roentgenograms showed resorption of large part of the

surface of the femoral head, with erosion of the superior portion of the acetabulum. The

head was beginning to rise out of the joint. By the 18th week after wounding, drainage had

ceased, and all the wounds in the region of the hip had healed by secondary intention.

Roentgenograms at this time showed further resorption of the femoral head, with definite

subluxation. During the maneuvers necessary for securing the last set of films, the foreign

body, which had been present in the hip joint in all previous roentgenograms, apparently

migrated into the pelvis from its original bed. Active motion consisted of 50 degrees of

flexion and 15 degrees of abduction and adduction, with limitation of rotation in both

directions.
BATTLE-INCURRED FRACTURES OF HIP JOINTS 243

At the end of months, because of complications related to the abdominal wounds and

the additional surgery which they had required, this patient was still on full bed rest. He

had received sulfadiazine for weeks and penicillin for weeks after wounding.

Resection of the femoral head.—Resection of the femoral head was performed in cases of suppurative arthritis, including case in which incision

and drainage through posterior incision had failed to effect cure. The

operation was performed through an anterior incision in cases and through

posterior incision, derived from enlargement of the original wound, in the third.

Opinions differed as to the relative value of these two incisions in military

surgery. In World War I,28 United States Army surgeons preferred the

posterior route, while British 29 and Continental 30 surgeons preferred the

anterior incision. In World War II, posterolateral and lateral incisions were

also used for resection of the femoral head.

This operation was first performed for pyoarthrosis during the wars of the

19th century. It has naturally become safer procedure as time has passed,

but even when the case fatality rate was prohibitively high, there was universal

agreement as to its value. Its prompt employment is amply justified for

number of reasons: Whether or not reconstructive procedures are contemplated

the femoral head, when it is badly damaged, is functionless structure and

nidus of infection, as well as poor aid for joint fusion. After it is eliminated,

drainage ceases and, when the greater trochanter has healed in traction,

functional articulation remains, which permits weight bearing and has useful

range of motion. There is resultant shortening, it is true, but this is easily

remedied by an elevation of suitable height attached to the shoe. It is also

true that for young men the result may not be as satisfactory in some ways as

fusion of the hip joint, but it is still desirable to give resection of the femoral

head fair trial, preferably for year or longer. If at the end of that period

the outcome is not satisfactory, arthrodesis can then be performed.

In 1943, during the course of the war, Girdlestone 31 described technique

for pyoarthrosis which permits saucerization of the entire hip joint on the

lateral aspect by resection of the greater trochanter and the head of the femur,

with minimum interference with muscle and minimum risk to the sciatic nerve

and femoral blood vessels. Wheeler 32 and Ellis 33 both reported excellent

results with it, and it is perhaps unfortunate that American surgeons did not

give this method more recognition and wider trial. It seems the logical

procedure in cases in which the hip joint and gluteal region are so peppered

with foreign bodies that their removal is impossible and there is nothing to do

but wait for exfoliation of the infected areas. Girdlestone’s operation also

28 See footnote 2, p. 225.

29 See footnote 3, p. 226.

30 (1) See footnote25, p. 239. (2) Auvray, M.: TheImmediate Results of Surgical Intervention in 111 Cases of Purulent

Arthritis of the Large Articulations. Bull, et m6m. Soc. nat. de chir. 43:683-690, 1917. In Abstracts of War Surgery;

An Abstract ofWar Literature of General Surgery That Has Been Published Since the Declaration of War in 1914. Prepared by the Division of Surgery, The Surgeon General’s Office. St. Louis: The C. V. Mosby Co., 1918, pp. 304-305. 31 Girdlestone, Q. R.:Acute PyogenicArthritisof the Hip. An Operation Giving Free Accessand Effective Drainage.

Lancet 1: 419-421, April 1943. 32 See footnote 8, p. 226. 33 See footnote 10, p. 226.
244 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

has other advantages. For one thing, it circumvents pressure by the weight

of the body on the bed, which is problem when posterior incisions are used.

For another, it prevents the puddling of exudates frequently observed when

anterior incisions are used. When it is employed in cases in which both the

hip joint and the sciatic nerve have been destroyed by infection, it really

amounts to first-stage disarticulation of the hip joint.

Surprisingly good results, as the following case shows, are sometimes

secured with resection of the femoral head.

Case 7.—An infantryman sustained perforating wound in the region of the right hip

(fig. 59) from bullet which entered the inferior medial aspect of the right buttock and

made its exit on the upper anterolateral aspect of the right thigh. Roentgenograms taken

at field hospital hours later showed comminuted fracture of the hip joint, with displacement of bone into the anterior muscles and soft parts. The wound was cleansed superficially with antiseptics, and arthrotomy was omitted.

Three days later, the wounds were debrided superficially at general hospital in

Belgium. Before the patient was evacuated to the United Kingdom Base by air, his temperature had risen to 101.6° F. (it had been 100.8° F. when he was first seen), and he had

begun to complain of pain in the hip and the inner aspect of the thigh and knee. At the

general hospital, diagnosis of “acute catarrhal asthmatic bronchitis” was recorded.

The patient continued to feel and look very ill, and the temperature elevations persisted.

On the 10th day after wounding, tender, swollen, fluctuant area in the right buttock was

incised, by enlarging the original wound, and about 75 cc. of greenish-whitepus was evacuated.

Culture showed mixture of organisms, predominantly Bacillus proteus and Bacterium coli.

Skeletal traction was instituted by means of Kirschner wire inserted through the tibial

tubercle, and the extremity was put up in Rouvillois splint. On the 15th day after injury,

the temperature was normal; the chest was clear; and the patient felt comfortable. Sulfadiazine was discontinued on the 20th day after wounding, but penicillin was continued

through the 5th week.

Drainage continued to be profuse through the eighth week. Then it began to diminish,

and for several days the temperature again rose to 101.8° F. daily. There was no tenderness

on palpation of the buttock, but deep, rather indefinite fluctuation could be made out.

When probe was introduced into the wound, it went directly down to the bone. No active

motion was possible in the joint, and attempts at passive motion, which were accompanied

by considerable pain, resulted in only slight flexion.

On the 50th day after injury, explorationwas carried out through an anterior iliofemoral

incision. The head of the femur was found shattered into multiple fragments by fracture

lines, but the pieces were well glued together and the head could be removed en masse.

Several fragments of bone were found in small pools of pus in the substance of the adductor

muscles anterior and medial to the joint.

Purulent drainage continued for another months through the posterior incision. At

the end of months, the wounds were completely healed. The patient was wearing nonweight-bearing caliper brace and had 30 percent motion in various directions in the hip

joint. At the end of 28 months after the last operation, he was able to walk with cane

and had useful range of motion. Although he suffered from some pain and instability,

he preferred his present status to the possible improvement which might be accomplished

by arthrodesis.

Amputation (disarticulation).—Neither amputation nor disarticulation was

performed in any case in this series. Amputation was considered in case, in

which series of pelvic abscesses with coxarectal fistulas developed after

performation of the hip joint and rectum, but excisional surgery proved ade-
BATTLE-INCURRED FRACTURES OF HIP JOINTS 245

quate. In another case, however, in which the followup was indirect, the patient died years after injury, of chronic sepsis and other causes. According

to local newspaper, he had had 40 operations in various hospitals in the Zone

of Interior.

It may be that this man would have fared better if amputation had been performed promptly after injury. It is easy to understand the desire to be

conservative in such cases, particularly if the limb distal to the injured joint is

intact. There are, however, number of arguments against this policy:

1. When there has been great mechanical destruction of the bone and soft

parts and when retained foreign bodies carrying fragments of clothing cannot be

removed, foci of infection are maintained for indefinite periods of time.

2. prolonged delay before amputation merely results in exhaustion of the

patient, so that, when the operation is eventually performed, it often poses

serious threat to life. Successful results are sometimes attained with late

amputation, but they are by no means the rule. It must be assumed that

patients with large areas of mixed, penicillin-resistant infection deteriorate

every day that they live and that their chances of survival after major surgery

become progressively less as time passes. All the experience of World War II

was to the effect that penicillin can prevent septicemia and perhaps limit local

extension of sepsis, but that it has no appreciable effect in persistent mixed infection sown in the substance of tissue and associated with massive necrosis.

Toxins are dispersed through the body, regardless of chemotherapeutic measures, and cachexia is the inevitable result and is very often fatal.

3. Amyloidosis has been reported in destructive injuries of the hip joint

in which infection persisted even though drainage was satisfactory. In these

cases, the patients were thought to be living in symbiosis with, or even to be

slowly conquering, the local and general infection by virtue of their own immune

resources. The assumption was unwarranted.

4. Observation of numerous instances of pyoarthrosis of the hip joint at

United States Army amputation centers made it clear that when the sciatic

nerve is lacerated the indication for early disarticulation of the hip is particularly

strong.

Avascular Necrosis

Avascular necrosis is possibility in every instance of battle-incurred

injury of the hip joint. When the substance of the head of the femur has

suffered direct impact fracture, the irregularities in the bone structure and

alterations in bony density suggest that this process is developing in this area,

exactly as it may develop at the line of fracture of cancellous bone anywhere

else in the skeleton. The difference between the reaction in the head of the

femur and in joints with less intra-articular bone is quantitative, not qualitative.

Another obvious reason for the appearance of avascular necrosis in injuries of

the hip joint is anatomic: in adults this joint has insufficient collateral circulation in the femoral head, if indeed it has any at all, and the injury may destroy

its end arteries temporarily or permanently.
246 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Avascular necrosis occurred in 15 cases in this series. This number includes almost every instance in which the head of the femur was struck by

bullet or shell fragment, as well as some cases in which the damage was chiefly

to the neck of the femur. In one or two of these cases, it seemed reasonable to

speculate that both the bony injury and the loss of circulation were the result

ofblast or concussion from bullet which passed through the limb.

The roentgenologic picture of avascular necrosis varied. Subchondral

fractures and undisplaced fractures were sometimes so neatly contained in

position in the acetabulum that they did not show up on routine roentgenograms

and became apparent only at arthrotomy and debridement, or, even later, when avascular necrosis developed. In cases in which the fractures were limited

to the inferior portion of the femoral head, roentgenograms showed no evidence

of this change until between and 12 months after injury. Roentgenograms,

when the condition became evident, always revealed rarefaction, resorption,

and sclerosis of the head of the femur. When the fracture involved the femoral

neck, stellate, incomplete fracture lines extended to the head of the bone. With

healing, the roentgenograms showed increased density or patchy sclerosis.

Since all of these patients were receiving penicillin in large dosages, it was often

difficult to exclude the possibility of previous or controlled infection in certain

cases in which resorption of parts of the femoral head had occurred. One

point of distinction was that when there was clinical evidence of established

suppuration, the bone substance was absorbed much more rapidly and more

extensively than in clean cases. In the latter type of case, the pattern of bone

rarefaction more nearly corresponded to the typical picture of creeping replacement seen in civilian fractures of the neck of the femur. In clinically

clean cases, these changes appeared late. When infection was present, on the

contrary, bone destruction was evident within few weeks after injury.

In several cases, suppurative arthritis was followed by spontaneous subluxation or resorption of almost the entire femoral head. These patients

were treated early, in skeletal traction, on the theory that this method supplied

mechanical protection to the necrotic head during the active stages of infection.

Although traction was maintained as long as possible during the period of

healing and creeping replacement, the joint surfaces were almost invariably

destroyed or irreversibly damaged within period of few weeks.

When the infection was mixed, particularly when B. coli was present

in fractures associated with extensive necrosis of the entire head of the femur, the constitutionalreaction was extremely severe, and the patients (as in case 5)

deteriorated rapidly.

The following case is an excellent illustration of avascular necrosis in

compound fracture of the hip joint.

Case 8.—An infantryman, hit by high-velocity bullet, sustained fracture of the neck

of the femur, with fissures into the head of the bone (fig. 59). The bullet entered on the

lateral aspect of the left hip, perforating the joint, ischium, and pubic bones, and tearing

the bladder and prostate. It then made its exit laterally below the greater trochanter

on the right. The bladder was repaired and the space of Retzius drained in field hospital
BATTLE-INCURRED FRACTURES OF HIP JOINTS 247

Figure 66 (case 8).—Roentgenogram [retouched] showing fracture of neck of femur

extending into head, with associated fractures of ischial and pubic rami and coxa vara

deformity.

on the same day. The wound of the hip was treated by debridement, and hip spica was

applied, in which the patient was evacuated to general hospital, in the United Kingdom on

the fifth day. Progress had been satisfactory, except for daily afternoon temperature

elevations to 100.8° F.

Roentgenologic examination at the hospital in England showed fracture of the base

of the femoral neck extending up into the head, with coxa vara deformity (fig. 66). The

fracture was reduced on the sixth day after injury by manipulation on fracture table.

It was then immobilized in skeletal traction with balanced suspension in the Rouvillois

splint. The patient developed urinary-tract infection which required drainage by an

indwelling urethral catheter for weeks. The hip joint showed no evidence of sepsis at

any time and healing was satisfactory.

Roentgenologic examination weeks after wounding showed the fracture of the neck

of the femur in excellent position and beginning to heal. There was, however, uniform

increase in the density of the femoral head.

Two weeks later (8 weeks after injury), the patient was evacuated to the Zone of Interior

in Whitman’s position in hip spica. At months, he was walking in non-weight-bearing

ischial caliper brace. Two years later, although the head of the femur was nearly revitalized,

the joint space was lost. The normal range of motion was limited by 50 percent, and the

man was still on total-disability pension.

Early Reconstructive Surgery

Attempts to salvage function in compound fractures of the femoral head

by the use of reconstructive procedures soon after injury were not encouraged

in military practice, because of the ever-present risk of actual or potential

infection. In this type of case, avascular necrosis was frequent, and the tissues

exposed had minimum amount of resistance to infection. When fractures

were limited to the trochanteric and subtrochanteric regions, conditions were

different, and early open operation was regarded as justified if the associated
248 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 67 (case 9).—A. Roentgenogram [retouched] showing subtrochanteric fracture

of femur caused by accidental, self-inflicted pistol shot wound. B. Roentgenogram of

subtrochanteric fracture of femur shown in figure 67A, weeks after wounding, weeks

after successful delayed primary closure of wound, and week after open reduction and

internal fixation with McKee nail and single transfixing screw.

soft-tissue wounds had been successfully closed by delayed primary suture.

In some cases in this series, it was possible to aline subtrochanteric fractures

by internal rotation, 90-degree flexion, and wide abduction of the hip in skeletal

traction. In other instances, however, the need for open reduction became clear

soon after conservative therapy had been instituted.

This policy was followed in only cases in this series, all of which were

treated by internal fixation by means of Smith-Petersen, McKee, or

Liverpool nail to weeks after delayed primary suture of the wound. The

McKee and Liverpool nails are basically Smith-Petersen nails with plates

attached. In the Liverpool nail, ordinary plates are attached at the angle of

the average neck of the femur. In the McKee nail, wide curved plates are

similarly attached (fig. 67B).

In all cases treated by nailing, extra-articular methods were used.

When plate was employed, it was attached at the same time, through

lateral incision. The results in these cases, in which weight bearing and

approximately 90 percent of function were achieved within year of wounding,

encourage the attempt at early functional salvage by the use of reconstructive

measures in carefully selected cases of fractures of the trochanteric and subtrochanteric regions.

The following case is an illustration of the good results of an early reconstructive procedure in properly selected patient.

Case 9. soldier from an armored unit accidentally shot himself while returning his

pistol to the holster. The bullet penetrated the anterior capsule of the left hip joint, fractur-
BATTLE-INCURRED FRACTURES OF HIP JOINTS 249

ing the femur below the lesser trochanter and lodging in the posterior margin of the fascia

lata at the middle third of the thigh (figs. 59 and 67). Arthrotomy and debridement, with

removal of the bullet, were performed in field hospital few hours later. Penicillin (10,000

units) was instilled into the joint at the conclusion of the operation. Five days later, delayed

primary closure of the wound of the soft parts was carried out at general hospital in the

United Kingdom. The patient was then immobilized in skeletal traction in Balkan frame

by means of Kirschner wire through the tibial tubercle.

The fracture was reduced by manipulation twice within the next weeks, but position

could not be maintained for any length of time. Open reduction and internal fixation with

the McKee nail (fig. 67B) were therefore carried out weeks after wounding. Weight- bearing exercises were begun at months. When the nail plate was removed month

later, the patient had 75 percent of normal motion in the joint. At months, the fracture

was solidly united, and disability was minimal.

An Ideal Plan of Management

The experience of World War and World War II suggest the following

routine as an ideal plan of management for battle-incurred injuries of the hip

joint:

1. Initial surgery should consist of debridement, arthrotomy, exploration

of the joint, irrigation if gross suppuration is not present, and primary closure of the joint if loss of substance does not prevent it.

2. The approach is preferably the anterior iliofemoral incision described

by Smith-Petersen or the posterior approach described by Kocher.

3. The operation should be carried out as promptly as possible after

wounding, but neither impending nor established sepsis contraindicates its

delayed performance, regardless of the length of time since injury.

4. Debridement should consist of complete excision of blood clots, devitalized muscle, fatty tissue, bone fragments, foreign bodies, and other foreign

material along the track of the wound. This is the general principle. In the

special case, the surgeon must use his judgmentin deciding how much chiseling,

scraping, and curetting are necessary to secure clean, bleeding bone surfaces. In the hip joint almost more than in other areas, the wounds of the

soft parts, the maceration of muscle, and the retention of shell-borne particles

of clothing and other foreign material may be even more important than the

articular damage. All tissue, including bone, which has no remaining circulation must be excised, to eliminate soil for infection.

5. The deeper soft parts should be closed over the joint, but the skin

wound should be left open, to be closed within to 10 days by delayed primary

suture.

6. The extremity should be extended and suspended, preferably by skeletal

traction in the Rouvillois splint, for to 12 weeks.

7. Active motion should be begun in traction as early as this is practical

and can be accomplished without undue risks or pain.

8. In cases in which sepsis is established when the patient is first seen,

open operation by the Smith-Petersen approach, with thorough debridement,

is the method of choice. If it fails, excision of the joint by Girdlestone’s
250 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

method, combined with drainage or disarticulation, should be done. The operation should not be unduly delayed if sepsis is severe, since the patient’s

condition deteriorates rapidly in these circumstances.

9. Whole blood should be used in liberal amounts as long as it is indicated.

Other supportive measures, including measures to correct protein deficits,

should also be used according to the indications.

10. Penicillin and sulfadiazine should be used parenterally before and

after surgery. Local chemotherapy is not indicated. Both drugs are adjuncts to surgery, not substitute for it.

11. In occasional carefully selected cases, reconstructive procedures with

internal fixation may be employed to weeks after successful delayed primary

suture of the wound.
251

CHAPTER XIX

Jeep Injuries of the Hip Joint

Marshall R. Urist M. D.

Basic Information

This chapter is based on an analysis of 58 injuries of the hip joint originating under generally similar circumstances of military traffic. They were

observed over period of 18months in the 802d Hospital Center in theEuropean

Theater of Operations, which, over the same period, admitted approximately

25,000 combat and noncombat casualties. Both before and after the institution

of definitive treatment, these men, as is inevitable in time of war, were treated

by various medical officers, who ranged from general practitioners trained

in the emergency to handle military casualties to experienced orthopedic surgeons whose views and practices, however, were frequently at wide variance

concerning the management of such injuries.

Although this series consists of only small number of cases, they furnish

an amply sufficient background for this chapter for several reasons:

1. This series includes as many instances of this type of injury as would

usually be admitted to any large urban hospital over period of 10 to 15 years.

2. No single surgeon in civilian life would be likely to have as large an

experience as this in the course of professional lifetime.

3. It is possible to derive from detailed clinical analysis of these cases

enough material for an evaluation of the teachings and practices concerning

these injuries when the United States entered World War II. There was then

no uniform teaching concerning them, and no Army directives for their management were issued.

4. Because of the many different medical officers who participated in one

phase or another of the treatment of these casualties, the series is of historic

interest and may be accepted as an overall picture of the management of traffic injuries of the hip in World War II.

Classification For convenience of analysis, these 58 cases have been divided into groups

(tables 11 through 15), as follows: (1) Dislocations of the hip joint (15 cases);

(2) fractures of the acetabulum without dislocations (16 cases); and (3) fracture-dislocations of the hip joint (27 cases). The dislocations, in effect, serve

as control group for the fracture-dislocations, while the fractures of the

acetabulum similarly serve as control group for the injuries to the articular

surfaces in the group of fracture-dislocations.

These three groups of cases have been analyzed from variety of points of
252 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

view, with particular emphasis on the nature of the traumatic lesion, methods of

treatment, complications, and followup studies. Followup reports were obtained in various ways, including personal examinations, letters and roentgenograms submitted by patients and their local physicians, and reports of examinations in Army and veterans’ hospitals.

The end results in these 58 military injuries were compared with the end

results of 18 similar injuries sustained in civil life and treated at the Massachusetts General Hospital. The rarity of this type of injury in civilian practice is

evident in the fact that these 18 cases represent 12- to 16-year experience in

thousand-bed civilian hospital.

Circumstances of Injury

All of these casualties sustained their injuries in traffic accidents, and 40 of

the 58 received them while they were riding in jeeps. Curiously, although jeeps

were used in all theaters of operations, the impression was gained from communications with other orthopedic surgeons working in other theaters that this

type of injury was frequent only in the European theater. This is perhaps to

be explained by the excellent concrete highways which are part of the European scene but which are less frequent or nonexistent in other parts of the

world. These highways permitted and encouraged travel at high rates of speed

and help to explain the high incidence of traffic injuries in this theater.

Other contributing factors were also operative. The excitement and recklessness of men at war, most of whom were young men, were responsible for

high incidence of all types of severe injury. In this series, one patient was 51

years of age, but all the others were between 19 and 33 years, the period of life

in which trauma always exacts its greatest toll.

Soldiers were constantly involved in accidents in trucks, tanks, and other

types of mechanized motor vehicles, under conditions which seemed just as

hazardous as those which prevailed when they were riding in jeeps. Nonetheless, the fact that the jeep was the most commonly used of all Army vehicles

cannot be overlooked as an explanation of the relatively high incidence of the

special injuries to be discussed in this section, particularly the dislocations,

which were present in 42 of the 58 cases.

The United States Army truck, one-fourth ton, more popularly called the

jeep, seemed to possess special structural characteristics which put its riders

into favorable anatomic position for the production of this special type of

injury. review of recorded experimental studies, beginning with Allis’

in 1896 and Bigelow’s in 1900, shows that it provided the exact conditions

necessary for the production of dislocations of the hip joint (fig. 68). It is constructed like an old-fashioned wagon, with minimum of protective framework,

and passengers readily fall out of it. Its seats are so low that when passengers are seated their hips are flexed more acutely than in other automobiles.

Allis, Oscar H.: An Inquiry Into the Difficulties Encounteredin the Reduction ofDislocations of the Hip. Philadelphia: Dornan, Printer, 1896, pp. 45-61, 91-103.

Bigelow, Henry J.: TheMechanism of Dislocationand Fracture of the Hip. Boston: Little, Brown and Company,

1900, pp. 1-16.
JEEP INJURIES OF HIP JOINT 253

Figure 68.—Artist’s interpretation of patients’ positions and attitudes at time of

injury, derived from their own descriptions. The accident was most often head-on collision. A. rider in this position could fall out, striking the pelvis and incurring fracturedislocation or fracture. B. rider sitting with legs abducted could sustain fracture of

the acetabulum or fracture-dislocation from dashboard blow on the knee. C. rider

sitting with hips acutely flexed and adducted could sustain dislocation of the head of the

femur with minimal damage to the bony rim of the acetabulum.

While the riders are in this position, the head of the femur is in internalrotation,

directed posteriorly and disposed toward posterior dislocation. The instrument board, or the back of the front seat, depending upon where the rider is

sitting, is so close to his flexed knees that in case of accident it is difficult to

avoid the so-called dashboard type of blow, which has become classical

injury in this modern mechanized age. There seems no doubt, therefore,

that the jeep, because of its special structure, must be assumed to be primarily responsible for the appearance of as many dislocations of the hip over

an 18-monthperiod in military experience as would occur over 10-ycar period,

or longer, in civilian practice.
254 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Anatomic Considerations

Fractures and fracture-dislocations of the acetabulum cannot be properly

discussed, any more than they can be properly evaluated and treated, without

recollection of certain anatomic considerations. The acetabulum, viewed

from within the joint cavity, consists of semilunar or horseshoe-shaped platform of bone covered with articular cartilage. This platform, which is the

weight-bearing surface, is formed mainly from the body of the ischium, which

receives the attachment of the posterior capsule of the hip joint on its outer

surface, several millimetersfrom the edge and well separated from, and proximal

to, the cotyloid ligament.

The anterior portion of the horseshoe, which is formed from the body of

the pubis, is about half as wide as the superior portion. The capsule on the

anterior, superior, and inferior aspects is attached close to the edge of the rim,

in contrast to its attachment on the posterior aspect and blends closely with the

fibers of the cotyloid ligament. Only areolar and synovial tissue covers the

central portion of the acetabulum.

The integrity of the posterior rim of the acetabulum is essential for the

stability of the joint. The rim of the anterior portion may be excised, as in

arthroplastic operations, without any serious harm to the weight-bearing

function, but the superior shelving portion, which is the thickest part of the

innominate bone, is also vital if function is to be preserved.

The retinacula are three flattened bands of loose fibrous tissue which are

covered with synovial membrane and which lie partly within and partly outside

the reflected capsule on the inferior, posteroinferior, and posterosuperior

aspects of the joint. They contain many blood vessels and serve literally as

aqueducts in that they carry the blood supply to the head of the femur from

the numerous branches of the medial femoral circumflex vessels in the intertrochanteric region. They pass through the superior and inferior pads of fat at

the margin of the articular cartilage and form great many of the terminal

arterial branches to the head of the femur. plexus of veins which drain the

superior capital epiphysis is also found in the retinacula. The clinical importance of the retinacula, which is considerable, is frequently overlooked in

injuries of the hip joint (pp. 275, 293).

Dislocations

Nature of the Lesion

As has already been pointed out, the hips of the rider in jeep are flexed

more acutely than in any other type of car, because jeep seats are so low. In

this position, the head of the femur is in internal rotation, directed posteriorly

and disposed toward posterior dislocation. Trauma could be received by the

greater trochanter or transmitted through the femur from the knee flexed

against the dashboard, or from the foot on the floorboard, or could be received

posteriorly and transmitted to the hip by the sacrum. Cases have been recorded of injuries received under all of these conditions. Specific inquiries into
JEEP INJURIES OF HIP JOINT 255

Figure 69.—Typical posterior dislocation of hip as result of jeep accident.

Note unequal length of legs, internal rotation of knee, and adduction of hip

on affected side. Note also severe bruises in both prepatellar regions.

the circumstances of injury in this series showed that in many instances the

head left the joint with minimal damage to the bony structure when the hip

was adducted and flexed, as it is when man is riding in jeep, perhaps with

his legs crossed. The result in these cases was an ordinary dislocation without

gross fracture (table 11).

Traumatic lesions of the soft parts were evident in many of these cases

(fig. 69), but otherwise, since the method of treatment was always closed

manipulation, there were no opportunities for direct observation of the damage

caused to the joint structures by the dislocations. From the standpoint of

accumulation of knowledge this was unfortunate. Observations in fresh

injuries might have supplied information which would indicate why some

dislocations are followed by avascular necrosis of the head of the femur while

others are not.

Roentgenologic studies, however, supplied information which, combined

with accumulated experience with experimental dislocations, seems significant

and relevant. These observations were as follows:

1. Prereduction roentgenograms revealed serrations of therim or avulsionchip fractures in three cases (fig. 70, case 11; cases and 6). The location of

these injuries suggested that the joint capsule might have been torn away at

its acetabular attachment. Avulsion fractures in the posterior intertrochanteric

region in two other cases (fig. 71, case 7; case 9) indicated that the femoral

attachment of the capsule was torn. Allis described both of these capsular lesions in his experimental study of dislocations, but further investigation is

needed to clarify the pathologic process. The location of the capsular tear

may play some role in the damage suffered by the local blood supply, especially

by the branches of the medial circumflex femoral artery which enter the hip

joint in the intertrochanteric area posteriorly, and may explain thelater development of avascular necrosis of the bony structures.

See footnote 1, p. 252.
256 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

—Dislocations 11.

of

hip

joint

without

significant

fractures

Case No.

Age

Fractures

(X-ray)

Other

Injuries

of

ipsilateral

extremity

Traction

Weightbearing

2-year results

21 90

Contusion,

knee

Weeks

Monthsafter injury

Pain. Do.

27 27 21 20 51 33 20 25

Contusion, knee;

dislocation, patella

Unknown.

do

Fracture,

patella;

posterior

dislocation, knee

Pain. Unknown.

Lacerated wound,

knee

Do.

Fracture,

upper tibia,

fibula,

and

patella;

pos12

Do.

19

terior

dislocation, knee.

Dislocation, midtarsus

Pain. Night

pain.

0)

Unknown.

24 20 20 21 19

Do.

12

Lacerated wound,

knee

Good. Do.

14 15

Unknown.

Lacerated wound,

knee

Do.

Unknown.
JEEP INJURIES OF HIP JOINT 257

Figure 70 (case 11). A. Emergency postero-oblique roentgenogram showing posterior

dislocation of hip joint. Film is of average quality for roentgenograms made under field

conditions. In these circumstances, bone detail was often lacking, and minor fractures were

not suspected. B. Anteroposterior roentgenogram of posterior dislocation shown in figure

70A after manipulationand reduction of dislocation by Stimson’s maneuver. Note improvement in quality of film (made in fixed hospital), which now reveals avulsion-chip fracture,

probably of posteroinferior rim of acetabulum. The acetabular attachment of the joint

capsule has presumably been torn away.

Figure 71 (case 7).—A. Emergency postero-oblique roentgenogram showing posterio

dislocation of hip joint, with possible fracture of femur. B. Anteroposterior roentgenogram

of posterior dislocation shown in figure 71A after manipulation and reduction by Stimson’s

maneuver. Improvement in the quality of the film now permits the demonstration of an

avulsion fracture of the superior portion of the intertrochanteric ridge, in the line of the

femoral attachment of the joint capsule posteriorly.

372572°—56 18
258 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

2. Prerechiction and postreduction roentgenograms also revealed other

minor fractures in the form of incomplete fissures of the posterior acetabular rim.

There were, in fact, only of the 42 dislocations and fracture-dislocations in

which there was no roentgenologic evidence whatsoever of bony damage.

Since roentgenograms of the hip joint usually show only gross defects, it seems

reasonable to assume that even in these cases there was some damage to the

rim of the acetabulum and the head of the femur and to assume, further, that

fracture, which may be major or minor, is an almost invariable accompaniment of dislocation of the hip joint.

Bollinger’s description of the traumatic lesion in 12 instances of inveterate

dislocation of the hip joint managed by surgery, although it was published in

1911, still remains the most complete on record. In these cases, tears were

found in all the posterior muscles, including the quadratus femoris. few

other notes on findings at operation for irreducible dislocations and few

autopsy observations, all in the older literature, suggest that in these injuries

the head of the femur most often escapes between the piriformis and obturator

interims and then tears the fragile gemelli muscles. When it finally comes to

rest, the more durable obturator tendons are stretched over and under the

protruding femoral neck. Damage to the intertrochanteric attachment of the

posterior capsule at the insertion of these muscles, the point at which the largest

part of the blood supply enters the hip, seems never to have been described.

Yet avulsion fractures are repeatedly observed in this region in postreduction

roentgenograms and furnish proof that the damage exists and that the fractures

should be searched for, by repeated roentgenograms, if they are not immediately evident.

Before the era of roentgenology, there were number of elaborate pathologic classifications of traumatic dislocations of the hip, all based on the position

of the head of the femur as determined by the position of the lower extremity.

Clinical diagnosis was made on the same basis. The advent of roentgenologic

examination made it clear that many of the types of injury described were

chiefly theoretic possibilities, and that the only really important consideration

is whether the dislocated head lies anterior or posterior to the acetabulum.

Posterior dislocations (Bigelow’s regular dislocations) are the most frequent variety. They were present in 14 of the 15 cases in this series. When

no fracture occurs in posterior dislocation, the head of the femur probably does not displace farther than just over the rim of the acetabulum, which was

its position in all 14 cases in this series. In the single anterior dislocation, the

head rested opposite the obturator foramen, but its position could not be determined by rectal examination. There were no instances in the series of Bigelow’s irregular dislocations in which the head of the femur is displaced into the

scrotum or is found in other bizarre locations.

case reported by Kleinberg in 1923 suggests that the excursion of the

Dollinger, J.: Die veralteten traumatischen Verrenkungen der Schulter, des Ellenbogens und der Hiifte. Erg.

Chir. Orthop. 3: 83-194, 1911. Kleinberg, S.: Fracture of the Acetabulum With Central Luxation of the Hip. Ann. Surg. 78: 806-813, December

1923.
JEEP INJURIES OF HIP JOINT 259

head may be less than the length of the ligamentum teres, which may not be

torn if the head escapes by way of the cotyloid notch. This possibility is easily

verified by fresh anatomic preparation of hip joint after circumcision of the

capsule. In most of the cases (fracture-dislocations) in this series which were

examined at open operation, this was not true. The ligamentum teres was

stretched and was partially torn if not completely severed.

There were no instances of bilateral dislocation of the hip in the series.

There was also no apparent damage to the vascular structures of the joint

capsule in any of the 15 cases. Theoretically, this variety of damage would

occur only in dislocations and fracture-dislocations.

Management

First aid and transportation.—First aid was well handled in all 15 cases.

The clinical picture is so striking in this condition, and the deformity (fig. 69)

is so obvious, that most of the dislocations were promptly diagnosed in battalion

aid stations and field hospitals. In most instances, preventive treatment for

shock was instituted, and the leg was bandaged to the litter or the patient was

otherwise protected against further trauma until an installation in the rear was

reached. In one or two cases, Thomas splint was used for immobilization.

Six patients had severe injuries, which of themselves required immobilization,

of other parts of the ipsilateral extremity.

Reduction. —Although the records are not complete in all respects and

it is not clear in some cases how many attempts at reduction were made or how

long time they took, considerable information is still available on these points.

In instance, spontaneous reduction occurred, without anesthesia; this patient,

who had sustained injuries of all extremities, was in shock. In instance,

the first attempt at reduction was unsuccessful, and second surgeon later

accomplished it. In 12 of the remaining 13 cases only Pentothal Sodium

(thiopental sodium) was used for anesthesia, which suggests that reduction was

accomplished without special difficulty, in spite of the relative inexperience of

most of the surgeons who were obliged to undertake it.

In some cases, reduction was accomplished by gravity alone after the joint

had been properly flexed and relaxation obtained under anesthesia. The

records indicate that posterior dislocations were successfully reduced at the

first attempt by Stimson’s maneuver, which was also employed secondarily

in other cases, after the Bigelow method of circumduction and the Allis supine

method had failed. The technique was not difficult if Stimson’s description

was closely followed: nothing was done until the muscles were fully relaxed

under anesthesia. Then, with the patient prone, the thigh was rocked slightly

to and fro to accomplish gentle internal and external rotation. The weight of

the hanging limb, supplemented by slight downward pressure on the upper

posterior tibia, supplied the needed traction. In every instance in which this

method was used, the head of the femur promptly slid down in the acetabulum.

The single anterior dislocation was easily reduced, with the patient supine,

by the reverse circumduction method of Bigelow. The essential feature of the
260 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

circumduction technique is flexion of the hip to relax the Y-ligament, which then

can be used as fulcrum. Bigelow’s post mortem studies showed that this

ligament is usually intact in posterior dislocations. After his demonstration of

this method, traction, which had been regularly employed up to that time, came

to be regarded as unnecessary and actually harmful.

However it was brought about, dislocation of the hip joint furnished no

particular difficulties in reduction if there were no obstacles in the pathway of

the displaced femoral head and if the acetabulum had not been distorted. As

this series demonstrates, Stimson’s method, or some one of its variants, is the

simplest and gentlest method of obtaining traction by manipulation. The

satisfactory results achieved by it, as this series also demonstrates, suggest that

inexperienced surgeons would always do well to use it in preference to any

other technique. Experienced orthopedic surgeons naturally based their

procedures in the special case on the clinical and roentgenologic findings and

did not adhere to any standardized technique. The modifications of the Allis

and Bigelow methods are not well known and most of them were not tested in World War II.

Immobilization.—When these patients were received at general hospitals,

at periods varying from few hours to 10 days after injury and reduction

of the dislocation, it was found that variety of methods had been used to

immobilize them during transportation from evacuation hospitals. Five,

chiefly those who had suffered fractures and other injuries of distal joints of

the injured extremity, were evacuated in plaster-of-paris hip spicas. One

patient was transported with his legs bound together in swathe. The others

were not immobilized by any special methods but were required to maintain

complete recumbency.

Definitive treatment.—Treatment at general hospitals was limited to

traction, in the form of (1) skin traction, accomplished by bilateral Buck’s

extension or Russell’s suspension, or (2) vertical skeletal traction, accomplished by means of Kirschner wire through the tibial tubercle, with 10 pounds’

pull. Traction was continued from to weeks. The optimum time would

seem to be weeks, which is the period theoretically required for complete

healing of the joint capsule and its ligaments. The wide variation in this

series was not intentional but was unavoidable because of irregularities in

the evacuation schedule caused, in turn, by the weather and the tactical situation in the theater. Every patient with dislocation of the hip was candidate for evacuation; treatment was necessary for at least year after injury,

and often longer, which far transcended the holding period permitted for the

theater.

Traction was employed arbitrarily in the management of these cases

because it seemed logical. In view of the complications which could arise

from injury to the vascular structures of the joint and which, at least theoretically, could be avoided by maintenance of the circulation and healing of

the blood vessels, rest in traction seemed highly desirable. The literature,
JEEP INJURIES OF HIP JOINT 261

however, offers no evidence to support this point of view and supplies no

control studies. At the start of the war, methods recommended for the management of dislocations of the hip varied widely, as follows: That the limb

be immobilized in hip spica for to weeks; that traction be applied for

to weeks; and that the patient be kept at bed rest but otherwise be permitted

complete freedom of motion. There is no evidence that any of these methods,

including the techniques of traction used in this military series of injuries,

is superior to any other method.

Weight bearing.—All patients, when they were evacuated to the Zone of

Interior, were instructed not to put weight on the injured extremity until

at least months after injury without specific permission from medical

officer who had examined recent roentgenograms. They were also strongly

urged not to dispense with crutches until at least months had passed. They

were told, in very plain words, that failure to follow these instructions might

be detrimental to recovery. In about half the cases, as might have been expected, weight bearing was practiced as early as months after injury,

either because of the patients’ own restlessness or because of advice from

medical officers in Zone of Interior hospitals. Only patients with associated

fractures of the knee or the foot are known to have refrained from weight

bearing for months or longer.

Again, the literature was of no help in formulating policy. In the reported cases, weight bearing was arbitrarily forbidden for periods ranging from

weeks to months. Neither the cases recorded in the literature nor any

cases in this series suggest that early weight bearing was harmful or that

abstinence from weight bearing contributed to recovery.

Complications

Recovery was uncomplicated in every case in this series, and there were

no sequelae in the immediate period of observation. Avascular necrosis and

degenerative arthritis appeared in number of cases of fracture-dislocation

of the hip joint (p. 293), and whether their absence in this group of dislocations is significant or accidental it is not possible to say. The literature suggests that avascular necrosis is almost as common in simple dislocations as in

fracture-dislocations, but the presence of associated fractures is frequently not

mentioned, and there is some doubt, therefore, as to the validity of the

observation.

Certainly, as already intimated, the absence of complications in this

series cannot be attributed to the method of treatment employed, which was

entirely arbitrary. The literature suggests that when these complications, as

well as ossification of the joint capsule, have developed, they are symptomatically aggravated by early weight bearing. No comment is possible from

the standpoint of this series.

Restriction of weight bearing is generally believed to produce disuse

atrophy of the base of the neck of the femur, which accentuates the density
262 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

of the dead parts of the head and therefore aids in earlier diagnosis of avascular necrosis. Again, no comment is possible from the standpoint of this

series, since disuse atrophy was not evident in any case in it.

Fractures of the Acetabulum Without Dislocation

Classification The 16 fractures of the acetabulum (table 12) which occurred in these 58

injuries of the hip joint fall into classes:

I. Fracture of the rim of the acetabulum, cases, including of the superior

and of the posterior rim.

2. Central fracture, cases, including of the body of the pubis and inner

table of the pelvis, and of the anterior rim and superior ramus of the pubis,

with intrapelvic protrusion of the head of the femur.

3. Comminuted or bursting fracture, with disorganization of the entire

joint cavity, cases.

This classification is practical, not theoretical, and is therefore not open

to the objection that is attached to the purely morphologic classifications. It takes cognizance of the morbid and roentgenologic anatomy of theregion, as well

as the physiologic considerations having to do with the localization of function

of various parts of the acetabulum (p. 254). It also takes cognizance of therapeutic problems.

The injury in every case was of the so-called dashboard type, with consequent incongruity of the joint surfaces. As is pointed out elsewhere (p. 276):

1. Fractures limited to the anterior portion of the articular surfaces

are suitable for conservative management, in traction.

2. Fractures which destroy significant part of the superior and posterior

rims of the acetabulum require open operation.

3. More extensive fractures, which destroy the entire joint surface, do not

respond well to any form of treatment and usually result in great disability,

frequently with associated ankylosis and degenerative arthritis (cases 29

through 31).

Nature of the Lesion

Fractures of the posterior rim of the acetabulum, of which there were in

this series, are not uncommon. They vary in magintude and in the particular portion of the lunate articulate surface involved. Fractures of the superior

rim, of which there were in this series, are extremely uncommon, presumably

because of the volume of the bone and the adaptation of the stress lines of the

trabeculae in this region to the burden of the weight of almost the entire torso.

In instance of superior rim fracture in this series (case 18, table 12), in which

open operation was required, 0.5 cm. of the full width of the articular cartilage

was attached to the fragment, while the entire iliofemoral ligament was at- tached to the outer cortex of its rim.
JEEP INJURIES OF HIP JOINT 263

The fractures of the central portion of the acetabulum showed an infinite number of patterns and degrees of displacement. The single instance

of intrapelvic protrusion of the head of the femur (case 28) was, like most

reported cases, only partial, which was fortunate, as the highly comminuted,

bursting type of fracture is almost irreparable. In the majority of reported

cases, as in this case, there was fracture of the anterior rim and body of the pubis, associated with second fracture of the superior ramus of the pubis.

This fracture acted as hinge and was responsible for the displacement of

the inner table of the pubis. In such cases, the head of the femur escapes into

the fracture site (that is, the anterior portion of the acetabulum) and the vital

superior and posterior lunate cartilages sustain relatively little damage.

It might be expected that intrapelvic protrusion of the femur would occur

in jeep accidents. The injury can be produced experimentally and accidentally

by blow on the flexed knee transmitted to the head of the femur, and it has

been reported, by Haines, during convulsions from shock therapy, possibly

as the result of indirect force produced by abnormal muscle action. Most

often, however, it follows blow on the greater trochanter. The degree of

abduction of the limb at the time of the accident, as well as the amount of

internal and external rotation of the head of the femur, determines the pattern

of the lesion and the portion of the rim of the acetabulum involved. If the

head is in external rotation, blow on the greater trochanter would drive it

into the anterior portion of the acetabulum, where, as in the case in this series,

intrapelvic protrusion is possible with minimal damage to the weight-bearing,

lunate-shaped articular cartilage.

In each of the cases (cases 29, 30, and 31) in which comminuted fractures involved all portions of the acetabulum, the joint was completely disorganized and incongruent. In of these cases, there was also an associated

fracture of the ipsilateral femur.

Management

Fractures of the rim of the acetabulum.—The patients with fractures of

the rim of the acetabulum received no treatment in forward installations other

than such first-aid measures as were indicated. All were immobilized for

transportation in hip spicas, in 30-degree abduction, 20-degree flexion, and

neutral rotation.

The treatment employed in the fixed hospital depended upon the degree

of displacement of the fracture and the size of the fragment of rim. In every

case, the diagnosis had been made by emergency roentgenograms taken in

field or evacuation hospitals, but repeated examinations, with more elaborate

equipment, revealed further details. Postero-oblique views were particularly

informative. In instances the fractures were found displaced. In others

there was either no displacement at all or very slight displacement. In the

Haines, H. FI.: An Unusual Complication of Convulsive Therapy. Fracture of an Abnormal Acetabulum (Otto

pelvis;. Psychiatric Quart. 18: 273-277, April 1944.
264 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

—Fractures 12.

of

acetabulum without

dislocation

Case No.

Age

Fractures (X-ray)

Other

injuries

ipsilateral

extremity

Treatment

Weightbearing

2-year results

16 17

21 20

Undisplaced

fracture,

superior

rim. Slightly

displaced

fracture,

Lacerated wound,

thigh,

leg,

knee.

Traction

weeks do

Monthsafter

injury

Normal

hip;

slight

pain.

Pain

and

difficulty

standing

for

long

periods.

Normal

hip;

occasional

mild

joint

pains.

Snapping

hip,

severe pain,

slight

limitation

of

motion.

Unknown. Normal joint.

Normal

motion joint,

slight

pain

and

clicking.

Unknown. Normal

motion,

slight

pain;

unable

to

lift

heavy

objects.Normal joint.

Normal

motion,

joint

pains,

difficulty

on

standing

for

long

periods.

18 19

32 29

superior

rim.

Displaced

fracture,

superior

rim. Widely

displaced

fracture,

posterior

and

inferior

rims,

do

Hemarthrosis; lacerated

wound,

knee.

Pott’s

fracture

Open

reduction, internal

fixation. Traction

weeks;

frac20

20

Fracture,

patella

ture

not

reduced.

Traction

weeks;

fracture

not

reduced.

21

35

Undisplaced central

fracture

22

24

do

23

26

do

Severe

contusion,

knee

24

21

do

Laceratedwound,

knee

do

25

42

Displaced

central

fracture.__

do

26

22

do

Fracture,

patella

do

27

29

do

do

28

39

Central

fracture,

fracture

body

and

descending ramus

pubis,

intrapelvic

protrusion,

femoral

head.

Lateral

and

longitudinal

traction weeks.

Do.
JEEP INJURIES OF HIP JOINT 265

29

29

Comminuted fracture,

disFracture, midshaft

femur_

Traction

weeks

Severe

pain,

ankylosis

placement

all

parts

and

superior

and

posterior

rims.

30

25

do

Compound

fracture,

upper

third

femur.

18

Do.

31

32

Comminuted fracture,

displacement

all

parts

and

do

Do.

superior

and

posterior

rims.

Multiple

bilateral

fractures

pelvic

ring.

This

patient

had

no

treatment

for

months,

while

he

was

prisoner

of

war.

Not

known. Injury

of

kidney,

persistent hematuria.

Suprapubic

cystostomy required

for

laceration

of

posterior

urethra.

Crushing

injury

of

testicle

required

extirpation.
266 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 72 (case 19).—A. Anteroposterior roentgenogram showing fracture of posterior

rim of acetabulum shortly after injury. In this view, the displacement of the fracture does

not seem significant. B. Postero-oblique roentgenogram of fracture shown in figure 72A,

showing displacement. When the hip was examined in flexion in this case, the joint was

stable, but little more than half of the original lunate cartilage of the acetabulum articulated

with the head of the femur.

remaining case (fig. 72, case 19) the patient had been prisoner of war, and the

existence of the displacement was not realized until weeks after injury because

of failure of enemy surgeons to study the important postero-oblique roentgenogram.

Four of the patients with fractures of the rim of the acetabulum (cases

16, 17, 19, and 20) were treated conservatively, in traction suspension, for periods varying from to weeks, the duration of traction depending upon the

extent of the lesion. Operative treatment would have been desirable, because

of the extent of the displacement, in of these cases (case 20), but it was

contraindicated because of serious head and chest injuries.

Open reduction and internal fixation were carried out primarily in the remaining case (fig. 73, case 18) because vitalportion of theacetabulum had been injured. The anterior iliofemoral approach, which gave excellent exposure,

revealed the joint capsule in the sulcus between the sartorius, tensor fascia

femoris, and rectus femoris. After irrigation and curettage, to remove the

blood and blood clots which obscured the fracture lines, it was possible to return the main fragment to its normal anatomic position, with its attachments to

the capsule and anterior iliofemoral ligament intact. The surgical approach

did not permit the insertion of the transfixing screw, and lateral stab wound

was therefore made in the gluteus medius, large enough to permit the introduction of long drill-point screw driver at right angles to the middle of the

fracture line. The parts dovetailed perfectly, and the fragment could be
JEEP INJURIES OF HIP JOINT 267

Figure 73 (case 18).—A. Anteroposterior roentgenogram showing fracture of superoposterior rim of acetabulum before joint repair. B. Anteroposterior roentgenogram showing

fracture shown in figure 73A week after anatomic repair of joint surface and internal

fixation of fracture. Note that screw penetrates inner table of pelvis; if it does not, immobilization of the fragment will not be reliable.

compressed into position so accurately that the fracture line was scarcely

visible in the postoperative roentgenogram (fig. 73B). Since the superior

rim is the strongest part of the acetabulum, fractures in it are correspondingly

uncommon, and it is not surprising that no case similar to this one seems to

be on record in the literature.

Central fractures of the acetabulum.—The patients with central fractures

of the acetabulum received only necessary first-aid measures in forward installations. All were immobilized in either Thomas splint or plaster spica,

with the joint in neutral position. second roentgenologic examination at

the fixed hospital revealed that in fractures there was no displacement.

In 3, all involving the dome of the acetabulum, the inner table of the pelvis

was displaced for distance about equal to the width of the cortex. The remaining fracture (fig. 74, case 28) was, as already noted, typical fracture of

the anterior acetabulum and body of the pubis, with intrapelvic protrusion

of the femoral head and wide displacement of the inner table of the pelvis.

All patients in this group were treated conservatively, by suspension and

skeletal traction, for to weeks. The fracture complicated by intrapelvic

protrusion of the head of the femur required special management. Reduction

was accomplished by means of vertical Kirschner wire placed just inside the

lateral cortex of the trochanter. The head of the femur was then restored

to its normalrelationship with the rim of the acetabulum by the use of the largesized wire-tautening spreader. The hip was suspended in Balkan frame

with pounds’ lateral traction and 10pounds’ bilateral skin tractionthrough the

lower extremities. The ipsilateral side of the bed was elevated slightly to

provide lateral countertraction. Suspension traction was maintained for
268 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

weeks. The failure of the fragments to follow the femoral head after its extraction (fig. 74B) was not unexpected; this observation has been made in

almost every case recorded in the literature. The displacement of the inner

table of the cortex was not modified by the technique employed, but the fracture

site and the anterior portion of the joint had been filled in with abundant callus

and healed with the formation of new bone and fibrocartilage before the patient

was evacuated to the Zone of Interior, months after wounding.

Figure 74 (case 28).—A. Anteroposterior roentgenogram showing central fracture

of acetabulum with intrapelvic displacement of anterior acetabular rim and inner table of

pelvis. Lowest arrow shows how the fracture of the superior ramus of the pubis acts as

hinge and causes displacement of the inner pelvic table. Other arrows indicate the main

fragments. B. Anteroposterior roentgenogram of fracture shown in figure 74A after withdrawal of head of femur from fracture site by lateral skeletal traction through vertical

Kirschner wire in the greater trochanter. In this type of fracture, the main fragments of

the fracture do not follow the femoral head.

Extensive comminuted fractures of the entire acetabulum.—The emergency management of the patients with extensive comminuted fractures of the

entire acetabulum (cases 29, 30, and 31) was limited to measures to forestall

shock. They were evacuated from the combat zone as promptly as possible,

with the limbs immobilized in hip spicas in slight abduction.

Definitive treatment was conservative, by traction, in all cases. Skeletal

traction by means of Kirschner wire through the supracondylar region brought

the fractures of the shaft of the femur into alinement but had little effect

upon the fractures of the acetabulum. It was realistically assumed, from the

time these patients were first examined, that arthroplasty or fusion of the joint

would be necessary at later date in Zone of Interior hospitals. In each case, at the time of the 2-year followup, the joint was ankylosed and painful.
JEEP INJURIES OF HIP JOINT 269

racture-Dislocations

Classification

The 27 cases offracture-dislocation in these 58 chiefly jeep injuries of the

hip joint fall into groups when they are classified according to the standard

textbook categories:

1. Fifteen cases of posterior dislocation, with fractures of the posterior

rim of the acetabulum (table 13).

2. Eight cases of fracture-dislocation of various types, with the common

denominator of irreducibility by closed manipulation (table 14).

3. Four cases of posterior dislocation associated with fracture of the head

of the femur (table 15).

Nature of the Lesion

The necessity of performing open operation in 15 of the 27 fracture-dislocations in this group of cases provided opportunities for direct examination

of the traumatic lesion from both the anterior and the posterior aspect of the

hip joint. The description which follows is based upon the observations

made at operation:

The major damage was sustained by the acetabulum, periarticular ligaments, tendons and muscles, ligamentum teres, and retinacula of the joint

(figs. 75 and 76).

Damage to the acetabulum could be assumed to represent the first stage

of fracture-dislocation of the hip joint. It was particularly likely to occur if

the hip was in abduction and the knee was flexed, so that the knee received

the full force of the dashboard blow and transmitted it proximally to the

acetabulum. The second stage of the injury, the excursion of the head of the

femur, explained the tearing of the soft parts of the joint and the laceration of

the periarticular structures.

Damage to the posterior rim of the acetabulum ranged in magnitude

from insignificant bruises or chip fractures, which can be assumed to be present

in practically all ordinary dislocations (p. 258), to fractures in which small

fragments of the edge of the cotyloid labrum were separated and more extensive

fractures, with disruption of large, crescent-shaped pieces of the articular

cartilage and wide areas of the posterior and superior portions of the acetabulum

associated with massive disruption of the whole width of the horseshoe-shaped

articular cartilage. Since less than half of the head of the femur normally lies

outside the bony acetabulum, the integrity of the posterior and superior portions of the rim appeared to be of increased importance to the stability of the

hip after many of the supporting structures in the capsule had been ruptured.

Small fragments from the edge of the rim of the acetabulum usually

contained little or no articular cartilage but were coated with cotyloid ligament on two sides. Frequently, they lay free in hematoma in or around

the joint cavity or were attached only by few fibers of periosteum or ligament.

Larger fragments, measuring centimeter in diameter on one aspect or the
270 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

—Fractures 13.

of

posterior

rim

of

acetabulum with

reducible posterior dislocations of

hip

Case No.

Age

Other

injuries

of

ipsilateral

extremity

Treatment

after

closed

reduction; operative

findings

Weighthearing

2-year results

32

28

Fracture,

upper third

tibia

and

Open

reduction, internal

fixation;

small

Monthsafter

injury

Excellent;

occasional

minor

33

26

fibula.

bone

chips

removed.

Open

reduction, internal

fixation;

extensive

pains. Good;

occasional

minor

pains.

34

25

comminuted

fracture,

acetabulum;

large

fragments

replaced, small

chips

removed.

Open

reduction, internal

fixation;

large

single

Excellent.

35

22

Contusion,

knee

fragment. do

Do.

36

33

“Bumper

fracture,” upper tibia

Open

reduction, internal

fixation;

large

Good;

occasional joint

pain.

37

25

and

fibula.

fragments

comprising

entire

superior

and

posterior

rims.

Open

reduction, internal

fixation;

large

frag0)

Unknown.

38

25

Supracondylar fracture,

femur

ment

replaced;

small

fragments

of

inferior

rim

excised. Open

reduction, internal

fixation;

large

frag0)

Do.

39

24

Lacerated wound,

prepatellar

ment

replaced. Traction,

weeks;

imperfection reduction

12

Poor;

early

degenerative

ar40

25

region. Compound

dislocation,

tarso-

(X-ray). do

10

thritis. Do.

41

25

metatarsal joints.

do

0)

Unknown.

42

25

do

Do.

43

29

Lacerated wounds,

leg

and

knee

___ do

Do.

44

25

Excision,

comminuted

fractures

of

rim;

large

Fairly

good;

occasional joint

fragment

without

soft-tissue attachments;

corrugated

articular

cartilage;

small

chips.

pain;

early

degenerative

changes.
JEEP INJURIES OF HIP JOINT 271

45

22

Excision,comminuted fractures

of

rim:

Fairlv

vood:

occasional

ioint,

small

intra-articular

fragments.

pain.

46

19

Lacerated wounds,

knee

Excision,

comminuted

fractures

of

rim;

large

Poor;

avascular

necrosis,

head

and

small

chips

detached from

viable

soft

of

femur.

parts.

Unknown.

Table

—Comminuted 14.

fractures

of

acetabulum with

irreducible dislocations of

hip

joint

Case No.

Fractures

(X-ray)

Other

injuries

of

ipsilateralextremity

Definitive treatment

Chief

operative

findings

Complications

2-year results

47

Seven

fragments,

posteLacerated wound,

knee

Arthrotomy,

anterior

iliofemoral

approach;

fragMinor

subchondral

comSciatic

neuritisPoor;

painful

hip.

rior

or

rim,

distributed

pression

fractures,

head

in

and

around joint.

ments

excised.

femur.

M8

Four

fragments,

posterior

rim,

folded

into

joint.

___do_

Posterior soft

parts

macerated

and

tom.

Fairly

good.

49

One

large

and

three

small

fragments in

and

Severe

contusion,

knee

_do

Massive

hemorrhage

into

reflected

capsule,

hip

Poor;

arthrodesis.

lapse

head

femur.

around joint.

joint.

250

Multiple

fractures,

acetabulum

and

pelvis.

Contusion, iniurv

knee

Vertical

skeletal

tractionDo.

turn.

151

do

Fracture, patella

None

___do.__

Death,

head

injury.

Massive

retroperitoneal and

subdiaphragmatio

hem52

Multiple

fractures,

acetabulum

and

pelvis;

Vertical

skeletal

traction--

orrhage

found

at

autopsy.

Poor;

arthrodesis.

throsis,

both

knees.

rectum. Traumatic

separation

of

symphysis

stricture

posterior urepubis.

thra.

Hematuria.

53

do

do_

Open

reduction,

anterior

iliofemoral

approach;

vertical

skeletal

traction.

Poor;

Vitallium cup

arthroplasty.

periarticular

soft

parts.

54

Displacement, inferior

Avulsion

and

ischemic

Open

reduction, internal

Inferior

rim

and

superior

Peroneal

palsy;

thromboUnknown.

and

posterior

rims

slough,

skin,

dorsum

of

fixation,

posterior

apramus ischium

formed

phlebitis.

across acetabular

fossa.

leg.

proach.

single

large

fragment,

displaced

toward

and

obliterating acetabulum.

Two

unsuccessful

closed

manipulations.

Three

unsuccessful

closed

manipulations.
272 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

—Fractures 15.

of

head

of

femur

with

posterior dislocation

of

hip

joint

Case No.

Age

Fractures (X-ray)

Other

injuries

of

ipsllateral

extremity

Definitive treatment

Weightbearing

Complications

2-year results

55

25

Avulsion

fracture,

inferior

Posterior dislocaReduction; traction, weeks.

Months

after injury 12

None

Good;

occasional minor

pain.

head;

fragment

attached

to

ligamentum

teres.

tion,

knee.

66

25

Slightly

displaced, extensive,

impacted

fracture,

entire

head.

do

Degenerative arthritis.

Fair;

painful

hip.

57

25

Slightly

displaced,

extensive,

impacted

fracture,

entire

head;

inferior

portion

impinged

on

anterior

rim,

acetabulum.

Arthrotomy, anterior

iliofemoral approach;

resection

anterior

inferior

head.

do

Do.

68

25

do_.

Fracture,

patella.

Traction,

weeks

do

Poor; severe pain.
JEEP INJURIES OF HIP JOINT 273

Figure 75.—Arthrotomy for fracture of posterior rim of acetabulum. Limits of exposure in posterior approach to injured joint. Sketch shows fracture in posterior rim of

left acetabulum and posterior joint capsule. [From The Journal of Bone and Joint Surgery,

vol. 30-A, pp. 699-727, July 1948.]

other, were usually attached to strips of capsule, and thin arcs of articular

cartilage could be seen on their inner aspects. Only large fragments, approximately to cm. long, were broadly attached to the capsule. These bled on

curettage and could be assumed to have sufficient blood supply to survive

when they were replaced. The larger the fragment appeared in the roentgenogram, the more articular cartilage could one expect to find upon it at

operation.

In addition to the changes listed, comminuted fractures of the rim of the

acetabulum were always accompanied by extensive, contused, lacerated wounds

of the posterior soft parts.

In almost every injury in this series, the parietal or external portion of the

capsule,rather than the visceral or reflected portion, sustained the major damage. This is significant observation, since it is the visceral portion of the

372572° 56——19
274 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 76.—A. Superficial anatomic relationships on posterior aspect of hip joint.

The reflection of segment of the trochanteric insertion of the gluteus maximus provides

the relaxation necessary to develop large window in this muscle. B. Demonstration of

small, deep muscles and relationships of sciatic nerve. The piriformis, when reflected

medially, envelops the sciatic nerve, and all further dissection is deep and lateral to the

short external rotator muscles of the hip. C. Demonstration of skeletal relationships,

fracture site, short external rotator muscles reflected medially, and rent frequently found

after injury in inferoposterior portion of joint capsule. [Parts and B, from Campbell,

Willis C.: Operative Orthopedics, The C. V. Mosby Company, as redrawn and modified

for The Journal of Bone and Joint Surgery, vol. 30-A, pp. 699-727, July 1948. Part

from The Journal of Bone and Joint Surgery, vol. 30-A, pp. 699-727, July 1948.]
JEEP INJURIES OF HIP JOINT 275

capsule which carries the greater part of the blood supply to the head of the

femur. When large segment of bone was detached from the rim, the capsule

was essentially intact except for single tear in the posterior portion. The

short external rotator muscles, however, sustained considerable damage; the

belly and tendon of the piriformis were stretched over the head of the femur,

which was dislocated into the fracture site. The tendon of the obturator internus was stretched over the neck. The gemelli were torn and shredded.

All of these structures were so infiltrated with blood and so matted together

with fibrinous exudate and granulation tissue when the patients were seen at

general hospitals that dissection was difficult, if more than weeks had elapsed

since injury.

The head of the femur could bo examined thoroughly at operation by rotating it through its range of motion in all directions at the fracture site. Almost every inspection revealed some damage to the articular surface of the head,

though many of the lesions were small and not visible roentgenographically.

Some fractures of even greater magnitude had not been demonstrated in

anteroposterior views alone and, of course, were not demonstrated in films

made by routine or imperfect techniques.

In cases in which therim had been fractured, lunate-shaped indentations

were seen in the anterior aspect of the head of thefemur and presumably represented cleavages caused by the edge of the rim. In subchondral compression

fracture, circular, flat depression cm. in diameter was noted on the anterior

aspect of the femoral head, almost as if it had been tapped by mallet. The

surface of the bruised cartilage was dotted with spots the size of pinhead and

of uniform distribution, which represented the tufts of granulation tissue known

to form early in the process of repair.

In cases in which the posterior portion of the acetabulum had been removed, the ligamentum teres was found stretched and frayed. Complete

visualisation was possible in only of these, in both of which disarticulation

of the hip was necessary. In both of the cases, the ligamentum teres had been

torn across. In the third case, in which complete visualization was not possible, it may have been only stretched. In many instances, the excursion of

the femoral head was not as great as the roentgenograms had suggested.

Blood clot and organizing hemorrhage were observed in the retinacula in

cases, in of which this structure was completely infiltrated with large,

subsynovial, dark-red blood clot. The significance of these findings was not

realized until year later, when the records were reviewed in preparation for

this presentation, and the roentgenograms in both cases showed avascular

necrosis of the head of the femur.

Management

In distinct contrast to dislocations without fractures, which responded

readily to conservative measures, the management of fracture-dislocations was

often complicated and difficult. The dislocation presented one set of problems

and the fracture another. Each required different management. The presence
276 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

of the fracture always prevented reduction of the dislocation. When the dislocation was reduced by closed manipulations, the fracture remained displaced.

If the fracture was extensive, open reduction and internal fixation were required

before an acceptable repair could be secured. Obviously, the end results in

these cases of fracture-dislocation could not be expected to be better than the

end results of dislocations without fractures or of fractures without dislocations.

Some cases in each category of fracture-dislocations were treated conservatively and some by open operation, the decision depending upon (1) the

surgeon’s clinical judgment and experience, (2) his evaluation of the individual

cases, (3) the physical and tactical circumstances in which treatment had to be

carried out, and (4) the results obtained from conservative treatment, which

was usually, though not invariably, given trial. As experience was accumulated, the decision to resort to surgical treatment promptly in certain types of

fractures was arrived at more readily and withless anxiety than early in the war.

Posterior dislocation with fracture of posterior rim of acetabulum.—In all

posterior dislocations associated withfractures of therim of the acetabulum, the

dislocation was reduced by closed manipulation, just as the 15 simple dislocations in this series had been reduced, and with as little difficulty. The management of the fracture was another matter. In instances, its

existence does not seem to have been recognized when the reduction was done.

In several other instances, its extent was not appreciated by the surgeons who

administered emergency treatment and manipulated the dislocation. This is

easy to understand. Unless crepitation was present or the rim fragment was

very large and consisted of the entire posterior aspect of the joint, as it occasionally did, physical examination did not reveal the presence of the fracture.

Furthermore, roentgenologic interpretation was often difficult because no one

had had experience with this type of injury. Unless one knew the roentgenologic anatomy of the hip joint intimately and in detail, the fracture was likely

to be obscured by the head of the femur in the roentgenograms taken before

reduction. Even when it was evident in postreduction films, false idea of the

apposition of the fracture lines was sometimes conveyed, if only the anteroposterior roentgenograms were examined. true picture of the displacement

of the rim fragments was best obtained in postero-oblique view, with the

patient lying supine on the cassette and the injured side tilted 60 degrees. In

this position, the posterior portion of the acetabulum could be visualized in

profile.

In of the 15 posterior fracture-dislocations, the hip was suspended in

traction for weeks, in Thomas splint with Pierson attachment. In of

these cases, the method of treatment was dictated by circumstances. The

patient had head or abdominal injuries which took precedence over the hip

injuries. In the remaining cases, the fractures of the rim, although they were

larger than chip fractures or avulsion fractures, were still not extensive enough

to affect the stability or the range of motion of the joint.

Quadriceps, hip flexion, and abduction exercises were begun weeks after

injury. Weight bearing was not attempted during the approximately weeks
JEEP INJURIES OF HIP JOINT 277

these patients were under observation overseas. At the end of this period,

when they were evacuated to the Zone of Interior as litter patients, they had

no special complaints to indicate joint irritation, but there was, in each case, approximately 25-percent limitation of motion, and internal rotation of the hip

was associated with some muscle spasm.

Ten other patients with dislocations associated with fractures of the rim

of the acetabulum were treated by arthrotomy, after the dislocation had been

reduced by closed methods. In seven cases in which the fragment of the rim

was large, viable, and attached to the parietal portion of the capsule, the fracture was reduced and immobilized by internal fixation with screw (figs. 77,

Figure 77 (case 34).—A. Postero-oblique roentgenogram showing posterior dislocation

of hip with fracture of rim of acetabulum and displacement of fragments. large fragment

from the rim, with its capsular attachment, lies above the head of the femur. B. Anteroposterior roentgenogram of fracture and dislocation shown in figure 77A, years after open

reduction and internal fixation. Arrow indicates ossification of attachments of joint capsule

and small muscles.

case 34, and 78, case 37). In the three remaining cases, (cases 44, 45, and 46)

the injury was irreparable; the main fragments were detached from their blood

supply or the articular cartilage was so severely damaged that removal of the

posterior rim was thought advisable (fig. 79).

The modern literature, including modern textbooks, was not in agreement

at the outbreak of World War II about the best approach for operations on

old fracture-dislocations of the hip. This sometimes confused the clearly defined problem of open reduction or the necessity for removal of extra-articular

bone fragments following fresh fractures of the posterior rim of the acetabulum.

In all of these cases in this series, the indications were clear cut. When large

single fragment of the posterior rim was attached to the posterior intertrochanteric region by large flap of parietal capsule, the flap served as hinge, and the
278 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 78 (case 37).—Postero-oblique roentgenogram of fracture-dislocation weeks

after closed reduction of dislocation and days after open reduction of fracture of rim of

acetabulum. Note penetration of screw through both cortices and accuracy of repair.

Both of these criteria must be met for sound fixation and good end result.

bone could readily be swung back and dovetailed into place. In such case,

although the fragment was large, the articular cartilage and cotyloid ligament

had been ripped apart and were so roughened that replacement of the fragment

would obviously have resulted only in an incongruent and perhaps painful

joint, and it was therefore removed. When multiple small fragments were

present, they were practically always lying loose or very loosely attached, and

for the most part they had no blood supply. They therefore had to be removed

to prevent ossification of the periarticular structures, migration of loose bone,

and probably, in later years, painful joint. In short, the decision as to replacement and fixation of the fragments or their excision had to be made at

operation and was made chiefly upon the presumed vitality of the bone fragments.
JEEP INJURIES OF HIP JOINT 279

The operation was performed with the patient prone, with small pillows

placed along the anterolateral aspect of the chest. The operating table was

equipped with dropleaf under the hip, so that the surgeon could use flexion

in his manipulations. The posterior approach described by Kocher, the similar

approach described earlier by Von Langenbeck, or Osborne’s modification

of these incisions was used in all cases (fig. 75). Although the number of reported surgical repairs of fractures of the acetabulum was still less than

hundred in 1944-45, several of the more recent case reports had indicated that this approach is particularly well suited to posterior dislocations associated

with fractures of the rim of the acetabulum, and it proved entirely satisfactory

in these cases.

The incision was begun along line drawn between the posterosuperior

spine of the ilium and the inferior portion of the greater trochanter. At the

latter point, it was turned distally for inches along the posterolateral aspect

of the thigh. The gluteus maximus was split along its fibers for its whole length above the line of the neck of the femur. Through this opening, the deep

fascia covering the short external rotator muscles of the hip was widely exposed

with the aid of Balfour self-retaining retractor. window inches square

was thus provided in the gluteus maximus. If larger exposure was desired,

part of the insertion of the muscle was also divided.

At this stage of the incision, the traumatic lesion in the short external

rotator muscles, the capsule, and the joint were usually visible. The joint, as

rule, was found filled with blood clots, the volume sometimes amounting to as

much as 75 cc. Removal of the hematoma exposed the fracture line and the

glistening white head of the femur.

Both sides of the fracture line were next fully exposed by section of the

tendinous insertions of the piriformis, obturator internus, gemellus superior,

obturator externus, and gemellus inferior. Stubs of all tendinous insertions

were left in situ on the trochanter for later repair. Heavy black silk sutures

were placed in each end of each transected tendon to facilitate retraction and

reflection of the short external rotators. In each one of these cases, the sciatic

nerve passed across the medial aspect of the operative field, in the plane between

the piriformis and superior gemellus, about cm. medial to the superior edge

of the acetabulum and cm. medial to its inferior rim. Reflection of the

muscles medially (fig. 76C) afforded sufficient protective covering for it. Reported variations in the course of the sciatic nerve in this region were not

observed in any of these cases.

Further dissection was limited to the region anterior or deep to the external

rotator muscles and was carried out subperiosteally, on the pelvic side of the

fracture line. In order to prevent injury to the blood supply, neither the periosteum nor the jointcapsule attached to the rim fragments was lifted from them.

Kocher, T.; Chirurgische Operationslehre. Jena: Gustav Fischer, 1897, pp. 323-327.

Von Langenbeck, Bernhard: Vorlesungen iiber Akiurgie. Berlin: August Ilirschwald, 1888, pp. 147-149.

Osborne, R. P.; The Approach to the Hip Joint: Critical Review and Suggested New Route. Brit. J. Surg. 18;

49-52, July 1930.
280 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 79 (case 46).—Posterior dislocation of hip joint with fracture of rim of acetabulum. A. Anteroposterior roentgenogram taken immediately after injury. B. Anteroposteriorroentgenogram following manipulation and reduction of dislocation. Rim fragment

remains displaced inferiorly. This position, rather than position superior and lateral to

the head, which is the usual location in displacements of the posterior rim, indicates that in

this case the capsular attachments of the bony fragment have either been subjected to

extensive injury or have been destroyed. C. Specimen of posterior rim of acetabulum removed at operation. The fragment, which was avascular and completely devoid of blood

supply, was attached to torn and twisted pedicle of joint capsule. In this case, the lost

segment amounted to almost the complete width of the acetabular cartilage. hemorrhagic

lesion of the retinaculum was also observed at operation.
JEEP INJURIES OF HIP JOINT 281

After loose chips of bone and flakes of articular cartilege had been removed, the

main fragment could always be fitted accurately into place by apposing the

dorsal edges as closely as possible. position of adduction, 10 degrees of

flexion, and slight external rotation provided maximum relaxation of the

Figure 79.—Continued. D. Anteroposterior roentgenogram years after original

injury, showing necrosis of superior segment of femoral head. E. Lateral roentgenogram

showing avascular necrosis of head of femur. Note cleavage line between necrotic and

viable portions of head. Dead bone is in process of separation and replacement by new

bone. F. Anteroposterior roentgenogram 2}i years after injury, showing additional absorption, separation, and replacement of necrotic portion of femoral head. G. Lateral roentgenogram years after injury, showing sheering of dead portion of head away from living bone,

posteriorly, at line of absorption and regeneration. In retrospect, the significance of the

hemorrhagic lesion of the retinaculum observed at operation became apparent. It had

been ignored at the time but undoubtedly furnished the genesis of the avascular necrotic

process which later occurred in the femoral head.
282 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

posterior capsule and eliminated pressure of the head of the femur on the

posterior rim, so that the circumstances for maintaining the reduction while

internal fixation was applied were optimum.

The location for the application of the screw was carefully calculated, so

that it would not be placed too near the articular cartilage. It was inserted

almost horizontally, at right angles to the plane of the fracture and was directed

somewhat superiorly. depth finder was used to make certain that it had

penetrated the cortex of the inner table of the pelvis. Bicortical penetration

(fig. 78) was necessary to secure fixation capable of withstanding the test of

cautious rotation and flexion, which were carried out at the conclusion of the

operation. Reduction of the fragments also closed the defect in the posterior

capsule. The operation was concluded by the excision of small amounts of

shredded muscle tissue, the repair of the tendons of the small deep muscles,

and closure of the wound in layers with black silk sutures.

Immediate postoperative care was instituted with the patient prone and

the hip flexed 20 degrees over pillow. Gluteal setting-up exercises were

begun as soon as the sutures were removed. At the end of to 10 days, the

patient was turned to the recumbent position, and the hip was suspended in

10 pounds’ skin traction in Thomas splint with Pierson attachment. Uncomplicated wound healing resulted in every instance in this series.

Irreducible fracture-dislocations.—Before roentgenograms were available,

the diagnosis of unreduced or irreducible dislocations of the hip was usually

established by assumption, based on failure of multiple attempts at reduction.

In most of the recorded cases, so few data are supplied that it is difficult to

determine why conservative therapy failed, beyond the fact that the injuries

are uncommon and treatment was carried out by physicians who bad had little

or no experience with them.

The eight patients in this series with irreducible fracture-dislocations

(figs. 80, 81, and 82, cases 47 through 54, table 14), all arrived in general

hospitals after at least two unsuccessful attempts at reduction had been made

in field and evacuation hospitals. Improved roentgenograms, including

stereoscopic films, at once revealed the difficulty: either the replacement of the

femoral head was obstructed by bony fragments detached from the rim or the

joint cavity had become so deformed and distorted by the injury that it could

no longer receive the head of the femur. For anatomicreasons, it was therefore

impossible to effect reduction by closed manipulation in any of these cases.

Under the circumstances, conservative therapy in traction was of limited value,

but it was employed consistently, partly for the patient’s comfort and partly

because it was necessary to retain anatomic approximation between the head

of the femur and the fractured pelvis.

In three cases (cases 47, 48, and 49) bone fragments had lodged between

the head of the femur and the jointcavity and provided an obstacle to reduction.

In one of those cases (fig. 80, case 49) an attempt was made to disengage the

fragments by pulling the head of the femur down over them and thrusting it

inward with grinding and scooping movements. These maneuvers, in addition
JEEP INJURIES OF HIP JOINT 283

to being futile, were obviously harmful to the joint surfaces. They were

therefore not employed in any other similar case. Instead, immediate open

reduction was resorted to.

The anterior iliofemoral approach was employed for arthrotomy in all

cases. In each instance, the anterior portion of the capsule was found intact, but the superior and posterior portions were stretched, frayed, and torn. Small

fragments of bone were removed, but all fragments sq. cm. or larger which

were found attached to pedicles of torn capsule or strips of the short external

rotator muscles were left in situ. In order to replace the head of the femur in

the joint, it was necessary, in addition to employing traction, to pry loose

interposed capsule, muscle, and torn tendon with the aid of smooth, flat

instrument. In case (case 49) large fragment of bone became lodged in the

acetabular fossa during the manipulations, and, to remove it, it was necessary

to make an incision in the intact anterior portion of the capsule and disarticulate

the hip. In all of these cases, however, the obstruction to replacement of the

head of the femur in the joint was not fragments of bone, but the interposition of the soft part attachments of these fragments.

In the five other cases of irreducible fracture-dislocation (cases 50 to 54)

the problem was not only the dislocation of the hip but also the extensive

fractures involving the entire acetabulum and the adjacent pelvis. In two

cases (fig. 81, case 52, and case 53) manipulations were undertaken to restore

the length of the extremity and place the head of the femur in more suitable

anatomic relationship to the pelvis. They were carried out with great caution

because therisk of injury to the sciatic nerve was fully realized. The result did

not justify the hazard.

In of the patients with disorganized hip joints, traction and suspension

were employed for several weeks, until improvement in the general condition

permitted either major reconstructive procedure or transportation to

hospital for prolonged convalescent care. In the remaining case (fig. 82, case

54) peroneal palsy developed while the patient was still in the fixed hospital.

Exploration was clearly indicated and was performed by thefollowing technique;

The hip joint was exposed through the posterior approach already described. The sciatic nerve, which was intact, was discolored by ecchymosis for

about an inch. It was stretched over large fragment of bone which represented the entire posterior portion of the acetabulum, and it seemed reasonable

to assume that the peroneal palsy was the result of compression of the nerve,

because of traction on the femur in the soft parts between the head of the

femur and the fragment of rim. The nerve was retracted medially in order to

expose the joint cavity. The head of the femur was adducted and internally

rotated beyond the normal range, and the rim fragment was retracted laterally

with bone hook. The acetabulum was obliterated by displaced, impacted

fragment of the body of the ischium. second fracture of the superior ramus

of the ischium was then found. In order to disimpact and reduce these fragments, it was necessary to mobilize and reflect the origin of the quadratus

femoris. The body of the ischium could then be pulled down, and this maneu-
284 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

ver immediately reestablished the joint cavity and permitted reposition of the

femoral head in the joint. The rim fragment was fixed in position with

single screw. Function of the hip was regained in this case, but in many similar

injuries, although the immediate surgical result may be good, fusion of the

joint or arthroplasty is necessary within few years of operation.

Posterior dislocation with fracture of the head of the femur.—Gross

fractures of the head of the femur, in contrast to minor bruises, fissures, and

subchondral fractures, are uncommon in dislocations of the hip. There were

four in this series (table 15). In two impacted fractures (cases 56 and 58)

Figure 80 (case 49).—Posterior dislocation of hip joint with comminuted fracture of

posterior rim of acetabulum. A. Postero-oblique roentgenogram shortly after injury. B.

Antero-oblique roentgenogram after closed reduction of dislocation, which was accomplished

immediately after injury. Note fragment of bone carried into acetabular fossa during manipulations. This view of the joint provided the best demonstration of the fragment and of its

relation to the head of the femur. C. Lateral roentgenogram after removal of bone fragment at open reduction, weeks after injury.
JEEP INJURIES OF HIP JOINT 285

Figure 80.—Continued. D. Bone fragments

removed from joint by anterior iliofemoral arthrotomy. The large fragment on the right was removed from the acetabular fossa. The three

smaller fragments on the left were embedded in the

posterior soft parts and were held in situ only by

shreds of capsule or cotyloid ligament. The size of

the fragments removed is in striking contrast to

the apparently slight loss of articular surface

demonstrated in figure 80C. E. Anteroposterior

roentgenogram 20 months after arthrotomy,

showing avascular necrosis of head of femur.

The patient had used crutches ever since he became

ambulatory, but this precaution did not prevent

collapse of the bone structure.

there was little displacement. In the third case (fig. 83, case 55) the antero- inferior portion of the head, including the fovea capitis fomoris and its attachments to the ligamentum teres, remained in the acetabulum. In the fourth

case (fig. 84, case 57) there was appreciable limitation of motion of the joint

underanesthesia, an observation not made in any of the other cases in this group.

Open reduction was therefore performed at once to reduce the size and diameter

of the deformed head and establish free motion as soon as possible. The following technique was employed:

The entire joint was exposed by the anterior iliofemoral approach and

disarticulation was carried out as in Smith-Petersen arthroplasty. The head
286 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 81 (case 52).—Extensive fracture of acetabulum with dislocation of hip joint.

A. Anteroposterior roentgenogram [retouched] showing fracture and dislocation, with disorganization of hip joint and separation of symphysis pubis. B. Anteroposterior roentgenogram showing patient in vertical skeletal traction after reduction of dislocation by

closed manipulation.
JEEP INJURIES OF HIP JOINT 287

Figure 81.—Continued. C. Patient in vertical skeletal traction. This was the only

position which would prevent redislocation of the head, with pressure on the sciatic nerve

and severe pain radiating down the leg. The virtue of this method of suspension was

the patient’s own comfort and the simplification of nursing care. He could actively lift

himself off the bed. Note the immobilization of the right arm and forearm in skin traction,

for the management of other fractures. The patient also had an injury to the posterior

portion of the urethra, for which urologic surgery and treatment were necessary.

of the femur was the site of an impacted stellate fracture, and the articular

cartilage was split into six segments which were separated by intermediate

areas of raw cancellous bone. The anteroinferior portion of the head protruded

from the acetabulum and was crushed against the rim. The ligamentum teres

was torn apart and was pressed into the substance of the crushed bone in the

fovea. The fractured, impacted bone which protruded from the head of the

femur was removed with sharp osteotome, and the head was thus reduced, as

nearly as possible, to its normal size and shape. The profuse bleeding which

occurred during this step of the procedure suggested that the greater part of

the circulation, or at least its capsular source, was still intact. After hemostasis

had been obtained by compresses soaked in warm physiologic salt solution, the

head was replaced and was now found to revolve freely in the acetabulum.

The management of these fractures of the head of the femur withposterior

dislocation was in accord with current trends. Such fractures must, properly,

all be regarded as serious, but the treatment instituted and the results obtained

necessarily vary with the exact type of lesion. Conservative management is
288 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

obviously preferable whenever it is possible, as it was in of these cases.

Arthrotomy with removal of displaced bone fragments is likely to be successful

only when the fracture is limited to the anteroinferior portion of the head, as it

was in the fourth case. Had the weight-bearing surface of the head been

involved, failure would have been inevitable.

Figure 82 (case 54).-—Irreducible fracture-dislocation of hip joint. A. Anteroposterior

roentgenogram showing fracture-dislocation. The body of the ischium is impacted into the

body of the ilium, and there is an associated fracture of the superior ramus of the ischium. The joint cavity is totally obliterated. B. Anteroposterior roentgenogram weeks after

open reduction of dislocation and internal fixation of fracture of acetabulum. Note that

single screw holds the posterior portion of the acetabulum in accurate position. C. Lateral

roentgenogram showing repair.
JEEP INJURIES OF HIP JOINT 289

Figure 83 (case 55).—Fracture-dislocation of hip. A. Anteroposterior roentgenogram

showing posterior dislocation of hip and fracture of head of femur. The separated segment

of the inferior portion of the head includes the fovea. It is attached to the ligamentum

teres, in the acetabulum. B. Anteroposterior roentgenogram 2% years after original injury.

The proximal fragment, which is demonstrable only with the femoral head in extreme

internal rotation, has become reattached to the femoral head and does not interfere with the

normal function of the joint.

Complications

Complications of fracture-dislocations of the hip may be either early orlate. In these 27 cases, early complications, some of which were actually part of the

original injury, included urinary-tract injuries, retroperitoneal hemorrhage,

thrombosis of the hemorrhoidal veins, thrombophlebitis, sciatic neuritis, and

sciatic-nerve palsy. Late complications encountered within period of weeks

to years after injury included ossification of the joint capsule, synovitis,

traumatic arthritis, and avascular necrosis of the head of the femur. From the

standpoint of possible late complications, injury to the soft parts proved fully

as important as injury to the articular cartilage.

Urinary-tract injuries.—Nine of the twenty-seven fracture-dislocations of

the hip joint were associated with multiple fractures and other injuries of the

pelvis, including displaced fractures of the superior and inferior pubic rami,

separation of the symphysis pubis, and dislocations of the sacroiliac joint. In

several of these cases, the urethra was obstructed or lacerated. number of

patients had symptoms evidently caused by irritation of the bladder, and, in

instance, gross bladder injury required suprapubic cystostomy. In all these

cases, treatment of the urinary-tract injury took precedence over treatment of

the skeletal injury.

Retroperitoneal hemorrhage.—Blood is probably extravasated into the

retroperitoneal space in all comminuted fractures of the acetabulum and may

diffuse upward to the under surface of the diaphragm. This observation was

372572°—56 20
290 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 84 (case 57).—Fracture of head of femur with posterior dislocation of hip joint.

A. Anteroposterior roentgenogram showing fracture-dislocation weeks after closed manipulation. Rotation of the hip was painful and the total range of motion was less than 76 percent of normal. B. Hip joint after exposure and disarticulation through anterior iliofemoral

approach. Note the impacted stellate fracture of the head of the femur, with segmentation

of the articular cartilage. The photograph has been retouched for clarity. C. Anteroposterior roentgenogram of hip joint after anteroinferior portion of mushroom-shaped

femoral head has been sculptured down to normal size at open operation, weeks after

original injury. D. Anteroposterior roentgenogram of both hips, years and months

after open operation. The head of the right femur shows normal density, but the articular

cortex is slightly irregular, and the old epiphyseal line is partially obliterated. Avascular

necrosis of the entire head of the femur probably has not occurred in this case.
JEEP INJURIES OF HIP JOINT 291

made at autopsy in case in this series (case 51), in which death occurred several days after wounding, from concurrent head injury. The possibility of

retroperitoneal hemorrhage is one of the reasons why period in traction for

to 10 days is always advisable before surgery on the hip joint is undertaken. If distention, vomiting, and fever are present in thefirst few days after extensive

fractures of the acetabulum have occurred, the possibility of retroperitoneal

hemorrhage shoidd be considered in the management of the case.

Thrombosis of the hemorrhoidal veins.—This complication, which does

not seem to have been reported previously in association with fracture-dislocationsof the hip, occurred in cases in this series. In cases, including thefatal

case just mentioned, it was transient and minor. In the third case (case 52),

massive edema of the rectum and anal orifice developed few days after the

patient had sustained an extensive fracture of the left acetabulum, complicated

by dislocation of the sacroiliac joint on the same side. There was no previous

history of hemorrhoids, and the manifestations were far more severe than would

ordinarily be observed in that condition. The edema diminished after treatment with hot compresses and disappeared entirely within weeks. There

was no recurrence within 2-year period of observation.

Thrombophlebitis.—There was oidy instance (case 54) of thrombophlebitis in the series. It was severe but was treated successfully with Dicumarol (bishydroxycoumarin). This is complication which is possibility in

all injuries of the lower extremity but is probably no more likely to occur in

injuries of the hip than in any other injuries.

Sciatic neuritis.—Four patients complained of severe pain over the lateral

aspect of the lower extremity. In each case, itbegan shortly after wounding and

persisted for several months. There was no motor weakness, and the changes of

sensation which were observed were inconsistent and followed no pattern.

Repeated neurologic examinations furnished no indication for exploration, and

it was assumed that the sciatic nerve had suffered minor damage from the dislocated femoral head or from displaced fragments of the rim of the acetabulum.

Sciatic-nerve palsy.—Attention has already been called (p. 283) to the

single case (case 54) in which the sciatic nerve was explored during open operation for an irreducible fracture-dislocation, and to the remarkable fact, in view

of the close relationship between the nerve and the displaced fragments of the

rim, that sciatic-nerve palsy did not occur almost uniformly in comminuted

fractures of the posterior portion of the acetabulum. In all such cases, the

shelf of bone which protects the nerve from the trauma of motion of the head

of the femur is missing. In this series there were no instances of permanent

damage to the sciatic nerve in the 15 simple dislocations and only instances

in the 27 fracture-dislocations. In all cases, the dislocations were irreducible

by closed manipulations (table 14).

In all cases in which it was present, the palsy was delayed phenomenon.

One patient, who had had good motor function and sensation in the foot immediately after injury, began to complain of pain and foot drop after he had

been en route for several hours from forward hospital to fixed installation.
292 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

In another instance, the foot drop became apparent after several hours of pain

which radiated down the extremity following manipulation of the dislocated

hip. In the remaining cases, the palsy appeared only after second manipulation of the dislocated hip. All cases illustrate the well-known, but as yet

inexplicable, fact that in all forms of trauma to the sciatic nerve at the level of

the hip joint, the peroneal portion is apparently more vulnerable than the remainder of the nerve. This portion is more commonly affected than the posterior tibial portion, and paralysis becomes evident sooner after injury.

Only of the surviving patients had any return of function of the peroneal nerve. The other 2, at the end of years, presented extreme atrophy of

the affected extremity and still had complete paralysis of the extensors and

evertors of the foot. The discouraging functional results are in correspondence

with those recorded in the literature, which show that return of function

is always slow and is usually incomplete if it occurs at all.

The significant feature of these instances of peroneal palsy is that in

every case it had been preceded by one or more attempts at manipulative

reduction of the dislocation. Obviously, the risk of nerve injury is so great in

these circumstances that manipulations should be avoided and dislocations

reduced under full vision at primary open operation, whenever the acetabulum

is too distorted by the injury to receive the head of the femur or there is other

evidence that manipulation will be difficult or unsatisfactory. Careful examination of even emergency roentgenograms will usually provide enough information

to determine these points.

Calcification of the joint capsule.—Ossification of the joint capsule, which

occurred in only simple dislocations without fracture, occurred in 14 of the

27 fracture-dislocations. In 12 of the 14 cases, the fracture was in the rim of

the acetabulum, and in instances it involved the femoral head. Roentgenograms revealed new bone formation in the posterior and superior portions of

the capsule, but in every instance the clinical limitation of motion of the joint

was slight. Almost all of the other patients with fracture-dislocations also

showed deposits of new bone in either the femoral or the acetabular attachment

of the capsule, but they were small and had no detectable effect on the range of

motion of the joint.

Synovitis.—A number of patients with simple dislocations of the hip

joint complained of minor aches and pains, discomfort in inclement weather,

clicking or snapping sensations in the joint, or severe pain when heavy objects

were lifted (p. 297). Similar complaints were made by number of the patients

with displaced fractures of the acetabulum (p. 302). These complaints were

almost universal in the 27 patients with fracture-dislocations, even in those who had normal range of motion. Slight muscle spasm was noted in some cases,

even when the roentgenograms showed flawless joint surfaces and no bone

atrophy. These symptoms and signs were regarded as indicative of traumatic

synovitis, and the tentative diagnosis was substantiated by the fact that in

number of cases they disappeared within year or two after injury. Whether

the other patients who still complained of them at the 2-year followup will
JEEP INJURIES OF HIP JOINT 293

eventually be rid of them, or will present traumatic arthritis or 10 years after

injury, is not possible to say. The literature is not helpful, as search of it

revealed no cases followed for these periods of time.

Traumatic arthritis.—Degenerative joint changes secondary to trauma

were observed in 12 of the 27 fracture-dislocations of the hip, sometimes within

weeks of injury and always within the 2-year followup period. Clinically, it was not possible to distinguish this complication from traumatic synovitis or

from the early stages of avascular necrosis of the femoral head. Roentgenograms clarified the diagnosis by revealing evidences of abnormal wear and tear

on the defective joint surfaces, in the form of irregularities on the articular surface opposite the defect on the injured side.

In of the 12 patients with traumatic arthritis, the defects revealed roentgenologically in the posterior rim of the acetabulum could be explained by unreduced fractures (cases 39 and 40), operative removal of bone fragments

(fig. 85, case 44), and healed fractures of the head of the femur (cases 56, 57, and 58). All of these patients complained of painful crepitations and clicking

sensations and had special discomfort when they climbed stairs or lifted heavy

objects. Some also complained of morning stiffness, pain during inclement

weather, and inability to stand for long periods without discomfort. These complaints were not easy to evaluate and in some instances seemed more closely

related to the compensation aspects of the injury than to the pathologic process.

The other patients with traumatic arthritis began to complain of severe

pain in the joint, with increasing limitation of motion, within year after

injury. All had extensive fractures of the acetabulum (table 14). Roentgenograms in every instance demonstrated irregularities and subsequent loss of

the entire joint space. All of these patients were regarded as immediate

candidates for arthrodesis or mold arthroplasty, depending upon their individual requirements. In instances (cases 49, 50, 52, and 53) it is known that these operations were done at Army or Veterans’ Administration hospitals.

Avascular necrosis of the head of the femur.—There were no instances of

avascular necrosis of the femoral head in the 15 simple dislocations in this

series (p. 261). This complication appeared, however, in patients with fracture-dislocations. In one instance (case 46, fig. 79) line of demarcation

separated living bone tissue of the femoral head and neck from an area of

increased density and necrosis in the superior portion. In this case, as already

noted (p. 275), the significance of the large blood clot present in the retinaculum

at the margin of the articular cartilage at the head of the femur was not

appreciated when it was observed shortly after injury. In the other (case 49, fig. 80), ecchymosis, new granulation tissue, and thickening of the entire

posterior portion of the reflected capsule had been observed at operation, as

in the case just described, again without appreciation of the importance of the

findings. In this case, there was nearly complete disintegration of the bony

structure of the femoral head. The observations made at operation seem to

supply sufficient evidence that avascular necrosis is associated with thrombosis

of either the retinaculum or the intertrochanteric branches of the medial
294 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Figure 85 (case 44).—Dislocation

of head of femur with fracture of

posterior rim of acetabulum. A.

Postero-oblique roentgenogram showing fracture of rim of acetabulum after

reduction of dislocation by manipulation. The posterior rim, as usual, has

not been influenced by conservative

treatment in traction and remains undisplaced. B. Anteroposterior roentgenogram of both hips showing loss of

considerable amount of posterior rim

of acetabulum on affected side, as

result of irreparable damage and surgical excision. C. Fragment removed at

open operation. The extensive damage to the acetabular cartilage and the

impacted fracture contraindicated its

replacement.

circumflex vessels. This proof is in line with the damage which can be done

experimentally (p. 255) by traction and tearing of the capsule in the posterior

intertrochanteric region.

Up to 1947, approximately 50 well-documented cases of avascular necrosis

had been encountered in total of 270 recorded posterior dislocations of the

hip joint. The lesion was usually observed within to 18 months after injury.

In the cases in this series it occurred within to 12 months. This time span

does not bear out the theories of some observers that avascular necrosis may

be late complication, occurring years or more after injury, though serial
JEEP INJURIES OF HIP JOINT 295

Figure 85.—Continued. D. Anteroposterior roentgenogram years and 10 months

after excision of posterior rim. Note irregularities and slight necrosis of surface of femoral

head, presumably due to irregular wear and tear on the articular surfaces. E. Lateral

roentgenogram showing area of degenerative changes in head of femur, corresponding to area

of fracture defect of articular surface of acetabulum. As yet, there is little if any narrowing

of the joint space. There is no evidence of avascular necrosis, and it is significant that

retinacular hemorrhages were not observed at operation. These roentgenograms should be

compared with those shown in figure 79, case 46, in which retinacular hemorrhages were

observed at operation, and avascular necrosis followed.

roentgenograms have not been studied in large enough group of cases to

determine the true incidence of the complication in adults. It is known that

it is relatively commoner in childhood and adolescence, probably because of

the larger and more vulnerable vascular network in the reflected capside at

these periods of life.

Since avascular necrosis occurs in variety of injuries of the hip joint,

the microscopic changes associated with it have been described in detail. The

literature concerning its pathogenesis is vast and highly controversial.

survey of 135 contributions published up to 1945 may be summarized about

as follows:

1. The blood supply to the superior portion of the head of the femur comes

long distance, through the reflected capsule, which receives it from numerous

branches of the medial femoral circumflex vessels in the posterior and

posterosuperior aspects of the intertrochanteric region.

The pathologic and roentgenologic appearance of avascular necrosis

in man differs from the process produced experimentally in rabbits, dogs, and

goats by surgical severance of all the arteries and veins which enter the hip

joint. In man, collapse of bone structure occurs relatively early, but

revascularization of the area and replacement of dead bone begins relatively

soon, so that there is only temporary interruption of the arterial circulation

or venous return. Repair is, however, imperfect, and the joint is permanently

defective.
296 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

3. The possibility that contusions and subchondral compression fractures

may be etiologic factors has been entertained, but the evidence is circumstantial

and inadequate.

4. The condition has been reported not only after posterior dislocations,

after which it occurred in the cases in this series, but also after anterior

dislocation and central fracture of the acetabulum with prolonged intrapclvic

protrusion.

5. Abstinence from weight bearing has been suggested as method of

prevention, but there is considerable doubt that it would be effective. One

of the patients in this series began weight bearing within months of injury,

but it was not permitted in the other case because roentgenograms showed

some loss of substance and irregularity of contour of the head of the femur.

One is forced to assume, therefore, that certain amount of necrotic bone is

crushed, independently of weight bearing, by the action of the pelvifemoral

muscles upon the head of the femur, just as happens in other ischemic and

destructive lesions of the hip.

6. There is doubt that so-called creeping bone replacement can restore

the joint structure in adults with avascular necrosis as effectively as it does in

children with Legg-Calve-Perthes disease, or in the occasional adult with an

impacted fracture of the neck of the femur.

The only treatment now available for avascular necrosis of the head of

the femur is restriction offull weight bearing. This is not practical method

for, as in these cases, there is lack of premonitory symptoms, and the prohibition usually begins only when roentgenograms show' the process in the articular

surface of the femoral head. Then the damage has already been done. Nonetheless, weight bearing should be prohibited, even after the process is established, to prevent torsion of the necrotic femoral head during the period of new

bone replacement.

Followup Studies

The value of the methods of treatment used in these 58 jeep injuries

of the hip joint can be determined only by the end results. Even with

all the resources available for tracing former military personnel, it was possible

to secure results in only 42 cases (chart 1; tables 11 to 15, inclusive). Furthermore, the followup covers only 2-year period, and there is much to be said

for the position of the observers who maintain that the results of such injuries

cannot be determined conclusively until to 10 years have elapsed. On the

other hand, although very few cases in the literature have been followed for

longer than years, as practical consideration, only traumatic arthritis is

likely to become evident after longer period.

In order to compare the results obtained in these three groups of military

injuries with those obtained in civilian practice, comparison was made with

patients treated on the fracture service of the Massachusetts General Hospital

who had sustained similar injuries in civilian life and who had been followed up

for years or more (tables 16, 17 and 18). To secure the civilian cases for
JEEP INJURIES OF HIP JOINT 297

Chart 1. Summarized results in dislocations, fractures, andfracture-dislocations ofthe hip

jointfollowed up for years or more after original injury.

YEAR FOLLOW UP 42 CASES AUGUST 1947

FRACTURE OF

HEAD OF THE

FEMUR WITH

DISLOCATION

FRACTURE

DISLOCATIONS

REDUCIBLE

10

FRACTURE

DISLOCATIONS

IRREDUCIBLE

FRACTURE

ACETABULUM

14

DISLOCATIONS

RIM OF THE ACETABULUM

REPLACED AT OPEN OPERATION

UNREDUCED FRACTURES

OF THE RIM OF THE ACETABULUM

ALL TYPES

The results are based on review of complete case histories and serial roentgenograms, supplemented by personal

letters from the patients specifying their symptoms and joint function (12 cases); personal letters and roentgenograms from

the patients or their personal physicians (6 cases); detailed examinations by Army or private physicians, including measurements of thejoint range and serial roentgenograms (14 cases); andpersonal examination of thepatients (10 cases). The

summary of results follows the method of grading used on the fracture service of the Massachusetts General Hospital,

which includes the anatomic (A), functional (F), and economic (E) results in each instance. gradeof excellentrequires

that all results be estimated as 4. grade of fairor good is applied to any combinationof grades of 4, 3, or 2. grade

of poor is applied to ratings of orless.

comparison, it was necessary to go back for period of 12 to 14 years. The

chief difference in therapy in the two series is that patients in civilian life were

immobilized for briefer periods than Army patients and were permitted earlier

weight bearing.

Dislocations

The (of 15) patients in the military series with simple dislocations of the

hip who could be followed up were compared with patients with similar

injuries treated at the Massachusetts General Hospital. The results (tables 11

and 16) were essentially similar. No immediate benefits were derived from

the extended period in traction and the extended restriction of weight bearing

practiced in the military group. Five of the nine patients in this group and

of the in the civdian group complained of slight aches and pains in the joints
298 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

—Selected 16.

traumatic dislocations of

hip

joint,

Massachusetts General

Hospital, 1931-47

House unit

No.

Age

Fractures

(X-ray)

Other

injuries

of

ipsilateralextremity

Treatment

Results

232707

11

Posteriordislocation

Sciatic

nerve contusion, temporary

peroneal

palsy.

Non-weight-bearing caliper

splint,

months.

Normal

hip

at

years.

13739

14

do

Crutches,

months

Avascular necrosis

and

complete

collapse,

femoral

head,

at

18

months.

225358

18

do

Bed

rest,

weeks

Normal

hip

at

years.

Occasional

mild

joint

pains;

330426

22

Posteriordislocation;

chip

Head

injury;

fracture,

Reduction in

Soutter

appafracture,

rim

acetabulum.

shaft

femur.

ratus;

bed

rest,

months.

normal

X-ray

at

years.

399281

22

Posteriordislocation

Hip

spica,

weeks;

crutches,

weeks.

Normal

hip

at

years.

235958

28

Anterior dislocation

Hip

spica,

weeks

Night

pain

and

slight

limitation

of

motion

at

years;

normal

X-ray.

543012

35

do

Bed

rest,

weeks

Normal

hip

at

year.
JEEP INJURIES OF HIP JOINT 299

Table 17.-

—Selected

fractures

of

acetabulum

Massachusetts General

Hospital,1938-46

House unit

No.

Age

Fractures (X-ray)

Treatment

Weightbearing

Results

493496

14

Central

fracture,

slightly

displaced

Traction,

weeks

Monthsafter

injury

Normal

hip

at

years.

78702

60

do

do

Normal

function

at

years; tires

easily

because

of

mild

pain.

Moderately

painful

hip,

narrowing

345913

64

Central

fractures;

medial

displacement, Bed

rest

320953

50

body

of

pubis

and

anterior

acetabulum,

do

do

joint

space (X-ray).

No

symptoms

at

year.

Normal

function,

slight

limitation

of

514457

40

Central

fractures;

medial

displacement, Lateral

and

longitudinal

3534G9

22

body

pubis

and

anterior

acetabulum;

intrapelvic

protrusion,

head

femur,

do

traction,

weeks.

Traction

flexion

at

year.

Normal

function,

slight

limitation

of

flexion

at

years.

Painful

hip,

moderate

ankylosis at

537224

52

Central

fracture,

comminuted,

bursting

Open

reduction

12

type.

year.
300 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Table

—Selected 18.

fracture-dislocations

of

hip

joint,

Massachusetts General

Hospital,1933-45

Unit

No.

ge

Fractures

(X-ray)

Other

injuries

of

ipsilateralextremity

Treatment

Complications

Results

523309

25

Large,

single

fragment,

posterior

rim.

Open

reduction, internal

fixation,

posterior

approach.

Sciatic

neuritis

Excellent at

years.

128308

47

Comminuted

fracture,

aceFracture,

patella.

Traction.

Peroneal palsy

Vitallium

cup,

arthroplasty.

tabulum;

displacement,posterior

rim.

104952

39

do

Acetabuloplastv

None

Hip

fusion. Fair;

degenerative

arthritis

at

years.

131819

25

do

Open

reduction,

replacement

large

fragments,

removal small

chips.

do
JEEP INJURIES OF HIP JOINT 301

at irregular intervals. In both groups, patients who did hard labor or who

worked on farms were uncomfortable when they had to lift heavy objects.

During the first few months of weight bearing, in each group complained of

pains in the joint when the weather was rainy, when they were engaged in

sports, or when they climbed stairs, but at the end of years these symptoms had

disappeared. One patient in the military group complained of night pain, for

which roentgenograms furnished no explanation. The only patient with

avascular necrosis in either series was 14-year-old boy in the Massachusetts

General Hospital group. This complication, as already noted, is more common

in adolescence than in adult life. There was no evidence of degenerative

arthritis in either group.

Fractures Without Dislocation

The 14 (of 16) patients with fractures of the acetabulum without dislocation who could be followed up in the military series were compared with

patients with similar injuries treated at the Massachusetts General Hospital

(tables 12 and 17). When like fractures were compared, the results in both

series were much the same.

At the end of years, 11 of the 14 military patients had no serious disability, though many complained of mild pain, snapping or clicking sensations

in the joint, stiffness early in the morning, and discomfort when lifting heavy

objects. Those with displaced fractures of the superoposterior rim of the

acetabulum appeared to have more symptoms and more disability than those

with anterior rim or central fractures. One patient (case 19) with an unreduced

fracture of the posterior rim had severe pain and some limitation of motion at

the extremes of normal range in all directions. Another (case 18), whose joint

was accurately repaired at operation, had normal hip. The cases were

similar in that in both the displaced rim fragment was relatively large. The

assumption is that when the fragments were thin and small and carried less

articular cartilage with them as disruption occurred, the important function of

the joint was not affected, regardless of whether the fragments were or were

not replaced. The patients with extensive fractures of the acetabulum and

destruction of the joint cavity (cases 29, 30, and 31) had ankylosis and complete

disability years after injury and were thus candidates for arthrodesis or

arthroplasty. Neither avascular necrosis nor degenerative arthritis was

present in any instance of fracture without dislocation at the end of years.

It is unfortunate that the single patient in the military series with an

intrapelvic protrusion at the head of the femur could not be followed up.

There were such injuries in the comparative series from Massachusetts

General Hospital, both of which were treated by the plan employed in the

single case in the military series. Neither of the civilian patients had any

disability at the end of year and years, respectively. It is difficult to

understand why, in this type of central fracture, with intrapelvic protrusion of

the head, healing could occur without functional disability, regardless of the

displacement of the inner table of the pelvis. The explanation may be that in
302 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

these successful cases the fracture affects the anterior rim of the acetabulum,

which is nonessential part of the joint, while the posterior and superior

portions of the horseshoe-shaped articular cartilage, which are vital to function,

are spared. On the other hand, when intrapelvic protrusion of the femoral

head is associated witli extensive fractures of the acetabulum and bursting of

the triradiate seam of ilium, ischium, and pubis, or with distortion of the rim of the acetabulum, the functional results, as might be expected, are poor.

Classification of these injuries into these two categories would do away with

the difficulty in explaining the discrepancies in results reported in the literature.

Fractures With Dislocation

The 19 (of 27) patients with fracture-dislocations of the hip who could be

followed up for years were compared with patients with similar injuries

treated by similar methods at the Massachusetts General Hospital (tables 13

to 15 and 18). It is interesting that, over 12-year period at the civilian

hospital, it was possible to locate only patients with this sort of injury, while

several times as many had been observed over an 18-month period in single

military-hospital center.

The civilian patients showed, variously, excellent results, fair results,

and, in cases, poor results, with hip fusion necessary in one and mold arthroplasty in the other. In the military series, the results were also varied. Dislocations without displacement of fragments or associated with only minor

fractures of the rim of the acetabulum showed, as would be expected, results

which did not differ from the best and worst results observed in uncomplicated

dislocations. Most of the patients, presumably because of scarification in the

synovial membranes and the joint capsule, complained of aching pains, morning

stiffness, and snapping of the hip, just as the patients with simple dislocations.

In both groups of cases, the integrity of the lunate acetabular cartilage and of

the rim of the acetabulum was presumably the critical factor in the end results.

In matched cases of fractures treated conservatively and treated by open

operation, good function and little or no disability were accomplished when the

joint surfaces were restored as precisely as possible, but one could be certain

that this had been achieved only when open operation had been done.

Dislocations which were reduced, associated with significant fractures of

the rim of the acetabulum which were not reduced, gave, for the most part, fair

to poor results after surgical removal of the entire posterior rim. Late degenerative changes in the joint were the rule. When, however, single large

fragment of the posterior or superior portion of the acetabulum had been

detached and could be replaced precisely, with the capsular attachment intact,

the results were excellent and were fully as satisfactory as the results of uncomplicated dislocations without fractures (fig. 86, case 32). Comminuted fractures

which disrupted the acetabulum produced serious disability, and arthrodesis or

arthroplasty was required in almost every case within years.

In all cases in which fracture-dislocations were associated with distortion

of the femoral head, slowly progressive degenerative changes occurred over the
JEEP INJURIES OF HIP JOINT 303

2-year followup period (table 15). One patient, whose injury was limited to

the anteroinferior portion of the head, had practically normal function and in the other cases, in which the entire head was involved, the range of motion

was still useful.

Traumatic arthritis occurred in 12 patients during the period of observation (p. 293) and avascular necrosis in others (p. 293).

Figure 86 (case 32)—A. Anteroposterior roentgenogram showing central fracture of

posterior rim of acetabulum and inner table, with posterior dislocation of hip joint. B.

Anteroposterior roentgenogram of fracture and dislocation shown in figure 86A, after manipulation and reduction of dislocation on day of injury. Note that posterior rim fragment

remains widely displaced and unaltered by treatment of dislocation. C. Anteroposterior

roentgenogram of fracture and dislocation shown in figure 86A and B, weeks after injury,

after open reduction of fracture and internal fixation with single screw.

Prognosis

At the end of years of observation, the results in the 42 Army patients

with dislocations, fractures, and fracture-dislocations of the acetabulum who

could be traced corresponded closely with the results in the 18 similar patients

studied comparatively from the fracture service of the Massachusetts General

Hospital. The conclusion seems warranted that except in fractures of the

posterior rim treated promptly by primary open reduction and internal fixation;
304 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

the nature and magnitude of the traumatic lesion, and not the technical procedure, determines the final outcome.

The experience gained in the management of these cases supports the

impression derived from survey of the literature that the seriousness of

fracture of the acetabulum depends upon whether the superior or the posterior

portion of the lunate articulate cartilage has been injured. In the past, the

tendency was to accept the imperfect results of conservative therapy because

of the formidable nature of surgical management and also because there was

no understanding of late degenerative changes in the joints. Now that the

Army experience in World War II has shown the possibility of these changes,

as well as the better results possible with surgical management in properly

selected cases, there should be more willingness to adopt the principle that reposition of the bony fragments is as necessary in injuries of the hip joint as

it is in injuries of other weight-bearing joints.
372572°—56 21 305

CHAPTER XX

Injuries of the Knee Joint

Mather Cleveland, M. D.

In the European theater, as in all other theaters, wounds of the knee

joint presented major problem. They were relatively frequent battle injuries, but none of the surgeons who were obliged to handle them had seen, in

civilian practice, sufficient number to standardize treatment, nor had they teamed from personal experience the precautions and safeguards to prevent

the development of infection. Furthermore, the devastating type of battleincurred injury of the knee joint observed in military surgery does not occur

in civilian practice. Suppuration of the joint was always the most dreaded

complication of wounding, and all treatment was directed toward its prevention. Improper or inadequate care could mean the loss of the limb, and even

death from sepsis.

Nature of the Injury

The most frequent cause of wounds of the knee joint was shell fragments,

followed in order of frequency by bullets, fragments of rock or gravel, wooden

splinters, and pieces of plastic from certain type of German land mine.

Other varieties of plastics, as well as wood fragments, were seldom encountered. The latter varieties of foreign bodies were readily overlooked because

of the difficulty of visualizing them by roentgenograms. Rock and gravel

were seldom driven into the joint by force of an explosion or the impact of

missile, unless the knee was in close contact with the ground.

The amount of initial damage which penetrating fragment inflicted

upon the joint depended in large measure not only on the size of the object

but also on the velocity of its penetration. small fragment, which had

barely penetrated the joint and which had produced, according to roentgenologic evidence, little damage to the bony structures sometimes caused fulminating suppuration, depending upon the material which it carried in with it

and the judgment with which the injury was managed.

Penetrating injuries of the knee joint were either direct or indirect. They

were direct when the missile itself entered or perforated the joint. They were

indirect when the missile fractured the femur, the tibia or the patella and thus

established communication between the synovial cavity of the joint and the compound fracture. Single or multiple structures could be damaged in either

type of injury.

The material in this chapter was secured from two reports made to the senior consultant in orthopedic surgery in the European Theater of Operations, one by Lt. Col. James E. Thompson, MC, Maj. William H. Cassebaum, MC,

and Capt. (later Maj.) Charles F. Stewart, MC, of the 9th Evacuation Hospital; and the other by Maj. (laterLt. Col.)

Louis A. Goldstein, MC, of the 19th General Hospital.
306 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Indirect injuries took wide variety of forms. Sometimes single long

fracture in remote part of the shaft extended through the condyles into the

joint. Frequently the indirect injury was compound fracture of the patella,

which was likely to be overlooked because of the difficulty of demonstrating,

by roentgenograms, fracture lines extending into the joint surface. Unsuspected penetration of the joint was often discovered at operation when the

compounding wound was at considerable distance from the knee joint and

the missile also lay at some distance.

Although the capsule and collateral ligaments of the medial and lateral

aspects of the joint, together with some of its tendons, were frequently damaged, the damage was seldom of considerable extent. On the anterior aspect

of the knee, there was greater opportunity for penetration. The capsule in

that area is normally much laxer, to allow greater mobility, and the suprapatellar pouch extends for some distance above the level of the joint.

Small and compact patellar ligaments were often severed or almost completely destroyed by the passage of fragment of any size. The lateral expansions of the larger quadriceps tendon, which blend with the capsule, made

damage to this tendon less of problem of management. Because of its

structure, retraction was minimized and future function more readily resumed.

missile which entered the knee on the mediolateral aspect and lodged

in the condyle of the femur might not have traversed the joint before reaching its destination. An accurate knowledge of the anatomic reflection of the

synovial membrane at that point was necessary before any opinion coidd

justifiably be expressed. fragment which had passed through one condyle

might damage it only slightly but might completely demolish the other condyle.

The main vessels and nerves to the lower extremity, because they lie in

the popliteal fossa, are safely protected from ordinary forms of injury, but

they were so frequently injured by penetrating wounds about the knee that

their integrity was suspect in any wound in the area. This was particularly

true of the popliteal artery, injury to which took precedence over the treat- ment of any other injury. Damage to the vessels almost invariably meant

loss of the limb; reparative procedures were seldom satisfactory. Damage to

the nerves, if the injury was irreparable, resulted in paralyzed limb, even

if the blood supply remained intact.

Diagnosis

Diagnosis of injury of the knee joint was based on combination of clinical and roentgenologic evidence. The experience of the surgeon, combined with his knowledge of the regional anatomy, often provided considerable part of

the proof. Many times the question of whether or not the joint was penetrated was not settled until operation. In such cases, exploration was actually

part of the diagnostic routine.

Motion in the wounded joint was likely to be limited and painful. Local

tenderness could be elicited at various points. There was always an evident
INJURIES OF THE KNEE JOINT 307

excess of intra-articular fluid, which was usually bloodstained on aspiration.

The amount present was usually in direct proportion to the severity of the

injury.

Roentgenograms could be misleading because they showed only bony

damage. They did not demonstrate cartilaginous coverings of the condyles,

and it was therefore necessary to bear in mind that the profile of the femur

or tibia observed in the joint was the representation of the cortex of the underlying bone and provided no information about the state of the cartilage.

When adequate exposure was obtained at operation, it was often surprising

to see the extent of the damage to important cartilaginous structures that had

been completely invisible on the roentgenograms.

Evaluation of the damage to the knee joint was based on the relative

importance of the structures damaged. Damage to the cartilaginous structures of the tibia! and femoral condyles and the inner surfaces of the patella was

of major importance. Damage to the menisci was of almost equal importance.

Damage to the synovial membrane and the cancellous bone of the condyles

was of lesser importance. These structures are rich in blood supply and therefore offer more resistance to infection than cartilage, which is notoriously

poor in blood supply, and which, when it was detached and devitalized, served

as an excellent nidus of infection.

Initial Wound Surgery

Treatment of injuries of the knee joint fell into three categories, as follows:

(1) First aid, given in forward aid stations; (2) initial wound surgery, performed in the evacuation hospital or, occasionally, in the field hospital; and

(3) definitive surgery, performed in the general hospital in the rear.

First aid consisted simply in the control of bleeding, if that was necessary;

the application of Thomas splint, if it was available, otherwise of some other

form of immobilization; and, until it was forbidden late in the war, the local

application of sulfanilamide crystals to the wound. Until late in the war,

each soldier was provided with sulfonamide pills which he was supposed to

take, if he was conscious, as soon as he was injured.

If the knee injury was associated with vascular injury, which always

demanded immediate attention, the casualty was cared for in field hospital

unless there was an evacuation hospital in the immediate vicinity. In the

great majority of injuries of the knee joint, initial wound surgery was performed in an evacuation hospital, in which these wounds had high priority.

Consultants and experienced traumatic surgeons lost no opportunity to emphasize to more inexperienced officers that the ultimate outcome of the injury

was decided in the forward hospital. The treatment the soldier received at

this point would determine whether he would recover with normal joint or

stiff joint, whether he would lose his limb, or whether he would lose his life

as the result of prolonged sepsis.

If vascular injury was present, it was always attacked first, regardless
308 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

of the amount of damage to the knee joint. Otherwise, whatever the nature

of the injury, the first procedure was debridement of the soft tissues and the

joint. An occasional officer believed, until the end of the war, that perforating

wounds caused by high-velocity missiles, with only small wounds of entrance

and exit and no demonstrable bone damage, did not require arthrotomy.

This was not official policy, and it was not sound policy. The only safe plan,

when penetration of the knee joint had obviously occurred or was suspected,

was to open the joint and determine, by direct inspection, the conditions

present. This policy held whether the injury was direct or indirect and regardless of the size of the wound.

Technique of debridement.—Operation on the joint was best performed

with tourniquet in place, so that the intra-articular structures would not be

obscured by troublesome bleeding. The incision into the joint was sometimes

made through the original wound; when it was on the medial, lateral, or posterior aspect of the knee, this was frequently possible. Most often, however,

the original wound was merely debrided, either at the beginning or the end of

the operation, and the exploratory incision was separate and elective.

The incision of choice was long medial or lateral parapatellar incision,

which was regarded as giving the most satisfactory exposure. If satisfactory

operation could not be performed through one incision, another was made on

the opposite aspect of the patella. At times it was necessary to combine

medial or lateral parapatellar incision with posteromedial, posterolateral, or

posterior midline incision, in order to care for damage in the posterior compartment of the knee joint. The trauma caused by multiple incisions was insignificant in comparison with the bad effects of inadequate surgery.

If the foreign body lay in the condyle of the femur, the approach of choice

was through the lateral extracartilaginous portion. If it had entered the

cartilage, the direct approach to it was usually best.

When the joint was entered, fluid and blood clots ere evacuated, and the

cavity was thoroughly irrigated with warm physiologic salt solution until the

fluid returned clear. Then the extent of the damage was determined by

inspection and palpation. If exposure was not adequate, the incision was

extended or another was made.

Thorough debridement of the joint was the keystone of the whole operation. It had to be both careful and complete. The initial irrigation removed

only blood clots, free bits of cartilage, and other debris from the recesses of

the synovial cavity. Then all loose and devitalized portions of articular

cartilage, bone, and menisci were removed. Traumatized surfaces were

debrided down to healthy tissue with knife or curette; leaving devitalized

cartilage and bone fragments in the joint was an invitation to suppurative

arthritis.

Whether penetration of the knee joint was direct or indirect, the damaged

articular elements required exactly the same careful excision.

Snug closure of all synovial defects, whether traumatic or surgical, was

mandatory. Leakage after operation invited ascending infection. The syno-
INJURIES OF THE KNEE JOINT 309

vial membrane, like the peritoneum, has great capacity for resisting infection, but once infection is established in the joint, this resistance is no longer effective. With these principles in mind, the policy was to close the synovial

capsule and membrane so tightly that leakage coidd not occur.

Large defects in the capsule, especially in the medial and lateral aspects,

introduced special problems in closure which demanded special techniques.

Anything was preferable to leaving the wound in the joint open. If large

capsular defects were not closed initially, the risk of infection was always

present, and it was usually impossible to close them successfully later by any

form of surgical procedure.

Plastic procedures often made prompt reconstructive surgery possible and

allowed the patient to recover such joint function as was compatible with the

degree of articular damage. Frequently, the best that could be done was to

approximate the synovial membrane and capsule as completely as possible,

then cover the remaining defect with one or more sliding grafts of skin and

subcutaneous tissue from the adjacent area. Results were usually excellent

with this technique, while closure under tension inevitably resulted in breakdown of the wound. If capsular substance had been lost and not enough deep

tissue was available to cover the defect, closure with skin was attempted,

relaxing counterincisions being made if they seemed necessary.

After closure, penicillin solution (10,000 units in cc. of physiologic salt

solution) was injected into the joint cavity, preferably through needle previously passed through the anterolateral aspect beneath the patella and known

to be in the joint cavity. less desirable technique was to close the synovial

membrane around small catheter or cannula, make the injection through it, and then, after it was removed, seal the opening with purse-string suture.

The soft tissues and skin were left open, as in the usual debridement, and

the wound edges were separated with light, loose packing of dry, fine-mesh

gauze.

After operation, the knee was immobilized in hip spica. Many surgeons

at this time cut large anterior window into the plaster to permit direct access

to the joint for inspection and treatment. modified Tobruk splint was also

satisfactory for transportation splinting.

Whenever penetrating wound of theknee jointwas diagnosed or suspected,

penicillin in 25,000-unit doses was instituted routinely every hours. Sulfadiazine was usually added after initial wound surgery. Treatment by this

routine was continued until after definitive surgery had been performed in

general hospital.

Other techniques.—Penetrating wounds through the patella which had

produced extreme comminution were best treated by complete excision of the

patella. After debridement of the joint, the synovial membrane and the

capsule were closed in the midline.

When destruction of the femoral and tibial condyles, or both, was so

complete that restoration of the joint was obviously impossible, the wisest

plan was to proceed at once with primary resection. This course was justified,
310 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

however, only if the structures were so hopelessly destroyed that reparative

surgery offered no possibility of securing functioning joint.

If the injury was such that it was not possible to seal off the joint cavity

without internal fixation of the fracture, hip spica or Tobruk splint was

applied and the patient was dispatched to the rear as soon as his condition

permitted. This type of problem was not suitable for management in an

evacuation hospital but was, instead, the responsibility of general hospital.

Treatment in the General Hospital

As rule, patient in good general condition could be evacuated in plaster

to general hospital within 48 hours after debridement. Here, the next phase

of treatment was instituted. The knee was examined for excess fluid, which

was usually present. The fluid was aspirated and the joint irrigated with

physiologic salt solution, introduced through one or two needles. When the

irrigation had been concluded, penicillin solution (10,000 units in cc. of

physiologic salt solution) was introduced into the joint. This procedure was

repeated at 24- to 48-hour intervals, depending upon the temperature reaction,

the degree of edema in the tissues, the character of the fluid from the joint,

and the patient’s general condition. If for any reason the patient could not

be evacuated, the procedure just described was carried out in the evacuation

hospital.

Delayed primary closure of the skin was performed anywhere between

the 4th and 10th days, depending upon the local condition of the wound and

the presence or absence of joint complications.

If the patient could not be evacuated within weeks, remedial regimen

was begun while he was still in traction, the exact time depending upon the

circumstances of the individual case. In the occasional case in which the

joint had not been opened, movement was begun within few days after

wounding. If arthrotomy had been performed but no fracture was present,

exercise was begun as soon as the wound had healed, which was usually within

or weeks. If fracture was present, movement usually had to be deferred

for somewhat longer period, depending upon the type and location of the

fracture and its current status.

The chief emphasis was on quadriceps-setting exercises. Failure to

employ them for all patients with any kind of disability of the knee accounted

for many inferior results. This was not, however, always the fault of the

orthopedic staff. When admissions were at peak, casualties with bone and

joint injuries had to be dispersed to other surgical wards and to medical wards, and trained personnel was not usually sufficient to supervise them.

Suppurative Arthritis

If an infection of the soft tissues did not involve the joint capsule or communicate with the joint, the end results of joint surgery were unlikely to be
INJURIES OF THE KNEE JOINT 311

affected by it. Suppurative arthritis, however, was constant hazard in

military practice in all joint surgery and was the most dreaded complication

of penetrating wounds of the knee joint. normal joint was almost impossible

of attainment after it had occurred. If the infection persisted for any length

of time, extensive destruction of cartilage and bone was almost inevitable.

In earlier wars, amputation was often required to save the patient’s life.

With the improved technical methods and efficient drugs available in World

War II, deaths were rare and amputation was almost never necessary, but the

functional results were none too good.

Suppurative arthritis usually appeared within the first week after operation or injury. The patient first complained of extreme discomfort in the

joint, then of excruciating pain on the slightest movement. Swelling and

tenderness were progressive. The rise in temperature was often abrupt. If

the rise was gradual, the fever reached peak of 103° to 104° F. within few

days and then rapidly assumed septic (picket fence) characteristics, with the

trend generally upward.

All military experience has proved that there is no satisfactory method of

draining the knee joint. Some surgeons attempted it by the use of two large

parapatellar incisions, with third incision behind the medial ligament and

fourth just posterior to the lateral ligament. These relieved the tension of

the purulent exudate, but pools of it still remained in the deep recesses of the

joint and film was maintained between the surfaces in close contact, where

it was held by capillary attraction between the condyles and between the menisci

and the condyles. It is at these points of contact between bones that the

earliest destruction of cartilage occurs in suppurative arthritis of the knee joint

and that the greatest damage occurs as the lesions advance. The medial

femoral condyle is usually the first affected.

What the French termed secondaryresection, to distinguish it from primary

resection of the knee joint practiced immediately after injury, was employed

in an occasional case of suppurative arthritis of the knee joint. The French

had employed this procedure even before World War I, but American surgeons

were slow to take it up in World War II. To cut through infected soft tissue,

bone, and cartilage, and to disturb areas of resistance seemed violation of

surgical principles, even though the objective of the operation was to shorten

the septic course by removing feebly resistant cartilage, as well as infected

bone and synovia. Once these structures had become infected, infection was

likely to be persistent. Life and limb could therefore bo saved by accepting

the fact that suppurative arthritis results in permanently damaged jointwhich

is either ankylosed or is extremely painful on motion. Resection eliminated

tissues of low vitality which harbored infection and at the same time secured

really adequate drainage. French surgeons were more liberal in their indications than American surgeons, who limited the method to suppurative arthritis

of the knee joint which was so extensive that there was no hope of regaining

joint function. The optimum time for its performance was within the first

weeks.
312 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Of the various incisions through which resection could be done, the most

satisfactory was an elliptical transverse incision, through which the patella

could be removed. Operation was preferably performed with tourniquet in

place. The anterior and posterior cruciate ligaments were divided and the

knee joint was flexed and supported with rolled towel in the bend. The

femoral condyle was sawed off at the highest possible level, that is, just proximal

to the intercondylar fossa, and the remaining cartilage was stripped free from

the underlying bone. The tibial condyles were then sawed off, the excision

being as conservative as was consistent with complete removal of all joint

surfaces. Cuts were made so that flexion of to 10 degrees resulted at the

knee. The synovial membrane was completely excised.

If tourniquet had been used, it was removed at this stage of the operation. Drains were placed at the angle of the incision. single heavy wire

suture was sometimes placed through the anterior margins of the bones, to

prevent their slipping forward and backward. few sutures were also inserted

to approximate the skin loosely and prevent retraction. If the original wound

was posterior, it was enlarged and used for dependent drainage. After the

wound had been dressed, the limb was put up in plaster-of-paris spica.

If posterior drainage had not been instituted, the patient was placed in

the prone position at intervals. Drains were removed in from to 10 days.

The plaster spica was changed as often as necessary. If abscess formation

developed, additional drainage was instituted.

Analysis of Cases

The management of 50 penetrating and perforating wounds of the knee

joint in 49 patients treated at the 19th General Hospital during 3-month

period in the spring of 1945 is typical of the problems presented by this type of injury in the late months of World War II in the European theater. Sixteen of the patients were United States Army personnel, and 33 were prisoners

of war. From that standpoint, as already noted (p. 63), conditions of treatment were less favorable than they probably would have been in group of

patients which did not include prisoners of war.

In 19 of the 50 cases, there were no associated fractures of the patella or

the articulating ends of the tibia and femur. From that standpoint, conditions of treatment were somewhat more favorable than they frequently were in such

injuries. In the remaining 31 cases, the fractures were distributed as follows:

Femoral condyles, 12; patella, 6; tibial condyles, 4; patella and femoral condyles, 4; patella and tibial condyles, 3; patella, femoral and tibial condyles, 1; and femoral and tibial condyles, 1.

Initial surgery.—In 40 of the 50 injuries, formal arthrotomy had been done at the time the wounds were debrided, most often through an incision separate from the original wound; in the remaining cases, the arthrotomy

incision was incorporated in the battle-incurred wound. In 34 instances, the

Semiannual Report, 19th General Hospital, European Theater of Operations, January-30 June 1945.
INJURIES OF THE KNEE JOINT 313

joint was explored through either medial or lateral parapatellar approach;

in instances, both medial and lateral incision were necessary.

In of the 10 cases in which arthrotomy was omitted at initial wound

surgery, the patients were prisoners of war. In other cases, penetration of

the joint was not recognized in the forward installation, and the injury was

thought to be only soft-tissue wound. In the other case, the omission was

deliberate.

While the records were not always clear on these points, it seemed likely

that all but or of the 40 arthrotomized patients had been treated by the

instillation of penicillin (10,000 to 50,000 units) into the joint at the time of

debridement and that most of them had received both penicillin and sulfadiazine at this time. At the general hospital, prisoners of war received sulfadiazine systemically both before and after reparative surgery but were given

penicillin only when necessary to control severe infections. United States

Army patients received both penicillin and sulfadiazine systemically before

and after operation.

Management of these 50 injuries in the 19th General Hospital is analyzed

from several standpoints. There is necessarily some overlapping of figures.

Delayed primary closure of soft-tissue wounds.—Delayed primary closure

of the soft-tissue wounds was undertaken in 32 cases in which initial arthrotomy

with closure of the capsule had been done. In 30 cases, there was no special

problem. The edges of the wound could be brought together without tension

and very little manipulation was necessary. Drainage was seldom necessary

because dead space could be obliterated. The interval between closure of the

wound and initial wound surgery ranged from days in cases to 16 days in

case. In all but of the 32 cases, closure was effected between the 5th and

10th days. After operation, the knee was immobilized in single plasterof-paris spica. If the patient had not been evacuated at the end of weeks,

knee motion was started, usually while skin traction was still in effect.

In 20 of these 32 cases, primary healing followed reparative surgery. In

instances, the wounds became superficially infected. In the other cases, evacuation was necessary in from to days, and evaluation of the end

results of wound closure was not possible within this period; there was, however,

no evidence of infection in any instance when the patient was evacuated. In

the cases in which the patients were under observation long enough to permit

some evaluation of end results, it seemed likely that satisfactory function

would be secured.

Delayed primary closure of capsule.—In 10 cases, delayed primary closure

of the capsule of the knee joint was carried out in the general hospital, in

instances with closure of the skin wound at the same time. In other cases, the soft-tissue wound was closed to days after closure of the capsule. In all

cases, the immediate results were good, the wounds being completely healed

within to weeks after the original injury had been sustained. In other

cases, the patients had to be evacuated before closure of the soft-tissue wound

could be accomplished.
314 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

In the remaining cases, the attempt at delayed closure of the capsule

failed. Both patients were prisoners of war.

Case 29.—Inthis case the synovial membrane had been sutured but the capsule had been

left open at initial wound surgery. The synovial closure did not heal well, and, when the

patient was admitted to the general hospital days after wounding, there were openings

into the joint. Penicillin had been instilled into the joint at debridement, but systemic

penicillin therapy had apparently not been instituted.

Although the soft-tissue wound appeared clean and ready for closure when the patient

was received, doubt was felt about the status of the joint. The openings in the synovial

membrane did not permit adequate visualization, and wide arthrotomy was done days

later. The degree of intra-articular destruction revealed made it clear that initial wound

surgery had not been adequate. Six days after this operation, infection in the joint was

evident, and drainage of the wound had to be instituted.

There are three lessons in this case: (1) Completeremoval of all intra-articular devitalized

tissue and foreign material is essential in all wounds of the knee joint. This is not possible

if arthrotomy is not carried out. (2) Closure of the joint cavity is best accomplished by

closure of the capsule, and not only of the delicate synovial membrane, which frequently

permits leaks at the suture line. (3) Penicillin, no matter how administered, is not

substitute for adequate surgery.

Case 42. —This patient had reparative surgery days after wounding. The capsule

was closed under moderate tension, and the very extensive soft-tissue wound was partly

closed at the same time. The newly sutured portion of the capsule was left exposed, for

subsequentcoverage with skin graft. The capsular wound broke down in part, and second

attempt at suture also failed. When the third attempt was made, the edges of the capsular

defect were found to be so friable that third failure was regarded as inevitable.

When the patient was evacuated, there seemed little doubt that the end result would be

loss of function, partly because of the original bone and joint wound and partly because of

failure to close the joint capsule at initial wound surgery. Regardless of the status of the

articulation, the open capsule, with contamination and inevitable low-grade infection, was

an additional liability. In this case, successful closure might possibly have been accomplished

without tension by mobilization of muscle, fascia, and some capsular substance, the capsular

mobilization being accomplished through partial tissue thickness in order to avoid new

openinginto the joint.

In cases, all in prisoners of war, closure of the joint cavity was accomplished by the use of skin; the considerable loss of capsular tissue would have made closure impossible otherwise. In the first case, portion of the skin

wound was sutured over the portion of the defect which could not be closed; the portion of the skin wound overlying the sutured capsular defect was left

open. In the second case, flaps of skin were brought down over the capsular

defect, the remainder of the skin wound being left open. In this case, there

was an associated comminuted fracture of the lateral femoral condyles, but

most of the articular surface was intact and extensive redebridement was not

necessary. In the third case, the same technique was used. In all cases, the joint capsule was successfully sealed off, and the portions of the skin

wounds which had been left open were closed between the fifth and seventh days after closure of the capsule. In the first and second cases, healing was

satisfactory. In the third, superficial necrosis of the skin flaps occurred but was not serious. It did, however, delay recovery. The other patient whose
INJURIES OF THE KNEE JOINT 315

capsular wmund had been closed by means of skin flaps was discharged 45 days

after operation, with function from 180-degree extension to 100-degrec flexion.

As all these cases show, the first essential of management of wound of

the knee joint is adequate debridement of the joint as well as of the soft-tissue

wound. The second essential is the complete, tight closure of the joint capsule.

If capsular defects do not permit this kind of closure, closure must be effected

by mobilization of whatever deep structures may be available. If this is not

possible, then closure of the defect with skin must be attempted, counterrelaxing skin incisions being used as necessary. If large capsular defects are

left open at the initial operation, they cannot be closed as successfully at later

date.

Omission of initial arthrotomy.—In of the 10 cases in which formal

arthrotomy was omitted at debridement, the wounds were penetrating and in

they were perforating. Associated fractures were present in cases (2 comminuted fractures of the patella, fracture of the medial femoral condyle,

fracture of the patella and tibia! plateau).

In the cases in the nonarthrotomized group in which fractures were not

associated with the joint injuries, conditions were favorable for uncomplicated

recovery. In all these cases, the joint injury was caused by small shell fragments of high velocity, and intra-articular damage was apparently slight.

Aspiration of blood from the joint, with instillation of 10,000 to 20,000 units of

penicillin into the joint and short course of systemic penicillin, was the treatment of choice. Early motion (within the first week after wounding) in traction

resulted in rapid return of function.

In of the instances in which fractures were associated and in which free fragments of bone were found in the joint, infection did not occur, although in

all of them soft-tissue damage was quite extensive. In the fourth case, an

instance of comminuted compound fracture of the patella and tibial plateau

in prisoner of war, the joint was not opened widely when the original debridement was done, and foreign bodies were permitted to remain in situ. The

patient had received systemic penicillin, with local instillations into the joint,

and sulfadiazine by mouth. The knee joint became infected, and spreading

cellulitis of the thigh developed. Treatment consisted of penicillin and sulfadiazine therapy, local heat, and traction. When arthrotomy was subsequently

carried out, metallic foreign bodies and loose bone fragments were removed

from the joint. The synovial membrane was closed, and early joint motion

was started in traction. Two months later, the wounds were healed, and the

range of motion was from 180-dcgree extension to 24-degree flexion.

The results in these 10 cases were, on the wdiole, better than might have

been expected in the light of the omission of arthrotomy at initial wound

surgery. They must not, however, be assumed to be the rule when this practice

is followed. Battle wounds of the knee joint are best treated by (1) formal

arthrotomy, which permits adequate debridement through an incision which

provides visualization of the entire interior of the joint, and (2) tight closure

of the capsule. Failure to close the capsule is always an invitation to infection.
316 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

Wound infections.—Eight of the fifty wounds of the knee joint in this

series were infected when the patients were received in the general hospital.

In instance, the infection was limited to small, localized collection ofpurulent

exudate in medial wound. The infection did not communicate with the joint,

and the lateral wound in the same knee was clean. Delayed primary closure

of both wounds was promptly accomplished, and, while the end result is not

known, it was thought that the infection would not influence the outcome of the

injury in any way.

In the other cases, in all of which compound comminuted fractures were

also present, the infection was serious and involved the joint. In cases, debridement and arthrotomy had been performed from 24 to 72 hours after

wounding. In the other cases, debridement of the soft-tissue wound had been

performed 48 hours after wounding, but in each instance arthrotomy had been

omitted. The amount of necrotic debris found in these wounds and joints

when reparative surgery was undertaken in the general hospital was clear

indication of the inadequacy of the initial wound surgery. The basic cause of

each of these infections was severe joint injury, considerable soft-tissue and

intra-articular damage, late and inadequate debridement or both, and, in

cases, omission of arthrotomy.

In of the infected cases, the records indicated that chemotherapy and

antibiotic therapy had been administered both locally and systemically, according to satisfactory regimen. In the seventh case, the patient had been

operated on in German hospital and had certainly received no penicillin; the

record did not indicate whether he had had sulfadiazine. In the eighth case,

the record contained no information at all about chemotherapy.

There were postoperative infections. One, in United States soldier,

was trivial-stitch abscess, readily controlled by removal of the sutures and

the application of heat. Two of the infections in prisoners of war were

also superficial and readily controlled. In the remaining case (case 29, already

described), severe infection of the joint and spreading periarticular infection required radical surgery. The infection at one time threatened the

vitality of the limb, but it was eventually controlled by combined surgery

and penicillin therapy.

Immediate functional results.—The final outcome of these 50 wounds of

the knee joint is not known. Under the theater holding policy, particularly

in the last days of the war, patients had to be evacuated too promptly to permit the necessary observation. In 10 cases, however, early functional results

could be evaluated. In 1, in which there was compound comminuted fracture

of the femoral condyle, movement 42 days after wounding was from 180-degree

extension to 100-degrce flexion. The immediate results in the other cases,

in none of which fractures were present, are summarized in table 19.
INJURIES OF THE KNEE JOINT 317

Table 19.—Immediate functional results in penetrating wounds of the knee joint

Case No. Days after wounding

Range of motion In degrees (expressed in extension to flexion)

18 180-140.

35 180-90.

22 60 All movements free; to duty.

33 56 180-90.

34 42 180-55. To duty.

37 52 175-85.

41 48 180-150.

43 60 180-40.

46 120 180-35.

Information secured by followup letter.

319

APPENDIX

Pertinent Directives

Cir 96 Hq ETOUSA 15 Dec 1943

II—ENLISTED MEN: DISPOSITION OF WHEN PHYSICALLY OR

MENTALLY UNQUALIFIED.

I. When an enlisted man is considered by his immediate commanding officer

to be physically or mentally unqualified to perform his assigned duties or any

other appropriate duty within the unit, under the general policy as contained

in Par 2, WD Cir 293, 11 Nov 1943, action will be taken as follows:

a. physical examination will be made to determine whether the subject

enlisted man is physically or mentally qualified to perform any duty within his unit.

h. In event the enlisted man is found to be physically or mentally unqualified

to perform any appropriate duty within the unit, his case will be reported

through channels with applicable recommendation for his reassignment within

the command or his transfer to the detachment of patients of an SOS, ETOUSA,

hospital. When the enlisted man is transferred to an SOS, ETOUSA, hospital,

the report of physical examination directed under above, together with his

service records and allied papers, will be forwarded to the commanding officer

of the hospital.

c. The commanding officer of the hospital will determine whether the man can

be utilized in the service or is to be discharged under current regulations.

d. Enlisted men who are to be retained in the service will be transferred from

the hospital to the 10th Replacement Control Depot, SOS, ETOUSA, if

formerly assigned to the ground forces or SOS, or to the 12th Replacement

Control Depot, Eighth Air Force, if formerly assigned to the army air forces.

At the time of transfer the commanding officer of the hospital will forward to

the depot commander report concerning the man, which will include statement as to physical and mental qualifications and duty limitations.

e. The commanding officer of the replacement depot will take the necessary

action to effect reassignment of such enlisted men to appropriate units.

2. The CG, Iceland Base Command, is authorized to make such modifications

as are necessary to accomplish the above directed action.

command of lieutenant general DEVERS;

DAVID G. BARR,

Official: Brigadier General, GSC, Chief of Staff s/ Ralph Pulsifer

HRS.

RALPH PULSIFER

Brigadier General, USA, Adjutant General.

Distribution: “B”
320 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

OFFICE OF THE CHIEF SURGEON

EUROPEAN THEATER OF OPERATIONS

File: 704. 701. 15 Alay 1944

CIRCULAR LETTER NO. 71

SUBJECT: Principles ofSurgical Management in the Care of Battle Casualties.

5. Surgical Procedures.

a. Dressings. Ideally, the primary phase of treatment will be completed

in the first unit reached that is equipped to provide it. The dressing is to

then be left undisturbed until the patient reaches third echelon unit for operation. There are certain safeguards and adjustments that must take place

en route, but these do not include inspection of the wound by removal ofthe dressing

unless definite indications for so doing are present. compound fracture case

may be halted at the Clearing Station for more adequate immobilization or

resuscitation, but the wound should not be re-dressed unless necessary to arrest

continuing hemorrhage. wound will not be re-dressed solely for the purpose

of re-applying local sulfonamide. Oral administration is sufficient safeguard.

The same principles apply after operation has been completed and the

patient is being evacuated to the rear. Uninformed hands do unnecessary dressings. The best safeguard for patient is an adequate and legible record that

accompanies him, which makes it possible for receiving officer to refer to the

record rather than looking at the wound. Infection arising from contamination incurred at the time dressings are changed, may make impossible secondary

suture of wounds after debridement and arrival at third echelon unit.

h. Debridement oj wounds. This is the basis of the proper treatment of

all battle casualties. It is definite!}" more important than chemotherapjq and

reliance on the latter must not diminish devotion to the proper surgical treatment of wounds. Use ample incisions, practice minimal removal oj skin and

bone and maximum removal oj all dead and devitalized muscle. Never close

primarily wounds debrided under field conditions. Pack wounds open lightly,

never plug tightly.

Under favorable circumstances, it is desirable that severed nerves and

tendons should be approximated, preferably with metallic or non-absorbable

sutures (see Manual of Therapy, ETO).

c. Amputations. Amputations for trauma will be circular open (guillotine) amputation at the lowest possible level, followed by the application of

skin traction. Skin traction will be applied immediately and must be maintained during all stages of evacuation, including evacuation to the Zone of

Interior, and until the stump is completely healed. Skin grafting will not be

used as substitute for skin traction.
PERTINENT DIRECTIVES 321

8. Secondary Closure.

a. Although the first principles for the military surgeon to bear in mind

is not to close the wound he has freshly debrided, it is essential that he close

this wound at the earliest moment that is safe. Early closure means limitation

of infection and fibrosis, and an earlier restoration to duty. If the primary

debridement has been thorough, small wounds may be closed as early as the

third day, though the average wound not until the fifth day. Observation of

the signs of inflammation, such as discharge, reddening, pain and swelling, will

determine whether or not wound can be closed. It is wiser not to dress the

originally debrided wound until the day when secondary closure might be practical, since each dressing invites contamination of the wound. If closure is

considered safe, it should be done loosely without undermining the edges or

using sharp instruments, and by using retention sutures of silk, or silk-worm

gut, spaced widely apart and loosely tied. Should mild infection appear, hot,

moist dressings may save breaking down of the wound and hasten the healing

process. Any signs of severe infection require immediate removal of the

sutures.

h. Closure of wounds with fractures should only be undertaken when

full penicillin therapy is being practised and when all the signs of infection are

absent.

c. Wounds closed early, before the establishment of granulation tissue

or scar tissue, are easier to close than those closed after one or two weeks.

In wounds that have been open for long time, skin grafting is often better

than closure by suture. If the original debridement has been practised with

the minimal of skin removal, as suggested above, closure by sutures will be

simple.

d. Removal of sutures from such secondary closures should not take

place before 10 days unless stitch infection develops. After removal of the

sutures it may be wise to maintain approximation of the wound edges with

adhesive plaster.

9. General Principles to he followed in the Use of Plaster Casts.

a. No circular bandages, dressings, or strips of adhesive shall be used

under plaster cast, as these constrict the extremity and may cause extensive

damage if swelling of the part occurs.

h. Adequately padded plasters are probably safer in average hands.

Padding should be applied to all bony prominences such as malleoli and heels,

knees, particularly over the head of the fibula, wrists and elbows. In addition,

sufficient padding should be used over the soft parts to permit some swelling

within the cast.

c. All layers of plaster sheet wadding or dressings must he cut thru down

to the skin immediately after the application of cast following an operation or

manipulation. Swelling of the part will occur and unless all layers of the plaster

padding and dressings are cut thru, it will he impossible to spread the cast to prevent

extensive damage when swelling occurs.

372572°—58 22
322 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

d. Attention should be paid to the position of the extremity encased in

plaster. The foot should be at right angle to the leg, the knee should be in

10-15° of flexion, the hip should be in neutral position or slight flexion. The

wrist should be supported in neutral position to prevent wrist drop, and the

elbow ordinarily is best supported at right angle. In these positions the

patient will transport comfortably, will not take up undue space, and the

tendency to develop troublesome fixed deformities will be minimized.

e. line diagram in indelible pencil should be inscribed on the cast,

indicating the approximate location of fracture and position of fragments.

The number of the unit, date of injury, date of operation and type of operations

should likewise be written on the cast so that if the Field Medical Record is

lost, reasonable satisfactory substitute record will be readily available.

f. Either platform or loop or wicket of plaster should be applied to

the foot of the cast in order to protect the toes from pressure of blankets, bed

clothes, etc. Plaster applied to the hand should be trimmed back to the

proximal palmar crease to permit full flexion of the fingers and metacarpal

phalangeal joints.

For the Chief Surgeon:

s/J. H. McNinch

J. H. McNINCH

Colonel, Medical Corps,

Executive Officer.

OFFICE OF THE CHIEF SURGEON

EUROPEAN THEATER OF OPERATIONS

File: 704. 30 July 1944

CIRCULAR LETTER NO. 101

Care of Battle Casualties

1. The information contained herein is supplemental to Manual of

Therapy, ETO, May 1944, and Circular Letter No. 71, Office of the Chief

Surgeon, subject: “Principles of Surgical Management in the Care of Battle

Casualties,” dated 15 May 1944, and is based on the experience acquired during the first five weeks of operations.

3. Wounds.

a. Wounds will not be plugged or packed with vaseline gauze. Only

sufficient gauze should be used to keep the wound temporarily open.

b. Sulfonamides are being dumped in excessive quantities in wounds, and this makes subsequent repair difficult.
PERTINENT DIRECTIVES 323

c. Wounds must not he closed by sutures at the time of the first debridement, except for the following:

(1) Neurosurgical injuries.

(2) Thoracic injuries.

(3) Wounds of eyelids.

(4) Certain maxillofacial injuries, as outlined in the Manual of

Therapy, ETO.

d. Penetrating wounds of the paranasal sinuses should be thoroughly

explored, foreign bodies and blood removed and external drainage provided

at the original operation. Drainage of the antrum into the nose is the method

of choice unless the wound has destroyed so much tissue that external closure

is not possible. The frontal sinuses should be drained through the wound or

through an incision to allow opening in the floor of the sinuses.

e. The routine culture of wounds is unnecessary, and wasteful of time

and materials. Cultures should be limited to those wounds where there is

clinical evidence of infection and where they may contribute to its subsequent

clinical management.

/. Wounds seen late, after wounding, without debridement, may be

debrided in the usual manner.

g. Wounds can usually be closed within to days after debridement.

satisfactory preparation of the wound for secondary closure has been the

application of warm saline dressings. Chemotherapy locally in the wound at

the time of secondary closure is not necessary; penicillin therapy should be

resumed before and after secondary closure in all large wounds.

h. As rule, foreign bodies which interfere with function or wound

healing should be removed. Modern chemotherapy obscures the signs of local

infection only temporarily and many times delayed infection, with breakdown

of the wound, may result after long interval.

i. Continued local and excessive applications of sulfonamides in wounds

are detrimental to wound healing, produce dermatological lesions, often increase

blood levels above safety limit, and are unsupported scientifically as the

proper therapy.

5. Gas Gangrene.

a. Incidence of serious infection with clostridia is fortunately low up

to the present time, and surgeons have shown wise discrimination between

diffuse myositis and cellulitis. This has restricted amputation, led to recovery

by simple incision, excision of involved muscle and adequate drainage.

h. Routine culture of wounds is unnecessary unless there is clinical

suspicion of gas bacillus infection. Gas-forming organisms can commonly be

cultured from wound, and such findings should not influence the surgical

treatment unless consistent with the clinical diagnosis. Only in clinical cases

of gas gangrene infection should cultures be taken and sent to the First Medical

General Laboratory for final identification of the organisms.
324 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

c. Amputations have in some cases been too radical. Always demand

consultation and always explore locally in wound before amputation. In many

cases the apparent diffuse involvement, as shown by swelling, crepitation

and discoloration of the skin, has extended far above the actual muscle involvement. Failure to appreciate that amputation or muscle excision can be carried

out at much lower level has at times resulted in the needless high amputation

of the thigh or upper arm. Extensive incision and drainage above the level

of amputation is commonly required in such instances.

d. Following amputation for widespread clostridial myositis, skin traction should not be applied for the first 24-48 hours, since some cases thus

treated have had unfortunate results because of restricting dressings. Such

cases should be held as non-transportable until skin traction is applied.

e. In performing the circular amputation, the skin should always, if

possible, be longer than the underlying soft tissue and bone. Except in amputations following clostridial infection, skin traction should in every instance be

applied immediately. The following dressing is suggested as an adequate and

comfortable method of protecting the stump and securing skin traction during

the period of evacuation or hospitalization:—

(1) Dress the stump with fine mesh gauze.

(2) Apply circular roll of stockinet to the stump; roll this proximally.

(3) Apply tincture of benzoin to the skin up to the cut edge.

(4) To the distal 1" of skin apply an ointment of equal parts of zinc

oxide and castor oil.

(5) Apply ace-adherent to the skin of the stump up to the ointment,

and then roll the stockinet over the stump and dressing.

(6) Apply several layers of sheet wadding on the stockinet and light

plaster of paris cuff over this, incorporating wire ladder splint anchored at

both ends. Traction is obtained by tying the stockinet to this wire. In case

there is short arm or high thigh stump, the wire ladder splint may be incorporated in short shoulder or hip spica plaster of paris bandage. In case

drainage is excessive, the stockinet distal to the amputation may be split into

two or more tails and spreader employed if desired. The intact stockinet

tends to cone the stump down to desirable size and may be preferable.

6. Plaster Splints.

a. These are being applied too thick, wasting material and time both

in application and removal.

b. If bilateral spicas are applied, they must be litter width, reinforced

with strut placed posteriorly.

c. All initial circular plaster of paris dressings, following trauma manipulation or operation, must be split to the skin and slightly spread.

d. In arm casts used for forearm or wrist injury, always trim the cast
PERTINENT DIRECTIVES 325

back to the proximal palmar crease so that full metacarpophalangeal flexion

can he maintained.

For the Chief Surgeon:

J. H. McNinch

J. H. McNINCH,

Colonel, Medical Corps,

Executive Officer.

HEADQUARTERS EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY

Office of the Chief Surgeon

File: 304 November 1944

CIRCULAR LETTER NO. 131

Care of Battle Casualties

The following instructions are supplemental to Manual of Therapy ETO,

May 1944; Circular Letter No. 71, 15 May 1944; and Circular Letter No.

101, 30 July 1944, Office of the Chief Surgeon.

1. Treatment of Wounds of Bones and Joints

The proper treatment of those wounds involving bones and joints may

be divided into the early stage in Field or Evacuation Hospitals and the later

stage when the wounded arrive at General Hospital. The early treatment

entails:

a. Debridement of the wound. Skin and bone will be conserved to the

maximum degree. Devitalized muscle will be excised, leaving viable muscle. Fascial planes should be widely opened by longitudinal and transverse incisions

so that no tension exists. All bits of clothing and available metallic bodies

are to be removed but prolonged search for metallic foreign bodies will not

be made at this time. The wound will be lightly dressed with vaseline gauze,

introduced into the depths but not packed.

h. Immobilization of fractures for evacuation. Field and Evacuation Hospitals and any type of medical unit acting as “transit” hospital will

prepare fractures for early evacuation with comfort and safety to the patient.

They will not be responsible for the anatomic reduction of these fractures.

(1) Fractures of the femur are for the most part most comfortably

immobilized in double circular plaster of Paris spica bandage extending from

the toes of the affected leg and from the knee of the sound leg. This should

be re-enforced by strut placed 'posteriorly, and the legs should not be spread

more than litter width. The knee should be slightly flexed.
326 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

The Army ring splint is, for the most part, to be employed as an emergency

measure. The traction strap or clove hitch, when left on the foot for periods

of time exceeding or hours, almost invariably results in skin necrosis. If

it is necessary to leave the Army ring splint on beyond the Field, Evacuation

or other “transit” hospital, adhesive plaster must he applied to the leg as means

of traction. The Army hinged splint for upper extremity fractures is extremely

uncomfortable and it should be discarded at the first installations where

plaster of Paris splint can be employed.

The use of the Army ring splint with adhesive plaster traction, posterior

moulded plaster of Paris splint applied from ankle to buttock and re-enforced

and stabilized with few rolls of plaster over the metal side arms of the splint,

may be satisfactory means of transportation in selected fractures of the femur

in this theater. It should not be used for fractures of the upper third of the

femur and it can not be employed if there are wounds below the knee as well

as above. No patients will be returned to the Zone of the Interior with this

form of splint.

(2) Fractures of the tibia and fibula should be immobilized in circular

plaster of Paris bandage from toes to groin; knee flexed 15 degrees, the foot in

neutral position at 90 degrees to the long axis of the leg.

(3) Fractures of the feet should be immobilized in circular plaster of

Paris boot extending from the toes to just below the knee, with foot in neutral

position at 90 degrees to long axis of leg. Gentle soap and water scrubbing of

these wounds of the feet will minimize the chance of infection.

(4) Fractures of the humerus should be immobilized by plaster of

Paris spica bandage with arm held forward and medially rotated so that the

forearm rests in front of the body. plaster of Paris Velpeau bandage may

be used for evacuation within this theater, but not to the Zone of the Interior.

The hanging cast is not an acceptable means of fixationfor transportation and will

not be so employed.

(5) Fractures of the forearm and wrist should be immobilized by

circular plaster of Paris bandage extending from mid-brachial region, with the

elbow flexed at from 90 to 110 degrees to long axis of humerus. This splint

should not extend distal to the metacarpo phalangeal joints.

ALL PRIMARY CIRCULAR PLASTER OF PARIS DRESSINGS WILL

BE SPLIT TO TLIE SKLN AND SLIGHTLY SPREAD. NO CIRCULAR

BANDAGE OR ADHESIVE PLASTER OR SHEET WADDING WILL

BE LEFT UNDIVIDED UNDER SPLIT PLASTER OFPARIS BANDAGE.

c. Treatment of wounds of bones and joints in General Hospitals. As

soon as the patient arrives at general hospital the plaster of Paris dressing

and all vaseline gauze should be removed.
PERTINENT DIRECTIVES 327

(1) Fractures of the femur, tibia, fibula, and humerus will be treated by

skeletal traction in every instance where it is possible to achieve beneficial

result within reasonable length of time.

(2) Compound fractures of the forearm may be treated with circular

plaster of Paris splints or traction when feasible. Badly displaced simple forearm

fractures, which cannot be reduced by other means, may require open reduction

and internal fixation. Such open reduction may be applied in some instances in

compound fractures of the forearm after successful secondary closure has

resulted in wound healing.

(4) Fractures of the foot. Simple fractures involving the metatarsals

and phalanges should not be immobilized for prolonged periods. Many of these

undisplaced or slightly displaced fractures are best treated by mobilization

without weight bearings. In compound fractures of the foot, every effort

should be made to heal the wounds by secondary suture or skin graft. Pulp

traction to the toes should be avoided. Early active motion of toes and feet

should be encouraged wherever possible.

(5) Compound fractures of long bones with loss of hone substance. In

fractures of the long bones with large initial loss of bone substance, traction

because of the limited evacuation policy of this theater, will be of little benefit,

and so should not be employed. Distraction in these cases is common cause

of non-union. Such patients should be returned at an early date to the Zone of

the Interior, in appropriate circular plaster of Paris splints with every effort

made in this theater to close the wound secondarily.

(6) Compound fractures of long bones with major nerve injury. In compound fractures of the long bones with associated injury to major peripheral

nerves, the nerve injury takes precedence, and these cases should be treated

as outlined in paragraph 2, a(2) below.

(7) Holding periods required for long bone fractures treated by skeletal

traction. Compound fractures of the femur, tibia and fibula, and humerus that

may be treated with skeletal traction comprise slightly less than 10% of all

battle casualties. The holding periods for these fractures in the ETO are

roughly as follows;

(1) Fractures of the femur 6-9 weeks.

(2) Fractures of the tibia and fibula 5-7 weeks. (3) Fractures of the humerus 4-6 weeks.

At the expiration of the indicated periods, these fractures should be “frozen” or

“fixed” sufficiently so that they will not displace during transportation if placed

in circular plaster of Paris splints as described in paragraph lb, above.

Base Sections of this theater which have an authorized holding period insufficient to allow completion of skeletal traction on these long bone fractures

should immediately evacuate these patients to Base Section where such

skeletal traction may be initiated and maintained for the indicated period of

time. At this date these long bone fractures may be treated by skeletal traction
328 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

only in the UK Base, and so these cases should be evacuated from the continent

at the earliest practicable moment.

(8) Metallic external fixation of fractures. The use of Steinmann pins

incorporated in plaster of Paris, of metallic external fixation splints has led to

gross infection and/or ulceration in high percentage of cases. This method of

treatment will not be employed in the ETO.

(9) Open reduction and internal fixation of long bone fractures must he

reserved for those few cases in which skeletal traction has failed to secure or

maintain reduction after adequate trial. Such open reductions may be performed only on simple fractures or on compound fractures where the wound has

healed. Open reduction should not be attempted until 2-3 weeks have elapsed

following healing of the wound.

(See paragraph Id below)

(10) Wounds involving major joints. These wounds should be closed

at the earliest moment by secondary suture or skin graft. The synovia should, if possible, be closed at time of debridement. If the joint surfaces are not badly

damaged, early active motion should be insisted upon. If, however, the joint

surfaces are so badly damaged that bony ankylosis is inevitable, the various

joints should he immobilized in the following positions;

Hip joint 25 degrees of flexion. 0-5 degrees of abduction.

Knee joint 10-15 degrees of flexion.

Ankle joint 10 degrees of equinus.

Upper extremity joints should be immobilized in the positions as outlined for

evacuation in paragraph 1, b, above. The wrist should be dorsiflexed about

40 degrees. The spontaneously ankylosed elbow joint offers the most serious

problem in the upper extremity. Many of these stiff elbows may be treated

later by resection.

d. Secondary closure of wounds over compound fractures. This is the

greatest single advance in the treatment of this type of fracture. The incidence

of serious infections is extremely low, and therefore many of the wounds may

be closed by secondary suture or skin graft as early as the time of the first

dressing in the general hospital. However, closure of wounds 10 days or less

from the date of injury is considered to be early closure. The skin edges at this time are still mobile and, if there is little loss of skin, may be readily approximated. Closure should be accomplished by widely spaced, deeply placed,

non-absorbable sutures without tension. If skin graft is done, it may be

well to clean up surface debris and small sloughs by moist dressings for or

days prior to grafting. Delayed closure of wounds is that performed after 10

days. The new epithelium at the margin of these wounds must be excised

and the edges undercut to approximate the skin edges. With large loss of

skin, necessitating skin graft, no mobilization of the skin edges should be required. All patients with compound fractures subjected to secondary closure

should receive penicillin parenterally, and sulfadiazine for 1-day prior to and

several days after operation. Approximately 50% of these compound fractures

are converted into simple fractures at the first attempt, with additional subse-
PERTINENT DIRECTIVES 329

quent attempts another 35% will heal, and failure to secure healing to any

appreciable extent has occurred in only 15% of those attempted.

Secondary closure of these wounds minimizes the incidence of osteomyelitis, conserves bone, and hastens convalescence. Two or three weeks after

secondary closure is accomplished, neurosurgical procedures may be performed,

and such few fractures as require open reduction may be so treated.

e. Amputations. The circular amputation and its subsequent treatment

has been described in Circular Letter No. 101, Office of the Chief Surgeon,

dated 30 July 1944. These amputations are often traumatic and the skin

edges are irregular. Traction will, in most instances, effect closure of these

stumps if it is adequately performed. Secondary closure of these amputation

stumps by suture often leads to infection and necrosis of the skin, and will not

be perjormed in this theater. Where the skin sleeve is inadequate to allow

closure by traction, or the bone ends are obviously too long and protrude,

revision of the stump should be performed at the lowest possible level. The

skin edges should be mobilized by undercutting and the bone and soft tissues

should be reamputated just sufficiently to allow closure by traction, which

should be promptly re-applied and continued. Amputations shouldbe evacuable

to the Zone of the Interior 2-3 weeks after admission to general hospital.

It is not necessary for the stump to be completely healed prior to evacuation

to the Zone of the Interior, but skin traction must be continuous. Split thickness skin grafts of the lower extremity will not tolerate prosthesis and their

use to cover amputation stumps is prohibited unless there is an unusual

indication.

2. Neurosurgical Problems.

a. Peripheral nerve injuries. All available information indicates that

early repair of severed major nerve contributes to theperfection of the ultimate

result. Not only does regeneration proceed more satisfactorily, but the surgical

problem of ‘‘making up” gaps between the severed ends is tremendously simplified. An attempt is being made in this theater to repair early, through the

facilities of the special treatment hospitals for neuro-surgery, as many of these

cases as is practicable. The following rules for the treatment and evacuation

of peripheral nerve injuries will be followed by the commanding officers of all

hospitals in this theater:

(1) All wounds with associated peripheral nerve palsies uncomplicated by fractures of long bones, should be closed by secondary suture and the

patient then promptly transferred to the nearest special treatment hospital for

neurosurgery for definitive treatment.

(2) All major nerve injuries complicated by fractures should have

early closure of wounds and adequate splinting without attempting to secure

anatomic reduction of the fracture. This plan permits early suture of the

nerve with later reduction of the fracture by open operation if necessary. The
330 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

restoration of length before the nerve repair is accomplished, may defeat the

possibility of end-to-end suture of the nerve.

(3) There is no necessity for prolonged immobilization of extremities

with peripheral nerve injuries uncomplicated by fractures. plaster splint

may be used, provided it is removed at regular intervals during the waking

hours.

8. Condition of Patients Evacuated to the Zone of the Interior.

Commanding officers of hospitals returning patients to the Zone of the

Interior will pay careful attention to the general physical condition of the

patients, and in those cases in casts, to the condition of the plaster of Paris

dressings in which they are to travel. Circular plaster of Paris splints over

open wounds should be changed just prior to departure from the hospital.

Careful attention to plaster technique is constantly necessary. Secondary

closure of wounds will prevent plaster splints from becoming soiled and foul

smelling. Secondary plaster of Paris circular splints applied weeks after injury

or operation do not need to be split.

order of the Chief Surgeon:

s/ H. W. Doan

H. W. DOAN,

Colonel, Medical Corps,

Executive Officer.

HEADQUARTERS EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY

Office of the Chief Surgeon

Ch Surg 704 17 March 1945

CIRCULAR LETTER NO. 23

Care of Battle Casualties

The following instructions are supplemental to Manual of Therapy, ETO,

May 1944; Circular Letter No. 71, 15 May 1944; Circular Letter No. 101, 30

July 1944, and Circular Letter No. 131, November 1944, Office of the Chief Surgeon.

2, Orthopedic Surgery

a. Notesfor disposition hoards.

Under the present evacuation policy to the Zone of the Interior, very

few simple or compound fractures can be rehabilitated to full duty in this

theater. Among the exceptions may be certain fractures incurred by key

personnel occupying sedentary positions. fracture of the clavicle, an un-
PERTINENT DIRECTIVES 331

displaced fracture of the head of the radius or of the lateral malleolus, some

fractures of the metacarpal bones, metatarsal bones or phalanges are cited as

examples of fractures that may be returned to full duty within the present

evacuation policy. There may be few other instances of minor fractures

which will require careful evaluation in order to determine whether there is any

possibility of salvaging the officer or soldier involved for further duty in this

theater within the time allowed.

Patients requiring elective surgical procedures for internal derangement of

the knee joint or recurrent dislocation of the shoulder joint should almost

invariably be returned to the Zone of the Interior for this surgery. The utmost

care should be exercised in arriving at diagnosis of either of these conditions.

sprain of the knee joint which may be rehabilitated should not be confused

with an internal derangement. recurrent dislocation of the shoulder joint

should be thoroughly authenticated before this diagnosis is made.

Osteo-arthritis of major joint with definite disability as result, should

be returned to the Zone of the Interior.

b. Amputations.

Skin traction on amputation stumps must be instituted immediately

and maintained adequately and continuously except as stated in par 5d, of

Circular Letter No. 101, this office, subject: “Care of Battle Casualties/’ dated

30 July 1944. In general hospitals this traction may be advantageously maintained by weight suspended over pulley. This form of traction must also

be continuous. The most effective means of maintaining skin traction on the

amputation stump during transportation has been described in par 5e, Circular

Letter No. 101, Office of the Chief Surgeon, 30 July 1944. This skin traction

should be inspected in each medical unit charged with the care or the evacuation

of the patient, and iffound to be inadequate, it should be reapplied immediately.

Closure of amputation stumps by suture or skin graft is not authorized in

this theater. Amputees should be evacuated to the Zone of the Interior as

promptly as possible with skin traction maintained throughout all stages of

their journey.

c. Wounds involving the knee joint.

These wounds have been most satisfactorily treated in the following

manner:

(1) thorough exploration of the joint is performed through adequate

medial and/or lateral incisions. bloodless field should be insured by the use

of tourniquet if there is no associated damage to the femoral or popliteal

arteries. The joint is completely irrigated with saline solution which should

remove all blood and debris. With adequate retraction, careful debridement of all damaged tissue, bone, cartilage and synovia is performed with

removal ofall foreign bodies from the joint cavity. If meniscus is detached or

damaged it should be excised. After further irrigation the synovia and capsule

are snugly closed with single layer of interrupted sutures. If there is loss of

capsular substance, the closure may require, in some instances, the utilization of

fascial flap.
332 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

(2) After closure of the capsule 10,000 units of penicillin in cc of

normal saline are injected into the joint cavity. The tourniquet should be

released and hemostasis insured by the ligation of all bleeding vessels. The

knee joint should be immobilized by means of plaster of paris spica bandage,

knee slightly flexed, with window over the joint. The joint is aspirated 48

hours after operation, gently washed with saline solution and another 10,000 units of penicillin instilled into the joint cavity. This procedure may bo

repeated several times at intervals of 24 to 48 hours if necessary. Parenteral

penicillin therapy is carried on throughout this period. The skin wounds may

be closed days after primary surgery if there is no evidence of infection.

d. Compound fractures. (1) Supracondylar fractures of the femur with sharp spicules of bone

which may damage the popliteal vessels should be immobilized with the knee

flexed at 20-25 degrees to minimize the danger of this complication. At the

time of primary debridement if there is found to be direct pressure against the

popliteal vessels by sharp spicule of bone, it should be excised. The excised

piece of bone should be replaced at the fracture site and not discarded.

(2) Internalfixation compound fractures recent report from the Office of the Surgeon General on the condition of battle casualties returning from the ETO has been received February

1945. The consensus of opinion expressed by qualified chiefs of orthopedic

sections, chiefs of surgical services and consultants in nineteen named general

hospitals in the Zone of the Interior was that metallic internal fixation of

compound fractures resulted in infection in 25 to 50% of the cases so

treated. The metallic fixative agent in all of these infected cases had to be removed. Delayed or non-union has resulted in many of these patients.

In view of the adverse report on the progress of these casualties, internal

fixation of compound fractures is prohibited as routine procedure. It should

be resorted to only after thorough trial of skeletal traction has failed to

secure adequate reduction, and after healing of the skin has been accomplished

by suture or skin graft. The concurrence of the local orthopedic or surgical

consultant will be secured in each instance where internal fixation of compound fracture is deemed necessary. Combined injuries involving compound

fractures and peripheral nerves present special problems. These will be

treated at specialized hospitals designated for neurosurgical problems.

3. Penicillin Therapy.

c. The use of penicillin locally in all wounds is not required, but its local use in joints and chests is necessary for best results.

By order of the Chief Surgeon:

s/ H. W. Doan.

H. W. DOAN, Colonel, Medical Corps,

Executive Officer.
PERTINENT DIRECTIVES 333

HEADQUARTERS EUROPEAN THEATER OF OPERATIONS

UNITED STATES ARMY

Office of the Chief Surgeon

Ch Surg 730 383.6 May 1945

CIRCULAR LETTER NO. 39

SECTION II. PROFESSIONAL POLICIES IN THE CARE OF POW’s

1. Adherence to the basic principles of ETO policies of professional management in the care of sick or wounded enemy prisoners is desirable. Where

POW’s are cared for by US Army personnel, ETO professional policies will be

adhered to except as noted below. Where POW’s are cared for by protected

prisoner personnel, greater latitude will be granted and the POW medical

personnel may practice their methods of therapy unless such are found to be

contrary to reasonable medical care.

2. The Manual of Therapy, European Theater of Operations, and Circular

Letters Nos. 71, 15 May 1944; 101, 30 July 1944; 131, November 1944; and

Circular Letter No. 23, 17 March 1945, will be made available to German medical officers as guides for treatment.

3. The Commanding Officers of hospitals utilizing protected prisoner

medical personnel will instruct German medical officers that skeletal traction in the treatment of long bone fractures, and closure of wounds by suture and/or skin graft is the treatment to be followed. In the hands of US Army medical

officers, this treatment reduced the period of hospital treatment and subsequent

disability.

4. Treatment of fractures. a. Equipment for the treatment of long bone fractures by skeletal

traction will be furnished German medical officers who are capable of using it,

Steinmann pins or Kirschner wires may be employed. External fixation

splints such as the Roger Anderson, Haines or Stoder types will not be distributed to German surgeons.

h. When skeletal traction is not employed in the management of compound fractures of long bones, treatment will be by means of circular plaster

of paris splints. If wounds are not closed by delayed primary suture, the OrrTrueta technique will be employed. Healing ordinarily takes place in time.

c. Internal fixation of simple and of compound fractures after the

wounds have healed will bo performed only after approval by US Army

medical officer.

7. Penicillin therapy in POW’s:

a. The only indications for the administration of penicillin to POW

patients will be the saving of life or limb.

b. Penicillin will not be used in the treatment of venereal disease.
334 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

c. Penicillin will not be issued to protected enemy personnel. It will be

kept under the control of US Personnel. The Commanding Officer of the

hospital concerned must approve the use and dosage of penicillin recommended in every instance where it is prescribed.

By order of the Chief Surgeon:

s/ H. W. Doan

H. W. DOAN,

Colonel, Medical Corps,

Executive Officer.
335

APPENDIX

Proposed Revision of Manual of Therapy

(Orthopedic Section)

CARE OF BATTLE CASUALTIES AND INJURIES

INVOLVING BONES AND JOINTS

Foreword

The Manual of Therapy, European Theatre of Operations, served useful

purpose as professional guide during the military operations in Europe.

Some of the policies of treatment were changed from time to time because of

the lessons learned from experience. These changes were published in Circular

Letters by the Office of the Chief Surgeon. In an attempt to summarize the

principles of orthopaedic treatment which were evolved in the course of the

various campaigns in the European Theatre of Operations, those sections of the

Manual and the Circular Letters which pertain to bone and joint injuries in

battle casualties have been combined. Policies which conflict have been

deleted, and considerable amount of material which appeared to be important

prior to the campaigns has been omitted in the interest of brevity.

The material has been dividedinto three sections:

A. Therapy in Division Installations (Battalion Aid Station, Collecting

Company, Clearing Company).

B. Therapy in Army Installations (Field Hospitals, Evacuation Hospitals,

Convalescent Hospitals).

C. Therapy in Communication Zone Installations (General Hospitals,

Station Hospitals).

SECTION

Therapy in Division Installations {Battalion Aid Station, Collecting Company, Clearing Company)

I. Strains and Sprains

1. Diagnosis: Great care must be taken to exclude the possibility of

fracture. Sharply localized tenderness over bone, rather than ligament,

As noted in the text (p. 161), the orthopedic section of the Manual of Therapy prepared for use in the European Theater of Operations required considerable modification as the experience increased. completely revised draft of this section was prepared in June 1945 by the senior consultant in orthopedic surgery, with the assistance of Lt. Col. John G.

Manning, MC, and Lt. Col. William J. Stewart, MC, but was not published because of the end of thefighting in the

Pacific. It is reproduced in this appendix precisely as it was prepared for publication in June 1945.
336 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

muscle, or tendon, and pain at the site of injury upon manipulation of bones at

distance from the injury are more characteristic of fracture than of sprain. If

there is any doubt as to the diagnosis, the patient should be evacuated to an

Army hospital where roentgenographic examination can be made.

2. Treatment: The objects of treatment are:

a. To prevent oedema and hematoma formation;

b. To disseminate, for more rapid absorption, any hematomata which

have formed.

This is best accomplished by the application of cold (where possible) to

the fresh injury, by compression, and by rest to the injured part. Heat in any

form as primary treatment is illogical and harmful and should not he applied.

All patients with strains and sprains which do not respond rapidly to

conservative treatment should be evacuated to the rear. Treatment of moderate and severe sprains of the major joints and of the back should not be

attempted in the forward areas.

II. Dislocations

No attempt should be made to manipulate or reduce dislocations prior to

roentgenographic examination or without anaesthesia. Pain should be relieved

with morphine. The patient should be placed in litter and the affected part

splinted b} use of folded blankets in the position of maximum comfort. The

patient should then be transferred as rapidly as possible to an Evacuation

Hospital.

HI. Simple Fractures

Simple fractures should be splinted. These patients should be transported

to the Evacuation Hospital as soon as conditions will permit, but in general

these are low priority evacuation cases.

IV. Compound Fractures

The following suggestions are made for the initial handling of patients

with compound fractures due to battle injuries:

1. Examination: rapid but careful examination of the patient should be

made to determine the site of the injury or injuries, so that proper splinting can

be applied. It is not advisable to remove the clothing from the patient for this

examination. Each extremity should be examined separately, and the thorax

and the back should be checked carefully.

2. Treatment:

a. Shock should be treated promptly by infusion of plasma or blood.

b. Morphine should be administered in sufficient quantities to relieve

pain, but morphinism must be avoided. Subcutaneous injections of morphine

are not easily absorbed by patients who are cold or who have low blood pressure

and are in shock. If these conditions are present, the morphine should be administered intravenously to assure immediate relief of pain, but overdosage

must be avoided. The dosage must be recorded on the Emergency Medical tag.

c. Wound
REVISION OF MANUAL OF THERAPY 337

(1) Hemorrhage: The first consideration in the local treatment of the

wound should be the control of hemorrhage. Unless large vessel has been

severed, this can be done by the application of pressure dressing. If this

fails, tourniquet must be applied. If tourniquet is required, every precaution should be taken to guard against the dangers of resulting ischaemia of the

extremity.

(a) Place the tourniquet at the lowest possible level.

(b) Attach red tag to the tourniquet and record the time of

application.

(c) Release the tourniquet and reapply it every hour. In the lower

extremity it may be left in place for two hours.

(d) Evacuate the patient rapidly to point where the hemorrhage

may be controlled surgically.

(2) Chemotherapy: Do not place sulfonamides in the wound, but start

oral administration if the patient does not have an associated belly wound.

(3) Cover wound with an ample sterile dressing.

(4) Immobilize extremity in the appropriate splint.

d. Tetanus Toxoid: Administer cubic centimeter of tetanus toxoid to

any member of the United States Forces and record on Emergency Medical tag.

Administer 3,000 units of anti-tetanic serum to any other patient, unless otherwise instructed.

V. Amputations

Amputations should not be attempted in the forward treatment stations

unless the extremity is almost completely detached. Complete or incomplete

traumatic amputations should be treated like other compound fractures.

Control pain, shock, hemorrhage and apply sterile dressing and adequate splint.

VI. Immobilization ofFractures

The following splints are recommended as emergency measures for application in the field and for immobilization during initial transportation.

1. Femur, Knee, and Proximal Half of Tibia: Apply the Army half-ring

hinged splint and foot traction strap. The shoe must not be removed.

tendency to apply too great degree of traction must be guarded against. If

too much traction is applied, there is great danger of causing severe and disabling pressure sores over the heel cord and dorsum of the foot. If the patient

is detained at any station, the ankle strap should be released temporarily.

2. Distal Half of Tibia, Ankle, and Foot: Apply well-padded wire ladder

splints in the following manner:

a. The first one should be applied posteriorly from the tip of the toes

to well above the knee.

b. The second wire ladder splint should be applied like sugar tong,

extending down the outer side of the leg around the sole of the foot (crossing

over the first splint) and back up the inner side of the leg.

c. Bandage the tw.o splints together snugly.

372572° 56- 23
338 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

3. Shoulder, Humerus, and Elbow: Bind the injured extremity to the chest

wall with triangular bandages or with Velpeau dressing made from gauze or

muslin bandages. Do not use the Murray-Jones hinged ring splint, as it is

painful, difficult to apply, and dangerous.

4. Forearm: Apply well-padded sugar-tong wire ladder splint, supported

with an arm sling.

5. Wrist and Hand: Apply well-padded wire ladder splint to the volar

surface of the forearm and palmar surface of the hand.

6. Lumbar and Dorsal Spine: Place the patient gently on litter, in the

prone position if possible.

7. Cervical Spine: Place blanket (folded so that it makes pad three

inches thick) beneath the shoulders, thus permitting the head to fall backward

slightly. Place folded blankets, articles of clothing, or any other convenient

object on either side of the head to reduce lateral motion of the head.

SECTION

Therapy in Army Installations (Field Hospitals, Evacuation Hospitals,

Convalescent Hospitals

I. Strains and Sprains

1. Acute Strains

Acute strains as rule respond rapidly to rest. The most common

strain is probably that of the lumbar muscles. Absolute rest until all tenderness has subsided is recommended. The patient is allowed to become ambulatory if the pain and spasm do not return; if he continues to improve, he should

be transferred to the Army Convalescent Hospital. Those patients with

strains which do not respond promptly to conservative therapy should be

evacuated to General Hospitals for study and treatment. Patients with

chronic disabling strains should be immediately evacuated to General Hospitals

for study and disposition.

2. Acute Sprains

a. Wrist Joint: An injured wrist should never be treated as sprain

until fracture of the navicular has been absolutely excluded. Roentgenograms

in three planes should be taken. Even if no fracture line is seen in the first

roentgenograms, clear-cut history of fall on the outstretched hand, with

tenderness in the anatomical snuff box, is usually sufficient to justify immobilization in plaster for ten days. At the end of this period, sufficient

absorption will have occurred to make the fracture line visible in re-check

x-ray.

b. Ankle and Knee Joint: Some minimal sprains may be treated in

Army installations. Patients with moderate and severe sprains should be

evacuated immediately, as they cannot be returned to duty within any normal

holding period. Any markedly distended joint should be aspirated under aseptic precautions. The involved joint should be immobilized in the appropriate circular plaster-of-Paris splint for evacuation.
REVISION OF MANUAL OF THERAPY 339

II. Dislocations

Dislocations of major joints should be treated as surgical emergencies. As soon as possible after the diagnosis has been confirmed by roentgenograpbic

examination, closed reduction under general anaesthesia should be performed.

After reduction, the joint should be immobilized in the appropriate circular

plaster-of-Paris splint and the patient should be evacuated as soon as possible.

If closed reduction cannot be accomplished or if, for any other reason, open

reduction is indicated, the patient should be transferred as rapidly as possible

to the nearest General Hospital. Open reductions should not be performed

in Army installations.

III. Simple Fractures

Only few of the simple fractures lend themselves to reduction by manipulation in Army installations. In fractures of the long bones, it is futile to

attempt reduction by manipulation if it is known that reduction cannot be

maintained by the use of circular plaster-of-Paris splint. Fractures should

be immobilized and the patient should be evacuated as soon as possible to

General Hospital where he can have definitive reduction by skeletal traction

and where he can remain until the fracture has become stable. No open

reductions should be performed in Army installations.

IV. Compound Fractures

1. Because of the high morbidity and permanent disability which result

from infection of compound fractures, it is essential that they receive high

priority for surgery. Only by an early, thorough, and adequate debridement

can infection be prevented.

2. Shock following compound fractures of the long bones is usually severe

due to the great loss of blood; this is especially true of fractures of the femur

and fractures of more than one of the long bones. Sufficient replacement of

whole blood is essential. Although it may appear that the patient has been

adequately resuscitated prior to the time of surgery, he may easily drop back

into state of shock during the time of operation. It is frequently necessary,

therefore, to continue the administration of blood during the procedure.

3. Preoperative roentgenographic examination is of value in determining

bone damage and providing information as to the number, size, and location

of opaque materials, besides giving some information as to the degree of softtissue disruption which has occurred. The x-ray films should accompany the

patient to the operating pavilion, so that they will be available to provide

information to the surgeon both before and during the operation.

4. Debridement: The value of an adequate and thorough debridement

cannot be overemphasized. An adequate debridement cannot be performed

unless the surgeon is able to see and differentiate what is healthy and what is

devitalized tissue. It is essential to avoid further insult to the wound, endangering vital structures which, although fortunate enough to have escaped

the enemy shell fragment, may not escape the careless surgeon’s instruments.
340 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

The following principles of debridement in connection with compound fractures

are therefore emphasized:

a. An adequate debridement cannot be performed under local infiltration anaesthesia.

b. Skin must be conserved. Excise only very narrow margin. Rarely

will it be necessary to excise more than one-eighth of an inch.

c. Incision: Every wound, with few exceptions, will require enlargement by incision, so that underlying damage can be visualized and dealt with

properly. Incisions for enlargement of the wound ordinarily are made in the

long axis of the extremity, but should be so placed that they will assist the

surgeon in the General Hospital in performing the delayed primary wound

suture.

d. Subcutaneous Fat: Remove all contaminated and crushed subcutaneous fat.

e. Fascia: Linear incision of the enveloping fascia is not sufficient to

afford adequate drainage and prevent accumulation of blood and hematoma

formation. It is, therefore, necessary also to incise it transversely. All

crushed and devitalized fascia must be excised.

f. Muscle: Excise all devitalized muscle. Non-viable muscle does not

contract when stimulated, or bleed when cut. Never cross-cut viable muscle

bellies to provide exposure. Adequate exposure can be obtained by musclesplitting incisions which are made parallel to the muscle fibers.

g. Retraction: The importance of retraction for visualization cannot be

overemphasized.

h. Irrigation: This should be utilized to the utmost. It is realized that

many times, due to actual water shortage, it will be impossible.

i. Foreign Bodies: All foreign bodies of any size should be removed. If

adequate exposure has been provided, their removal will not present any

problem. Blind probing and prolonged searches for very small metallic foreign

bodies are condemned. j. Bone: Do not remove bone fragments. Any obviously dirty bone

fragments should be cleaned. If detached bone fragments are left in situ they

act as framework for new bone formation.

k. Internal Fixation: No internal fixation is to be performed. Reduction of fractures is not of importance at this time.

l. Wound dressing: Cover the wound with dry, fine-mesh gauze

dressing. In no case should the wound be packed or plugged. Place large

absorbent dressing over the entire wound and fix it in place by use of circular

wraps of sheet wadding.

m. Immobilization: Immobilize the extremity in the appropriate

circular plaster-of-Paris splint.

V. Amputations

1. Indications for Amputation

a. Complete destruction of the blood supply. This means the loss of

the main artery and most of the collateral arteries.
REVISION OF MANUAL OF THERAPY 341

b. Diffuse clostridial myositis.

2. Level of Amputation: Amputation should be performed at the lowest

possible level which the nature and situation of the wound will permit.

3. Type of Amputation: Experience has shown that the open circular

amputation is the procedure of choice in the treatment of war wounds. The

guillotine amputation has not been found as satisfactory and it should not be

used. The skin, muscle, bone and all tissues are divided at exactly the same

level in guillotine amputation, while in circular amputation each tissue

layer beneath the skin is allowed to retract before it is severed, so that, after

amputation has been completed and traction has been applied to the skin, the

stump has the appearance of shallow inverted cone or saucer.

4. Technique of Open Circular Amputation

a. Prepare skin of extremity for surgical procedure.

b. Apply tourniquet.

c. Skin incision is made at the lowest possible level in circular manner

down to the deep fascia. The incision may be made obliquely where indicated

in an effort to conserve skin and length of extremity.

d. Allow skin to retract and next divide deep fascia at the level to which

the skin had retracted.

e. Divide muscle in circular sweeps, cutting about three-fourths of an

inch deep with each sweep, so that as the muscle retracts the next muscle

division takes place at slightly higher level.

f. Cut the periosteum of the bone circularly at the level to which the

last muscle layer has contracted.

g. Saw the bone off cleanly at this level. Do not elevate, strip, or

attempt to remove the periosteum at level higher than the saw cut.

h. Nerves should be severed cleanly at the level of surrounding muscle

division. Do not crush or ligate the nerve ends, or inject them with alcohol. i. Hemostasis of the stump is essential. All large veins and arteries

should be doubly ligated, each one separately, and extreme care should be

taken not to include large amounts of muscle when ligating small vessels.

After all the larger vessels have been ligated, the tourniquet should be removed

and all remaining bleeders ligated.

j. Cover stump end with dry fine-mesh gauze. Do not “dust” or “frost”

the stump with sulfonamide.

k. Skin traction should be applied immediately and be maintained continuously, while the patient is being evacuated and until healing takes place.

There is one exception to this rule. In those cases where amputation is for

clostridial myositis, skin traction shoidd not be applied for the first twenty-four

to forty-eight hours. No patient, however, should be evacuated from an

Army installation until skin traction has been applied. Skin traction for transportation has been found to be most satisfactory if applied in the following

manner:

(1) After the stump end has been covered with sterile fine-mesh
342 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

gauze, apply circular roll of stockinette to the stump and roll this proximally

as far as possible.

(2) Paint the skin with tincture of benzoin and allow it to dry.

(3) Apply an adherent to the skin down to the cut skin edge, then

unroll the stockinette down on the stump. Allow it to adhere to the skin.

Then place traction on the stockinette and put more dressings inside the stockinette up against the end of the stump.

(4) While an assistant continues to apply traction on the stockinette,

apply several layers of sheet wadding loosely over the stockinette which covers

the stump. Then apply circular plaster pylon with an outrigger made of

wire ladder splint. Tie the end of the stockinette to the outrigger with short

piece of elastic traction cord. Plasma tubing may be substituted if elastic

traction cord is not available.

(5) The plaster pylons indicated in each instance are as follows:

(a) Below-the-Knee Stump: Below-the-knee-to-groin pylon, with the

knee in full extension;

(b) Thigh Stumps: Single hip spica pylon, with the hip in neutral

position;

(c) Forearm Stumps: Full-arm pylon with the elbow flexed at 90

degrees;

(d) Arm or Humerus Stump: Shoulder spica pylon with as little

abduction as possible. The axilla should be well padded to avoid pressure.

5. Consultation: Decision for amputation should not be made without

consultation with the Chief of the Surgical Service, or the Senior Surgeon

present. The consultation should be noted in the patient’s medical record.

6. Psychotherapy is of utmost importance in the rehabilitation of the

amputee, and the surgeon, by few words, can help in this program. It is

important that the operating surgeon himself verbally inform every amputee

of the following before the patient is evacuated from the hospital:

a. That the amputation was necessary as life-saving procedure;

b. That it was decided upon after consultation;

c. That further surgery for revision of the stump will probably be

necessary;

d. That he will be sent to center where he will be given limb and where

there are otherfacilities for his rehabilitation.

7. Disarticulation: disarticulation should be performed only when ab- solutely necessary. The stumps are difficult to handle, discharge profusely,

and skin traction is most difficult to maintain. The stumps all need extensive

revision and the majority of these revisions have to be performed in two stages.

Disarticulation of the knee may be undertaken as an emergency measure, but

should not be done routinely.

VI. Immobilization oj Fractures for Evacuation

1. General Principles

a. No bandage, dressing, or adhesive tape which encircles an extremity,

other than sheet wadding, is to be used under plaster splint.
REVISION OF MANUAL OF THERAPY 343

b. Adequately padded plasters are safer in average hands; therefore,

padding should be used over all bony prominences, and sufficient sheet wadding

should be over the soft parts to allow for some swelling.

c. All layers of plaster and sheet wadding encircling the affected extremity must be cut through down to the skin immediately after the application

of the splint, and the splint must be slightly spread. In large percentage of

cases, swelling of the extremity will occur and, unless all layers of the plaster

and sheet wadding are cut through, it will be impossible to spread the cast

sufficiently to prevent extensive damage. This is safety measure which must

be strictly and universally adhered to.

d. Attention should be paid to the position of the extremity encased in

plaster. Ordinarily the foot should be at right angle to the leg, the knee

should be in flexion of 10 degrees to 15 degrees, and the hip in flexion of 20

degrees. The wrist should be supported in slight dorsal flexion, and the elbow

ordinarily at right angle. Plaster applied to the hand should be trimmed

back to the proximal palmar crease to permit full flexion of the fingers and

metacarpophalangeal joints. loop of wire or wicket of plaster should be

applied to the foot of the plaster splint to protect the toes from pressure exerted

by blankets. plaster splint must never extend beyond the width of the litter.

e. line diagram in indelible pencil should be inscribed on the circular

plaster splint to indicate the approximate location of wounds and fractures.

The date of injury, date and type of surgical procedure, and the name of the

unit to which the patient belongs should be written on every circular plaster

splint.

2. Circular Plaster-of-Paris Splints: Experience has shown that the best

form of splint for use in immobilizing fractures for transport from Army installations to the Communication Zone is the circular plaster-of-Paris splint. The

following splints are recommended for the fractures indicated:

a. Double Hip Spica: Any fracture involving the hip joint, femur, knee

joint, and proximal end of the tibia should be immobilized in hip spica. The

spica should extend to the toes on the affected extremity and to just above the

knee on the unaffected extremity. Abduction at the hips must not exceed that

which would cause the extremities to spread beyond the width of the litter.

strut should be placed posteriorly to anchor the thigh sections together and

to furnish strength. This should be placed as far distally as possible so that

bed pan can be used. The body portion of the spica need not extend higher

than the rib margin. folded bath towel should be placed over the abdomen

during application of the splint, and removed when the splint is completed, so

that there will be room for some abdominal distention. The posterior portion

should be trimmed adequately to allow for bowel movements. patient

withfracture of the pelvis will be most comfortable in full-length double hip

spica. The Army hinged half-ring splint should be used only as an emergency

measure and should not be used for transportation of patients from the Army

installation to the General Hospital. If it is necessary, because of the tactical

situation, to use this splint for evacuation of patients from the Army Zone,
344 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

the traction strap must not he used; adhesive plaster applied to the skin of the leg

should be substituted for the traction strap to provide maintenance of traction.

b. Toe-to-Groin Circular Plaster Splint: All fractures of the lower half of the tibia, of thefibula, and of the ankle joint should be immobilized in toe-togroin splint. toe-to-groin cast should extend up to within an inch of the

groin. However, this type of splint is not sufficient immobilization forfractures involving the knee joint and the proximal end of the tibia.

c. Toe-to-Knee Circular Plaster Splint: All fractures of the fore part of

the foot should be immobilized in toe-to-knee splint. The plaster should

extend up to point approximately two inches from the knee joint. Mid-calf plaster boots are very uncomfortable and should never he applied.

d. Plaster-of-Paris Velpeau Bandage: Patients with fractures of the

scapida, shoulder joint, and the proximal two thirds of the humerus, travel

very comfortably in this type of splint. Adequate padding about the elbow

and over the bony prominences of the shoulder is essential. Care should be

taken not to bind the arm too tightly to the chest. However, the splint is not

comfortable if the patient is expected to be ambulatory. It is not an adequate

splint for fractures in the distal third of the humerus, and those involving the

elbow joint.

e. Shoulder Spica Splint: This is the best immobilization for all fractures

of the shoulder joint, humerus, and elbow joint. It should be applied with the

arm held forward and internally rotated, so that the forearm rests in front of

the body and slightly below the level of the nipple line. The medial epicondyle

of the humerus must be adequately and carefully padded. The elbow should

be flexed to or slightly beyond 90 degrees.

f. Circular Arm Plaster Splint: All fractures of the radius, ulna, and

wrist joint should be immobilized in circular arm splint. The splint should

extend from the proximal palmar crease to within an inch of the axillary folds, with the elbow in flexion of 90 degrees. The forearm should be in slight pronation. circular arm splint applied for transportation should not be

employed as hanging cast for fractures of the humerus.

g. Anterior Molded Plaster Splints: Fractures of the metacarpals and

phalanges are best splinted for transportation by the use of an anterior molded

plaster splint, with the hand and fingers in position of function, the wrist

slightly dorsiflexed, and the fingers flexed approximately 30 degrees to 40

degrees at all joints, the thumb adducted and slightly flexed. Only those

fingers involved should be immobilized.

h. Body Jacket: Compression fractures of the vertebrae in which the

spinal cord is not involved, or in which there are no accompanying fractures

of the laminae or pedicles, should be reduced by hyperextension, and plasterof-Paris jacket applied with the patient in this position. For fractures of the

lumbar or lower thoracic vertebrae, the jacket should extend from the symphy- sis pubis to the sternal notch. Cervical and upper thoracic spine fractures

will require an extension of the jacket to include the head. If there are fractures of the pedicles orlaminae withoutinvolvement of the spinal cord, manipu-
REVISION OF MANUAL OF THERAPY 345

lation or hyperextension must not be performed, and the spine should be

immobilized in plaster jacket in neutral position. Plaster-of-Paris jackets

should not be applied in cases of paralysis caused by gunshot wounds of the spine unless the stability of the spine has been destroyed.

3. The following forms of immobilization will not be used:

a. Any form of internal fixation.

b. Any form of skeletal fixation with whes or pins.

c. Murray-Jones hinged ring splints for the upper extremity.

d. Unpadded splints.

e. Unsplit circular plaster splints.

f. “Pulp” or finger-nail traction.

VII. Treatment of Joint Wounds

The following principles will be followed in the treatment of battle wounds

involving joints.

1. All joint wounds must be debrided thoroughly.

2. bloodless field should be obtained by the use of tourniquet whenever

possible.

3. Where adequate exposure cannot be obtained by enlargement of the

wound, it should be assured by use of standard arthrotomy approach.

4. All foreign bodies, loose fragments of bone and cartilage, including

damaged intra-articular cartilages, must be removed.

5. All small debris and blood must be removed by thorough irrigation

of the joint with normal saline solution.

6. The synovium and joint capsule should be closed with single layer

of interrupted non-absorbable sutures. (Sometimes it will be necessary to

close defects in the capsule by swinging fascial flap from the outermost layer

of the capsule.)

7. If the patella has been badly shattered it should be excised, and the

quadriceps and patella tendons sutured together with interrupted nonabsorbable sutures.

8. After the joint capsule has been closed, aspirate the joint and inject

10,000 units of penicillin in cubic centimeters of distilled sterile water.

9. Do not close the skin wound.

10. Do not place sulfonamides into the joint.

11. Do not leave drains in the joint cavity.

12. Arthrotomies should not be performed for recovery of very small

metallic foreign bodies; in the majority of instances they would not be found.

In these cases, aspirate the joint and inject 10,000 units of penicillin.

13. Immobilize the joint by use of the appropriate circular plaster-ofParis splint.

14. Aspiration of the joint and re-injection of penicillin should be carried

out at the end of twenty-four to forty-eight hours, or as may be indicated in

each individual case.

15. The skin wound may be closed at the end of five days if no evidence of

infection is present.
346 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

16. If the tactical situation permits these cases should be held for

minimum of ten days.

VIII. Care oj Hand Wounds

The hand is an extremely useful member of the body and great disability

results from its loss or its relative loss due to dysfunction. Experience in

civilian and military fields has shown that early closure of wounds of the hand

is essential to recovery of good function. In selected cases, primary closure

may be performed in Army installations. Good surgical judgment and technique must be exercised in this procedure. Therefore, this type of work should

not be relegated to the untrained and unqualified surgeon. The following

instructions are guides to be followed in early surgical treatment of battle

wounds of the hand.

1. Surgical procedure

a. Thorough cleansing of the entire hand with soap and water is essential.

This should include the clipping of the fingernails.

b. Debridement must be thorough, but should be done with meticulous

care to avoid further damage. It is essential that the surgeon have an assistant.

All devitalized tissues and foreign bodies must be carefully removed. Hemostasis must be complete and should be accomplished by ligation of all severed

vessels with the finest ligature available (silk, cotton, or chromic catgut). Do

not remove bone fragments. Only that portion of the tendon which is macerated should be excised. The suture of tendons at this time is not indicated.

c. Closure should be performed with widely placed interrupted sutures

without tension. Drains should not be inserted into the wound. If it is impossible to close the wound without tension, approximate the skin edges as

closely as possible with few well-placed stay sutures. It is important that

bone and tendons be covered by soft tissue wherever possible. In few selected

cases, thin split-skin graft may be taken to cover large denuded areas.

d. Amputation oj Fingers: Amputate only those fingers which are irretrievably destroyed. It is possible sometimes to save some skin from finger

which must be amputated; this will aid in the closing of the remainder of the

hand. It is important to salvage every possible portion of the thumb.

2. Dressings

a. Dressings will be applied snugly but not tightly and will adequately

cover the entire wound.

b. Immobilization: The hand will be supported on molded anterior

plaster splint, with the hand and fingers in the position of function, that is, wrist in slight dorsiflexion, the fingers flexed approximately 30 to 40 degrees

at all joints, and the thumb slightly flexed and in moderate adduction and

apposition.

3. Aftercare

a. If primary suture of hand is done, the patient must be held minimum of five days for close observation.

b. The hand must be kept elevated continuously during this period to

minimize swelling and oedema.
REVISION OF MANUAL OF THERAPY 347

c. Penicillin is to be administered throughout the entire period.

d. The primary dressing should not be disturbed until the fifth day,

unless there is evidence of sepsis. Iffever or increase of pain occurs, the wound

should be inspected; and, if infection is present, enough sutures should be removed to allow adequate drainage.

e. Change dressing on the fifth day and inspect the wound under aseptic

conditions. This is to avoid placing in the chain of evacuation the occasional

patient who may have low-grade infection without clinical manifestations.

f. Instruct the patient to keep the hand in position of elevation during

his evacuation.

IX. Gas Gangrene

1. Types of Wound: Wounds destroying muscle, either directly or by interruption of the blood supply, are articularly susceptible to anaerobic or clostridial infections.

2. Types of Infection: The following types of infection must be recognized,

since they require different methods of treatment.

a. Clostridial Gas Gangrene

(1) Diffuse myositis;

(2) Localized myositis;

(3) Cellulitis or “gas abscess”.

b. Streptococcal Gas Gangrene (rare); Myositis.

3. Diagnosis

a. Clinical: Differential diagnosis of the various types of clostridial gas

gangrene and streptococcal myositis must be made to avoid unnecessary or

radical surgical treatment.

(1) Clostridial myositis, diffuse: This may develop within six hours from the time the wound was received and usually develops within three days.

The onset is acute, with severe systemic reaction. Locally there is pain,

mar ked swelling, frequently profuse serous exudate, slight gas formation, variable

odor of decay and pale or blue-gray appearance of the involved muscle. The

skin is tense and often white, but may be mottled with livid appearance if

the process is widespread.

(2) Clostridial myositis, localized: Symptoms and signs are the same as

for the diffuse type except that the process is restricted to single muscle or

group of muscles.

(3) Clostridial cellulitis: This process is limited to the immediate area

of the wound. The onset is gradual, usually three days after injury, with

slight systemic reaction. Locally there is abundant gas formation with foul

odor and slight swelling, and little local change of the muscle and overlying skin

is present.

(4) Streptococcal myositis: The onset is delayed for three or four days,

and severe systemic reactions do not appear until the late stages of infection.

Locally, there is marked swelling, with profuse purulent discharge, slight gas

formation, and slight odor. The involved muscle is slightly oedematous and the
348 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

overlying skin is tense, often with coppery tinge. Streptococcal myositis

comprises only few of the cases of gas gangrene.

b. Laboratory Evidence: Recognition of the infections mentioned must be

made on the basis of clinical findings because adequate laboratory facilities are

not usually immediately available. Confirmatory laboratory evidence is of

statistical importance only and should be obtained when possible, but should

not influence the treatment.

c. Roentgenographic Evidence: The mere presence of gas shadows in

roentgenogram is not sufficient evidence of gas gangrene infection.

4. Prophylaxis: Early adequate debridement of wounds is the best prophylaxis for anaerobic infections. Debridement in cases where there has been

massive destruction of tissue, more particularly in the region of the perineum

and the proximal portion of the femora, and in cases where major vessels are

injured, must be radical and thorough, and long incisions must be made.

5. Treatment

a. Surgical: This depends upon the extent of the disease and the type of

anaerobic infection.

(1) Clostridial myositis, difuse: Amputation well above the site of

involvement must he carried out immediately, using the circular method, and

leaving the wound open. Do not apply skin traction for forty-eight hours.

(2) Clostridial myositis, localized: Extirpation of the involved muscle, or group of muscles, is indicated.

(3) Clostridial cellulitis: Incise the localized area and remove the

devitalized tissue. Radical surgery is not indicated.

(4) Streptococcal myositis: Extensively incise and drain the involved

muscles. Radical extirpation or immediate amputation are not indicated. b. Serum Therapy

(1) Gas-gangrene antitoxin is only effective in combatting the toxin.

Its use is not indicated in those cases in which toxic manifestations are not

present. When indicated, it should be administered intravenously and the

dosage should be governed by the degree of toxicity manifested. Precaution

should be taken to guard against allergic reaction, both early and delayed.

c. Antibiotics and Chemotherapy: None of the sulfonamides nor the various antibiotic agents have any specific action against clostridial infection, but they may be used parenterally or by mouth to help control other bacteria present in these wounds. In the European Theatre in 1944 and 1945, when

only penicillin and sulfonamides were available, the following routine was used:

(1) Penicillin: Give an initial dose of 20,000 units intravenously and

20,000 units intramuscularly, followed by 20,000 units intramuscularly every

two hours for period of three days. Period of therapy may be modified as

necessary.

(2) Sulfonamides: Give grams of sulfadiazine by mouth initially

and gram every four hours thereafter.

d. X-ray irradiation is not indicated.
REVISION OF MANUAL OF THERAPY 349

e. Supportive treatment: Since there is rapid destruction of erythrocytes, frequent whole-blood transfusions will be necessary.

f. All instruments used in cases of anaerobic infections should be sterilized by autoclaving, wheneverpossible. The instruments must not be covered

with oil, since bacteria surrounded by oil are protected against moisture and

therefore are not killed at the usual temperature.

g. If gas-gangrene antitoxin is used, record the number of ampules used and the name of manufacturer.

X. Vascular Injuries

All patients whose extremities are affected and who have had injuries

or ligatures of major arteries should be held in Army hospital installations

for treatment and observation until the danger of either circulatory or gas

gangrene is past. In most cases, this time interval is approximately ten days.

If either gas or circulatory gangrene develops, amputation and other indicated

procedures should be carried out before the patient is evacuated.

Patients with damaged popliteal artery and exhibiting cold extremity,

with hard muscles and loss of sensation distal to the lesion, should have

transcondylar amputation as primary procedure.

SECTION

Therapy in Communication Zone Installations (General Hospitals and Station Hospitals

I. Strains and Sprains

1. Strains: Those strains which do not recover rapidly with conservative

treatment should be studied thoroughly for definite diagnosis or to establish

the cause of continued symptoms.

2. Sprains

a. Ankle joint: Severe sprains lead to partial permanent disability if

they are not properly diagnosed and treated early. The possibility of diastasis

of the inferior tibiofibular joint and rupture of the collateral ligaments must

be considered.

b. Knee joint: differential diagnosis of the pathological findings in

the joint must be made. Treatment and disposition will depend upon the

evacuation policy. If the patient has sprain of the knee, he may be returned

to duty within six weeks. If the injury is more serious, such as an internal

derangement, the period required for recovery and return to full duty will be

four to six months. Many will never be able to return to full duty. No

purely exploratory arthrotomy of the knee joint will be performed.

II. Dislocations: Ordinarily reduction will be performed by manipulation under

general anaesthesia. Open reduction may be resorted to, after adequate consultation, when closed reduction has failed.

III. Simple Fractures: Fractures of the long bones should be treated by skeletal

traction. Open reduction is not to be performed routinely, but only after an
350 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

adequate trial of reduction by skeletal traction has failed. After these fractures have become stable, they should be placed in the appropriate circular

plaster-of-Paris splint and the patients will be evacuated to the Zone of the

Interior. Double pin and plaster fixation is not to be used. Badly displaced

fractures of the radius and ulna which cannot be reduced by other means may

be treated by open reduction and internal fixation.

Fractures of the metatarsals and phalanges should not be immobilized

for long periods of time in plaster casts. “Pulp” traction should not be used.

IV. Compound Fractures

1. Belayed Primary Wound Closure: This is the greatest single advance

in the treatment of compound fractures due to battle wounds. Experience

has shown that it is desirable to close these wounds as early as possible after

the patient arrives in the General Hospital. This should be performed at the

time of the first wound dressing, providing the wound is clean and there is no

gross evidence of infection. If infection is present, it should be treated; and,

as soon as the infection has been controlled, the wound may be closed. Some

wounds may require secondary debridement to control or eliminate infection

before they are ready for delayed primary closures. If the closure is done

within the first ten days, the skin edges are usually still mobile and may be

readily approximated with widely spaced and deeply placed non-absorbable

sutures without undue tension. Where wounds cannot be closed without

tension because of loss of skin, the closure should be completed with skin

grafts. If the wound is ten days old or older, it will usually be necessary to

excise the new epithelium at the margin of the wound and undercut the skin

edges to make them mobile so that they may be approximated. Penicillin or

other antibiotics parenterally or by mouth should be administered one day

prior to and several days after the operation. Sulfonamides should not be

placed in the wound.

2. Reduction and Immobilization

a. Fractures of the Long Bones: Fractures of the femur, tibia and fibula,

and of the humerus will be treated by skeletal traction in every instance where

it is possible to achieve beneficial result within reasonable length of time.

Skeletal traction will be maintained until the position of the fragments has become sufficiently stable so that they will not displace or angulate during transportation in circular plaster-of-Paris splint. The average periods during which patients with these fractures were held in the European Theatre of

Operations are as follows:

Femur to 12 weeks

Tibia and fibula to weeks

Humerus to weeks

b. Fractures of the Long Bones with Loss ofBone Substance: Those patients

who have had large loss of bone substance should not be placed in skeletal

traction. The part affected should be allowed to shorten so that there will be

bone contact. This method is far from ideal. Alignment should be maintained
REVISION OF MANUAL OF THERAPY 351

by plaster immobilization and every effort made to effect an early primary

closure of the wound. These patients need not be held until the fracture

becomes stable, but should be returned to the Zone of the Interior at an early

date in the appropriate circular plaster-of-Paris splints.

c. Fractures of the Long Bones with Severe Nerve Paralysis: In these

patients, the nerve injury takes precedence; therefore, they should immediately

be transferred to neurosurgical center where they will be handled in the

following manner:

Do not overcome shortening by application of skeletal traction as it may

defeat the possibility of accomplishing an end-to-end suture of the nerve.

Splint the fracture in good alignment and perform primary delayed wound

closure at the earliest possible date. If closure is successful and there is no

evidence of residual infection at the end of three weeks from time of closure,

combined operation should be done, suturing the nerve end to end, performing

open reduction of the fracture and using internal fixation when indicated.

d. Internal Fixation in Compound Fractures: Internal fixation of compound fractures is prohibited as routine procedure. It should be resorted to

only after thorough trial of skeletal traction has failed to secure adequate

reduction, and after healing of the compound wound has been accomplished

by suture or skin graft.

e. Fractures ofForearm: These may be treated by circular plaster splints

or by skeletal traction when feasible. Badly displaced fractures may require

open reduction with internal fixation if other methods have failed. This will

not be performed until three weeks after successful delayed primary closure

of the compound wound.

f. Fractures of the Hand and Fingers: In no case should they be immobilized for more than two weeks (see Care of Hand Injuries, VIII).

g. Fractures of the Foot: The primary consideration should be the healing

of the wounds through treatment by suture or skin grafting, followed by early

active motion of toes and tarsal joints.

h. Steinmann Pins and Plaster, Anatomical Splint: The use of double

Steinmann pin with plaster-of-Paris fixation and external metallic fixation

splints is not to be permitted as routine procedure. This method of reduction

and immobilization has led to gross infection and ulceration about the pin

wounds in high percentage of cases.

V. Amputations: The same principles for amputation as are outlined in Section

will also be followed in General Hospitals. All amputations performed are to

be done by the open circular technique. (In cases where traumatic amputations

were followed by amputations done in the forward areas, the stumps showed

irregular skin edges.) In most instances, skin traction will effect closure if it is

adequately applied and maintained. Secondary closure of these stumps will

not be performed in this Theatre. If the skin sleeve is inadequate for closure

by traction, or if the bone ends are obviously too long, revision of the stump should be performed. The skin edges should be mobilized by undercutting.

The protruding muscle and bone should be re-amputated just sufficiently to
352 ORTHOPEDIC SURGERY IN EUROPEAN THEATER

allow closure by continuous skin traction. Split-thickness skin grafts on stumps

of the lower extremity will not tolerate prosthesis. The use of such grafts to

cover amputation stumps is prohibited unless there is an unusual indication.

Skin traction should be maintained continuously. As soon as possible after

an amputation case is admitted to General Hospital, the temporary pylon

splint and skin traction should be removed and replaced. In the General

Hospital traction is best applied by use of weights and pulleys attached to the

bed. The traction apparatus should be arranged so that in thigh and leg

stumps greater degree of skin traction is exerted on the posterior portion of

the stump. Patients withamputations should be in condition to be evacuated

to the Zone of the Interior two or three weeks after admission to General

Hospital, Stumps do not have to be completely healed. However, skin traction

is to be maintained during evacuation by the reapplication of the plaster splint

pylon with outrigger as described in Section B.

VI. Splinting of Fractures for Transfer to the Zone of the Interior

The same general principles (Section B, VI) will be followed in the application of circular plaster-of-Paris splints for evacuation to the Zone of the

Interior, with the exception that these are secondary plaster-of-Paris splints

applied weeks after the injury or operation and therefore need not he split.

All patients should have new plasters applied just prior to departure.

VII. Joint Wounds: These wounds should be closed at the earliest possible

moment by suture or skin graft. If the joint surfaces are not badly damaged,

early active motion should be insisted upon. If, however, the joint surfaces

are so badly damaged that ankylosis is inevitable, the various joints should

be immobilized in the best position for function. The following positions are

recommended.

1. Hip Joint: Flexion of 25 degrees and abduction of degrees, and

neutral position without medial or lateral rotation.

2. Knee Joint: Flexion of 10 to 15 degrees.

3. Ankle Joint: Foot, 10 degrees less than right angle for males; 20 degrees

less than right angle for females.

4. Shoulder Joint. Abduction of humerus of 65 degrees, 45 degrees forward

of the transverse axis, and in midrotation. This position enables the

patient to reach his face with his hand.

5. Elbow Joint: Flexion of 90 degrees. In bilateral cases immobilize

the more seriously damaged joint at 90 degrees and the other at 130 degrees.

6. Wrist Joint: Dorsiflexion of 40 degrees withoutradial or ulnar deviation.

VIII. Hand Injuries:

Centers have been established to care for hand injuries, as these present

special problems. Those hand wounds which have not had primary

closure in hospitals in the forward areas should be closed by delayed primary

closure or with skin grafts as early as possible. The danger of prolonged

immobilization of the hand and fingers cannot be overemphasized. useful

hand with imperfectbone alignment is far more desirable than stiff hand with
REVISION OF MANUAL OF THERAPY 353

perfectly reduced fractures. In selected cases, skeletal traction may be used,

but every effort should be made to maintain active motion of the uninvolved

fingers. Such traction should not be employed longer than two or three weeks.

In no instance should “pulp” traction be used. Amputations should be performed early if there is no possibility of restoring some useful function. Whenever possible, any portion of the thumb should be saved. Effective active

exercises under the supervision of physical therapist must be instituted

early and pursued with diligence.

IX. Gas Gangrene: Same principles of treatment apply as outlined in Section

B, IX.

X. Vascular Injuries: These are not considered to be orthopaedic problems

except for those cases which require amputation, and those which require

treatment of an associated fracture.

XI. Elective Orthopaedic Surgical Procedures: It must be borne in mind that

any major procedure of this kind requires relatively long period of convalescence and that there are few which will result in complete elimination of

partial permanent disability. As rule patients requiring the following procedures will be transferred to the Zone of the Interior:

1. Arthrodesis of the spine or of any major joint;

2. Bone grafts for non-unions;

3. Any t} pe of operation for recurrent dislocation of the shoulder;

4. Arthroplasties, including bunion and hammer-toe operations;

5. Arthrotomies for correction of internal derangement of the knee joint.

Certain exceptions may be made for the possible salvaging of key personnel.

In such cases the concurrence of the local orthopaedic or surgical consultant

will be secured before such procedure is carried out.

372572°—56 24

355

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 II, prepared

by The Surgeon General and published under the direction of the Chief of

Military 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.

357

INDEX

Aachen, 28

Abdomen, wounds of, 10, 55, 56, 59, 78, 81, 223,276

Abduction

in fractures of humerus, 24

of plaster spica, 110

Abduction exercises, 276

Abduction force in fractures of radial head,

122, 123

Abrasions in acromioclavicular dislocations, 198

Abscess formation after secondary resection of knee joint, 312

Abscess of clostridial origin, 174

Access to wounds in plaster for dressings,

46, 52, 105, 114, 175

Acetabulum:

anatomy of, 254

damage to, in jeep dislocations, 255-

256, 258

fracture-dislocations, 254, 269-273

fractures of, 251, 254, 262-268, 269,

275, 276, 292, 301-302

function of, 254, 262, 301

resection of, 232, 302

retroperitoneal hemorrhage with fractures of, 289-291

Achilles tendon, 187

Acromioclavicular cartilages, resection of,

210

Acromioclavicular joint(s):

anatomy of, 195-197

ankylosis of, 202, 210, 212, 218

arthritis of, 202

compression fractures of, 203

dislocation(s) of:

acute, 191

chronic, 185-186

complete, 191-219

complications of, 216-219

incidence of, 191

management of, 195, 202-215

effusion into, 202

function of, 201

fusion of, 212

healing of, 199

Acromioclavicular joint(s)—Continued

roentgenologic examination of, 195-197

sprains of, 207

subluxation of, 196, 207

congenital, 196

synovitis of, 202

variations in, 195-197

Acromioclavicular ligaments, 195

calcification of, 211

experimental studies on, 200

Acromion process:

fractures of, 191, 199, 206, 215

manipulation of, in shoulder dislocations,

203

relation of clavicle to, 195

Adhesions:

after acromioclavicular dislocations, 219

prevention of, in fractures of radial head,

130

Adhesive strappings in acromioclavicular

dislocations, 205, 207, 211

Adjunct therapy, 114, 167-171, 237-238. See also Blood replacement, Fluid

balance.

Adjustments to shoes, 44-45

Administrative considerations:

consultant system, 7-18

hospital facilities and orthopedic equipment, 41-54

management of bone and joint injuries

in prisoners of war, 63-66

mass management of casualties with

bone and joint injuries, 55-61

representative hospital experiences, 67-

70

tours of hospitals, 19-34

training of personnel, 35-39

Adolescence, avascular necrosis of femoral

head in, 295, 301

ADSEC Headquarters, 30

Aerial bombs, 69

Affiliated hospitals, 14, 17, 18

Age:

and incidence of avascular necrosis, 295, 301

and incidence of civilian-type lesions, 68

Unless it is otherwise specified,all references in this index are to (1) orthopedic surgery, (2) the senior consultant in

orthopedic surgery, (3) battle-incurredcompound fractures, and (4) the European Theater of Operations in World War II.
358 INDEX

Age—Continued

as factor in jeep injuries, 252

effect of, in reaction to trauma, 134

influence of, in delayed primary wmund

closure, 100

Air evacuation, 22, 30, 32, 55-56, 58, 70,

78, 191

Airway, patency of, ac surgery, 167

Aldershop, 116

Alinement of fractures

by internal fixation, 116

in plaster traction spunt, 47

in traction cradle, 50

Allied wounded;

amputation in, 157

penicillin therapy in, 169

preferential care of, 63

Allis, Oscar H., 252, 255

Allis technique in dislocations of hip joint,

259

Ambulation

after use of plaster traction splint, 47

in fractures of ankle, 152

American Board of Orthopaedic Surgery, 11

American Board of Surgery, 11, 20

Amputation, 25-26, 32, 155-166

after ligation of popliteal vessels, 106

after use of Tobruk splint, 113

anemia after, 87

application of tourniquet at, 164

at elective site, 159, 161, 165

case fatality rates for, 157-158

consultation before, 165

errors in, 25-26

evolution of technique of, 158-165

frequent use of, by German medical officers, 66

in civilian practice, 157

in combined nerve-bone injuries of femur,

104

in injuries caused by land mines, 166

in noncombat injuries, 67

in suppurative arthritis of

hip joint, 244-245

knee joint, 311

in World War I, 157

in wounds of knee joint, 306, 311

incidence of, 157-158

indication(s) for, 155-157, 158-159, 174

ankylosis of elbow as, 77

clostridial myositis as, 156, 157, 159,

161, 165, 174

gangrene as, 26, 159

massive tissue damage as, 113, 155

Amputation—Continued

indication (s) —continued

revised, 161-165

trauma as, 157, 158-159

vascular damage as, 113, 144, 155, 157, 161, 166

wounds of foot as, 156

level of, 159, 161, 165

of foot, 26, 154

of functionally useless viable limb, 26

of upper extremity, 156, 159

psychotherapy at, 165

skin traction after, 165-166

statistics on, 157-158

technique of, 77, 162-163, 165-166

transportation splinting after, 165-166

traumatic, 77, 166

See also Disarticulation, Primary amputation.

Amputation centers, 162

Amputation stump:

closure of, 25-26

revision of, 162, 163

Amputees:

morale of, 8, 61, 154, 162, 165

priority of evacuation of, 32

rehabilitation of, 162

segregation of, 59, 170

Amyloidosis, 245

Anaerobes, growth of, in devitalized tissue,

173

Anastomosis of

major arteries, 155-156

popliteal artery, 155

Anatomic distribution of fractures of

femur, 112

Anatomic pathology of jeep injuries of hip

joint, 254

Anatomic predisposition to jeep injuries of

hip joint, 252-253

Anatomy of—-

acetabulum, 254

acromioclavicular joint, 196-197 hip joint, 276

knee joint, 306

radial head, 121-122, 128

Anemia

after amputation, 87

in fractures about hip joint, 238

Anesthesia:

for aspiration of elbow joint, 127

for debridement, 87

for inspection of wmunds before surgery, 102

for reduction of fractures, 114
INDEX 359

Anesthesia—Continued

in jeep dislocations of hip joint, 259

in transit hospitals, 58

maintenance of free airway during, 167 See also special types and agents.

Aneurysm, 174

Anglo-American consultants, meeting of, 31

Anglo-Boer War, 221

Angulation of fractures, 89

Ankle:

arthrodesis of, 153

fracture-dislocations of, 153

fractures of, 56, 76, 102

mobilization of, during skeletal traction,

25

sprains of, 151

Ankylosis of

acromioclavicular joint, 202, 210, 212,

218

elbow joint, 77

hip joint, 262, 268, 301

knee joint, 311

Anorexia during chemotherapy, 239

Anterior dislocation of hip joint, 258

Anterior iliofemoral (Smith-Petersen) incision, 232-233, 241, 243, 244, 249, 283

Anterior lateral muscles of leg, 106

Antibiotic therapy, 114, 168-170

in delayed primary wound closure, 103-

104

in fractures about hip, 223, 238

in wounds of knee joint, 316

See also Penicillin.

Anti-gas-gangrene serum, 173

Aponeurosis of deltoid muscle, 199

Appendectomy, 21

Appetite, effect of transfusion on, 167

Appliances for—-

management of compound fractures, 45

54

shoes, 39

Application of

dressings on battlefield, 167

plaster casts by ward attendants, 38

skeletal traction by ward attendants, 38

tourniquet on battlefield, 169

Arch supports, 44-45, 188

Arches, congenital malformations of, 187

Ardennes campaign, 70

Arm:

position of, in plaster spica, 76

wounds of, 102

Armored units, 69

Army Air Forces, 74

Army areas: consultants in, liaison between, 10

holding time in, 25

orthopedic consultants in, 10-11, 15

orthopedicsurgeons in, 18

Arrival of hospitals—-

in United Kingdom Base, 14, 16, 17, 35

on Continent, 17

Arthritis:

after acromioclavicular dislocations, 202, 216-217

after fractures ofradial head, 127

degenerative, 138, 139

excision of clavicle in, 212

See also specific types.

Arthrodesis

after injuries of hip joint, 243, 292, 301,

302

in acromioclavicular dislocations, 210

in fractures of foot, 154

of ankle, 153

Arthroplasty of hip joint, 254, 268, 284, 285, 293, 301, 302

Arthrotomy in—-

acromioclavicular dislocations, 210

fractures of femur, 150

injuries about hip, 224-232, 234, 249,

277, 288

wounds of knee joint, 185, 186, 308, 312-

313, 315, 316

Articular cartilage, damage to

in fractures of radial head, 128-129

in injuries of hip joint, 269

Articulation of radial head, 121

Artificial limb. See Prosthesis.

Aspiration of

elbow joint, 127, 128, 130, 131

knee joint, 150, 307

Assignment of

beds for orthopedic casualties, 16

consultant to field army, 15

orthopedic personnel, 7, 8, 9, 10, 11, 14-

18, 57, 59, 60

technicians for plaster work, 38-39

Associated injuries. See injuries of special

viscera, structures.

Astragalectomy, 153

Astragalus:

fractures of neck of, 153

recurrent luxation of, 151

Atrophy of

clavicle after acromioclavicular dislocations, 217

limbs treated in plaster, 50
360 INDEX

Atrophy of—Continued

muscles, 114, 178

Autogenous bone grafts, 27, 105

in carpal scaphoid fractures, 140-142

Autopsy observations in injuries about hip,

258, 260, 281

Auxiliary surgical groups, 11, 15-16, 37-38,

56

3d—111

4th—86

Avascular necrosis—-

after acromioclavicular dislocations, 217

after carpal scaphoid fractures, 137

after injuries about hip joint, 245-247,

255, 261, 275, 289, 293-296, 301

of astragalus, 153

Avascular sclerosis, 142

Avulsion fractures of—-

acetabulum, 255, 258, 276

clavicle, 207

coracoid process, 215

trapezoid ridge, 215

Azochloramid (chloroazodin), 175

Bacillus proteus, 233, 239

Back, noncombat disability of, 68

Bacterial contamination in injuries about

hip joint, 225

Bacteriology of

joint infections, 233, 239

wound infections, 97

Bacterium coli, 233, 239, 246

Balanced suspension in combined nervebone injuries, 104, 105-106

Balkan frames, 42, 46, 50, 56, 205, 267

in decubitus ulcers, 175

in tented hospitals, 41

Ballottement of clavicle, 209

Bandages—-

in acromioclavicular dislocations, 205

in transportation splinting, 224

Barbiturates, 170

Battalion aid stations, 170, 259

Battey General Hospital, 101

Battle casualties:

British arrangements for care of, 36-37

management of, 19, 73, 75, 81

Battle exhaustion, 170 Battle of Bulge, 79

Bed capacity of tented hospitals, 41

Bed space for orthopedic casualties:

allotment of, 16, 41, 57

location of, 42

Belgian medical service, 39

Belgium, 22, 67, 68, 78, 112

Berkshire, 36

Bigelow, Henry J., 252

Bigelow reduction of dislocations of hip

joint, 259-260

Bigelow’s dislocations of hip joint:

irregular, 258

regulation, 258

Bilateral dislocation of hip joint, 259

Bilingual order forms for shoe corrections,

45

Bipartite scaphoids, 134

Bivalving of transportation casts, 84, 109

Bladder, wounds of, 34, 97, 227, 233, 237,

289

Blake traction, 143, 144

Blandford, 42, 45, 191

Blast injuries, 166, 167

uremic syndrome after, 70

Bleb formation, 120

Bleeding point, ligation of, in secondary

hemorrhage, 175

Blister formation on feet, 187

Blood loss:

at debridement, 147

in fractures of femur, 147, 167

in injuries about hip, 70

Blood replacement, 114, 167-168, 169, 223

after amputation, 87

before initial wound surgery, 167

before internal fixation, 117

before reparative surgery, 95, 100, 102, 103, 167-168

in injuries about hip joint, 224, 238, 249

Blood supply:

damage to

in clostridial infections, 173

in injuries about hip joint, 224, 225,

227-228, 259, 260, 275, 279-280

in wounds of knee joint, 306, 307-308

destruction of, 155-156

of head of femur, 254, 275, 295

of hip joint, 245, 255, 278, 295

of knee joint, 307

of retinacula, 293

Blood vessels:

damage to, by splints, 174-175

erosion of, 174

Blown-straw fractures of femur, 149

Boeck’s sarcoid, 28

Bohler-Braun frame, 47, 49

Bohler-Braun technique in fractures of

bones of leg, disadvantages of, 151

Bohler-Braun traction cradle, 27, 50
INDEX 361

Bombings in Great Britain, 37

Bone, shortening operations on, 104, 105-

106, 144, 146

Bone and joint injuries, casualties with.

See Orthopedic casualties.

Bone fragments:

adjustment of position of, 67

conservation of, 84, 85

displacement of, 123, 151

distraction of, in skeletal traction, 25

excessive removal of, 85, 102

management of, 27, 277

position of

after internal fixation, 118

in fractures of femur, 149

Bone grafts, 83, 102, 106

bone chips used as, 84

elective, 185

in carpal scaphoid fractures, 141-142

in fractures of

bones of forearm, 121

humerus, 27, 144, 146

in prisoners of war, 66

See also special types.

Bone nails, 43

Bone punches, 43

Bone replacement in avascular necrosis,

296

Bones of arm (leg). See Humerus, Tibia, etc.

Bony prominences, protection of, during transportation, 109

Bony spurs, 132

Boobytraps, 69

Bosworth, Boardman M., 211

Braces, 44—45, 205

Braceshops, 39

Brachioclavicular splint, 204, 206

Bradford frame, 52, 236

rotating type, 27

Bristol, 67

British, air evacuation by, 22

British Armv consultants, 39, 111

British Emergency Medical Service, 36

British hospitals, 23, 36-37

British incision for resection of femoral

head in World War I, 243

British Isles. See United Kingdom Base.

British management of

battle casualties, 36-37

injuries about hip in World War I, 226

British Orthopaedic Association, 36

British orthopedic experience used in

training United States personnel, 36-37

British prisoners of war, 66

British provision of supplies in United States hospitals, 42, 44

British use of Tobruk splint, 110-111

Brodie’s abscess of radius, 28

Bromsgrove, 177

Buck’s apparatus, 235, 261

Buerger’s exercises, 32

Bunions, 187

Buried sutures, 88

Bursitis, 67

Bursting fractures of hip joint, 262, 263

Buttocks, wounds of, 34, 84, 111, 157, 235

Buzz bombs, 69

Cachexia, 245

Cadenat, F. M., 201

Calcification of

acromioclavicular ligaments, 211, 216,

219

capsule of hip joint, 289, 292

conoid ligaments, 217

fascia lata, 211

soft tissues of shoulder joint, 217-218

trapezoid ligaments, 217

Calcium gluconate, 168

Callus formation in—-

fractures of femur, 149

fractures of humerus, 145, 146

plaster traction splint, 47

Canadian Army consultants, 39, 113

Cancellous bone chips, 174

in radial head, 121

Capitate bone, 28

Capitellum, 121, 123, 132

Capsular ligament:

calcification of, 216, 219

role of, in acromioclavicular dislocations,

200, 201

Capsule of—-

acetabulum, 254

acromioclavicular joint, 199, 200

hip joint:

blood supply of, 295

calcification of, 289, 292

closure of, 234

damage to, in jeep injuries, 255, 258,

259, 269, 272-275

experimental damage to, 294

ossification of, 261

knee joint, closure of, 306, 308, 309,

313-315

Care of protected German prisoner personnel, 63-66

Carentan, 69
362 INDEX

Carpal navicular fractures. See Carpal

scaphoid fractures.

Carpal scaphoid fractures, 28, 119, 133-143

classification of, 134

diagnosis of, 141-142

factors influencing healing in, 137-142

function after, 135

management of, 134-135, 138, 140-142

mechanics of, 133-134

prognosis of, 142-143

results in, 135-142

statistics on, 134-143

Carpometacarpal joints, 120

Carpus:

application of traction through, 120

dislocation of, 28

Cartilages of knee joint, damage to, 307,

311

Case fatality rates in—-

amputation, 157-158

clostridial myositis, 174

fractures about hip joint, 221, 223, 224

fractures of long bones, 157

wounds of extremities, 81

wounds of knee joint, 305

See also Statistics.

Case histories:

complete dislocation of acromioclavicular

joint, 206, 210, 213-214, 214-215

compound fractures about hip joint:

avascular necrosis, 246-247

inadequate debridement, 228, 229, 241-243

infection from colostomy, 240

reconstructive surgery, 248-249

resection of femoral head, 244

Smith-Petersen approach, 232-233

errors of management, 27-29

fractures of radial head, 132-133

wounds of knee joint, delayed closure of

capsule, 314

Caseload of

evacuation hospitals, 15, 81

field hospitals, 32

forward hospitals, 10

general hospitals, 67-70

hospitals in United Kingdom Base, 22

hospitals on Continent, 29, 78-79

hospitals, relation of, to

mass management of casualties, 55

orthopedic personnel, 14, 60

station hospitals, 56, 57

Causalgia, 107

Casualties with bone and joint injuries.

See Orthopedic casualties.

Causes of secondary hemorrhage, 174

Cavus foot, 187

Cellulities, 315

Centers for specialized care, 21, 25, 59, 61,

86, 104, 162, 177

Certificate of disability discharge, 106

Cervical spine, fractures of, 53, 147

Change of casts

after delayed primary suture, 109

in carpal scaphoid fractures, 135

in evacuation hospitals, 30

Chaplains, 171

Character of compounding wounds, 81

Check of digits during evacuation, 109

Chemotherapy, 67, 168-169

in delayed primary wound closure, 103-

104

in fractures about hip joint, 223, 238, 241

in wounds of knee joint, 307, 316

limitations of, 173

studies on, in primary wound closure, 74

See also special agents.

Cherbourg, 68

Chest, injuries of, 10, 32, 55, 56, 59, 78, 81,

223

Chief Surgeon, European Theater of Operations. See Theater Chief Surgeon.

Chiefs of orthopedic section, utilization of,

in training programs, 16

Chiefs of surgical services, 19

Childhood, avascular necrosis of femoral

head in, 295

Chip fractures of—-

acetabulum, 269, 276

acromion process, 215

clavicle, 215

Chronic dislocations of acromioclavicular

joint, 185-186

Cicatrices, 67

Cicatriciaf formation in coracoclavicular

ligaments, 199

Circular incision for debridement, 85

Circular letters, 7, 33, 36, 63, 66, 68, 75, 77, 163, 169

Circular plaster splints, 23, 24, 76, 110

necessity for splitting of, 33-34, 109

Circular plaster type of countertraction,

165

Civilian care of British battle casualties,

36-37

Civilian concept of medical care, 77
INDEX 363

Civilian orthopedic practice:

amputations in, 157

closed plaster technique in, 73

dislocations of shoulder in, 191

fractures of femur in, 246

injuries about hip joint in, 251, 252, 253,

296-304

results of arthrotomy of knee joint in, 186

wounds of knee joint in, 305

Civilian traffic accidents, 14, 68, 224

Classification of

fractures of—-

carpal scaphoid, 134

humerus, 144-146

radial head, 123

jeep injuries of hip joint, 251-252, 258,

262, 269

wounds of knee joint, 305

Clavicle;

atrophy of, 217

avulsion fractures of, 207

ballottement of, 209

congenital absence of. 212

displacement of, in dislocations of shoulder, 201

excision of, 185-186, 204, 209, 212-216,

217, 218, 219

experimental studies on, in acromioclavicular dislocation, 200-201

fixation of scapula to, 202

fractures of, 95, 143, 191, 198, 199, 215

function of, 210, 212

management of injuries of, 117, 203, 204,

206, 212

overriding of acromial end of, 196, 203

position of, in acromioclavicular dislocations, 204, 206, 207

rarefaction of, 217

relation of, to acromion process, 195

synostosis of, with scapula, 218

Cleveland, Col. Mather. See Senior

consultant.

Clinical data, collection of, 8,

Clinical investigations, supervision of,

Clinical policies, 73-80

Closed fractures. See Simple fractures.

Closed plaster technique, 63, 67, 73, 82

prolonged timelag as indication for, 67

Clostridial infections, 26, 173-174

Clostridial myositis, 26, 80, 110, 174

as indication for amputation, 156, 157,

159, 161, 163, 165

Clostridium welchii, 26, 156, 167

Closure of—■

amputationstump, 25-26, 77

hip joint, 234, 249, 314

knee joint, 306, 308-309, 313-315

wounds

by skin grafts, 88-89, 104

in prisoners of war, 66

of joints, 77

See also Delayed primary wound closure.

Clot formation in fractures of radial head,

130

Colchicine, 28

Collapse ofradius in comminuted fractures,

120

Collateral circulation of femoral head, 245

Collateral ligaments of knee joint, 306

Collection of clinical data, 8,

Colies fracture, 121, 134

Collom, Maj. Spencer A., Jr., 239, 241

Colostomy, 52, 60, 81, 146, 237, 240

Columnar bone in radial head, 121

Combat fatigue, 191

Combat soldiers:

arch supports for, 44

return of, to duty after elective surgery,

185, 186

Combat training, injuries in, 14

Combined penicillin-sulfonamide therapy,

169, 174, 309, 313, 315, 316

Command responsibility in cold injury, 32

Commercy, 41, 69

Comminution:

as indication for excision of patella, 309

cause of, in fractures about hip joint, 225

in combat injuries, 119

in fractures

of bones of foot, 154

of bones of leg, 151

of femur, 149

of humerus, 144

of pelvis, 146

of radial head, 120, 122, 128

resulting from land-mine explosions,

166

Comparison of 1944-45 techniques of

amputation, 163-165

Compensation aspects of injuries of hip

joint, 293

Complete dislocations of acramioclavicular

joint, 191-219

arthritis after, 216-217

case histories, 206, 209, 213-215

complications of, 216-219
364 INDEX

Complete dislocations of acramioclavicular

joint—Continued

diagnosis of, 202

etiology of, 191

experimental observations in, 200-201,

210

fractures associated with, 215-216

literature of, 194, 195, 198, 201, 210

management of, 195, 199, 202-215

nature of lesion of, 197-199

pathologic process in, 199-201

prognosis of, 195, 203

prognostic tests in, 207-209

results in, 202, 204, 205, 206, 207-210, 211, 212, 217

roentgenologic examinations in, 199, 202,

207, 216, 217, 219

subluxation after, 209

surgery in, 203, 204, 207, 210-215

Complications of

combined bone-vascular injuries, 107

dislocations of acromioclavicular joint,

216-219

external fixation, 116

injuries about hip joint, 238-247, 261-

262, 289-296

Tobruk splint, 113

Compounding wounds, nonclosure of, 76, 150, 151

Compresses in—-

osteitis, 173

osteomyelitis, 174

wound infections, 23, 89, 173

Compression fractures of

acetabulum, 275

acromioclavicular joint, 203

clavicle, 199, 215

femur, 296

os calcis, 154

Concepts of orthopedic surgery, 19

Concurrent illness, 170

Concussion injuries, 167

Conditions—-

governing timelag, 78

of wounding, 74

Condyles of

femur, 306, 307, 308, 309

knee joint, 306, 309, 311, 312

Conferences—- with senior consultant, 8, 20

with British and Canadian consultants,

29

See also Meetings.

Congential absence of

clavicle, 212

diarthrosis of shoulder joint, 196

Congenital malformations of bones of feet,

187

Congenital subluxation of shoulder joint,

196

Conoid ligaments, 198, 200, 201, 211, 217

Conservation of—-

bone fragments, 28, 84

skin, 84, 160

Conservatism in amputation of upper extremity, 156, 159

Conservative management of

acromioclavicular dislocations, 195, 199,

203-210

carpal scaphoid fractures, 134-135, 138-

139, 142-143

injuries about hip joint, 226, 227-228,

262, 266, 275, 282, 287, 304

radial-head fractures, 123, 127-129

vascular-bone damage, 155-156

Constitution of hospital centers, 10, 11, 16,

17

Constriction as cause of cold injury, 31

Construction of

lumbosacral splint, 236

plaster traction splint, 45-56

revolving orthopedic frames, 52-53, 236

traction cradle, 50

Urist splint for acromioclavicular dislocations, 206-207

Consultant(s):

access of, to army areas, 10

access of, to higher medical authority,

Anglo-American, meeting of, 31

in medicine,

in orthopedic surgery:

Ninth U. S. Army, 10, 29

Royal Air Force, 36

in surgery, 7, 10

Ninth U. S. Army, 10, 29

Consultant system, 7-18, 37, 73

Consultation

before amputation, 161, 165

with psychiatrist, 170

Continent, the:

evacuation from, 22, 58, 78, 165

air, 32, 55-56

holding period on, 68, 78-79, 113

hospital centers on, 17 hospitals on:

administration of, 30

arrival of, 17, 55, 70
INDEX 365

Continent, the—Continued

hospitals on—continued

utilization of, 17

visits of senior consultant to, 8, 19,

29-34

inadequate debridement on, 89

invasion of, 14, 16, 17, 55, 73, 74

junior consultants on, 8-9, 39, 75

orthopedic facilities on, 41, 43-44

provision for shoe corrections on, 45

use of skeletal traction on, 79, 113

Contraindications to

delayed primary wound closure, 79, 82,

83

internal fixation, 120

local anesthesia at debridement, 87

surgery in injuries about hip joint, 247,

266

Tobruk splint, 111

wound closure in injuries about hip joint,

234

Control of—-

hemorrhage, 167, 224, 307

trenchfoot, 32

Contusions of nerves, 104, 105

Convalescent installations:

4th Convalescent Hospital, 32

827th Convalescent Center, 134-143

Convalescent wards, 60

Conwell, H. Earle, 205, 206

Copper sulfate hematocrit determinations,

167

Coracoacromial syndesmosis, 195

Coracoclavicular ligaments, 199, 200, 201, 216, 218

Coracoclavicular screw, disadvantages of,

211-212

Coracoid process, fractures of, 191, 198-

199, 206, 211, 215

Coronary ligament of elbow, 122

Cortex of bone, damage to, in war wounds,

307

Cotton sutures, 88

Cotyloid labrum, 269

Cotyloid ligament, 254, 278

Cotyloid notch, 259

Counterdrainage, 84, 88, 173

Oounterincisions for dependentdrainage, 95

Counterpressure in management of fractures, 49, 165

Countertraction, 235

Coxarectal fistula, 244

Coxa vara, 149, 235

Cramer wire, 46

Creeping bone replacement, 296

Crepitation in—-

acromioclavicular dislocations, 202, 219

injuries of hip joint, 276, 293

Crimean War, 221

Criteria of

delayed primary wound closure, 82, 86

discharge in fractures of radial head, 130

evacuation in trenchfoot, 32

wound closure after secondary debridement, 88

Cross union in fractures of forearm, 119

Cruciate ligaments of knee joint, 312

Crutchfield tongs, 53

Curettage in osteomyelitis, 174

Cystic bone changes in carpal scaphoid

fractures, 137, 138, 142

Cystotostomy, 146, 237

Damage to —•

blood supply in—■ injuries about hip joint, 275, 278

wounds of knee joint, 306

capsule of knee joint, 306

collateral ligaments of knee joint, 306

nerves in popliteal fossa, 306

quadriceps tendon, 306

retinacula in injuries about hip joint, 269

sciatic nerve, 283

soft tissues in injuries about hip joint, 255,

258, 269, 270

Dashboard blow, 253

Dashboard fractures of acetabulum, 262

Data. See Statistics.

Data of injury recorded on cast, 109

D-day, 19, 91, 168

amputation caused by special missiles

after, 166

caseload of general hospitals after, 57

caseload of transit hospitals after, 56

chemotherapy after, 169, 238

correction of errors in transportation

splinting before, 110

directions for amputation before and

after, 158-161, 162-163

elective surgery before and after, 185

hospital staff conferences before, 39

incidence of noncombat injuries before

and after, 119

management of special fractures before,

143, 144, 152, 154, 224-225

preparation of Manual of Therapy before, 36, 74-75, 82

professional training before, 35-39, 110
366 INDEX

D-day—Continued

provision of arch supports before, 44

psychiatric therapy after, 170

rehabilitation program after, 177

use of internal fixation before, 117

Dead space, obliteration of, 88

Deaths

from clostridial myositis, 26, 156, 174

from orthopedic injuries, 69, 70, 240, 305,

307

from transfusion reactions, 113

from wounds of

buttocks, 84

thigh, 84

See also Case fatality rates.

Debridement, 15, 23, 55, 57, 68, 73, 74, 83-87

before amputation at elective site, 164

by nonorthopedicpersonnel, 15

delayed, 43, 67

edema after, 168

errors at, 37, 101-102

in clostridial infections, 26, 174

in fractures, 76

about hip joint, 224—232, 249

of femur, 147

in transit hospitals, 58

in wounds of knee joint, 315

inadequacy of, with local anesthesia, 87

influence of, 86, 89, 100, 169-170, 173,

174, 226-227, 316

ligation of popliteal vessels at, 113

omission of, 23, 307

principles of, 37, 83-85, 103-104

secondary hemorrhage after, 175

technique of, 84-85, 308-310

wound closure after, 82

wound infection after, 173

See also Initial wound surgery, Secondary debridement.

Decubitus ulcers, 52, 109, 113, 168, 176

Deficiencies in orthopedic supplies, 43

Definitive splinting after reparative surgery, 109-110

Definitive surgery—•

in combined nerve-bone injuries, 105

in United Kingdom Base, 43

in Zone of Interior, 26

on prisoners of war, 66

Deformity—■

after acromioclavicular dislocations, 199,

202, 211

after closed plaster management, 73

after wounding, 171

Deformity—Continued

in fractures of—-

clavicle, 143

shaft of femur, 149

in supracondylar fractures of femur, 149

Degenerative arthritis aftercarpal scaphoid fractures, 138, 139

injuries about hip joint, 261, 262, 301

Delay in—-

delayed primary wound closure, 85-87, 88, 91, 95

because of infection, 87

evacuation because of vascular damage,

175

wound healing, 87

Delayed primary closure of capsule of knee

joint, 313-315

Delayed primary wound closure, 22-24, 37, 61, 73, 82-83, 85-89, 168

by pedicle grafts, 89

by split-thickness skin grafts, 88-89

contraindications to, 79, 82, 83

definitive splinting after, 109-110

evolution of, 81-83

in fractures—-

about hip joint, 234, 240-241, 248, 249

of bones of leg, 151

of femur, 147, 150

in Mediterranean theater, 81-82, 83

in osteitis, 173

in prisoners of war, 63, 66, 103

in unfavorable cases, 101-104

in wounds of

forearm, 119

knee joint, 310, 313, 316

incidence of infection after, 118

management of fractures at, 89-91

removal of sutures after, 109

results of, 82, 83, 91-104, 313

shock after, 115

skeletal traction after, 114

tactical situation in relation to, 79

technique of, 87-89

Delayed wound healing—-

in closed plaster technique, 73

with foreign bodies in situ, 23-24

Deltoid muscle, 199, 201, 209

Demonstration of corrective exercises, 178

Dentate fractures of femur, 149

Dependent drainage

after secondary resection of knee joint,

312

by counterincision, 95

in fractures of femur, 117
INDEX 367

Derwin Training School, 38

Desert areas, wounds sustained in, 74 Destruction of tissue as indication for amputation, 155

Developmental malformations of feet, 187

Deviation of

radius, 120

ulna, 120

Diagnosis of

carpal scaphoid fractures, 21-22, 133-

134, 138, 141-142

clostridial myositis, 156

complete acromioclavicular dislocations,

202

diastasis of inferior tibiofibular joint, 153

fractures of radial head, 126-127

injuries about

ankle, 152

hip joint, 263, 282, 292

trenchfoot, 31

wounds of knee joint, 306-307

Diarthrosis, 195, 196

Diastasis of inferior tibiofibular joint, 153

Dicumarol (bishydroxycoumarin), 291

Diddington, 14

Dietary supplements, 114

Differential diagnosis of

clostridial infections, 156

traumatic arthritis, 293

Difficulties

in management of injuries about hip

joint, 275-276

in reduction of acromioclavicular dislocations, 204

in rotation of orthopedic personnel, 18

in training of orthopedic personnel, 35, 37

of supply, 43

of surgery for vascular injuries, 155-156

Digits, circulatory status of, during transportation, 109

Dilatation of peripheral vessels by whisky,

107

Dillehunt torso cast, 206

Diplomates of American Board of Orthopaedic Surgery, 11

Direct injuries of knee joint, 305

Directives, 7, 82, 88

Dirty wound after inadequate debridement,

83

Disability:

after acromioclaviculai dislocations, 199, 202, 207

after arthrotomy of knee joint, 186

Disability—Continued

after fractures of radial head, 121, ISO132

after injuries about hip joint, 262, 268, 301-302

after resection of clavicle, 212

after wounding, 171

of feet, 187-188

reduction of, by proper methods of

wound closure, 63

Disarticulation:

disadvantages of, 162

of hip joint, 244-245, 249, 275, 283, 285

Dislocations:

civilian type, 67

of carpus, 28

of clavicle, 201, 206, 207-209

of elbow joint, 27

of hip, 28, 70, 258, 260-261, 275-288

of knee joint, 166

of sacroiliac joint, 289

See also Complete dislocations, Incomplete dislocations.

Dispensaries, general;

9th—45

10th—45

Displacement—-

in fractures of

femur, 149, 150, 258, 263, 269, 275, 282, 284-288, 291

foot, 154

inner table of pelvis, 263

leg, 151

neck of astragalus, 153

posterior malleolus, 152

radial head, 122, 123

scapula, 198, 199

of fractures during transportation, 148

Disposition boards, 179, 186

Dissemination of policies, 7, 8, 74-77

Distal traction in fractures of pelvis, 146

Distraction of bone fragments, 25, 115, 116

Disuse atrophy of neck of femur, 261

Diveley, Col. Rex L., 7, 177, 187

Division clearing stations, 29, 78

battle exhaustion in, 170

penicillin therapy in, 169

Division medical units, training of, 36

Division of Rehabilitation, Office Theater

Chief Surgeon,

Dollinger, J., 258

Donor site, 89
368 INDEX

Drainage:

after debridement, 84

after delayed wound closure, 83, 88, 95,

173, 313

after inadequate debridement, 83

after internal fixation, 118

after secondary debridement, 88

after secondary resection of knee joint,

312

in fractures

about hip joint, 234

of femur, 25

in osteomyelitis, 26

in superficial wound infections, 173

in suppurative arthritis of hip joint, 249

in wounds of buttocks, 84

of knee joint, 311

prolonged timelag as indication for, 67

See also special types.

Drainage fluid, loss of serum in, 95

Draining sinuses, 173

Drains, secondary hemorrhage from pressure of, 174

Dressing of

amputation stump, 161, 162

wounds in skeletal traction, 114, 235

wounds on battlefield, 167

Dressings, access to wounds in plaster for,

46, 52, 105, 114, 175

Drill points, 43

Duration of

conservative management in acromioclavicular dislocations, 203

drainage in superficial infections, 173

elevation of extremity after debridement, 168

evacuation splinting, 84

fracture operations, 114

hospitalization:

in combined nerve-bone injuries, 105, 106

in fractures of radial head, 129-132

reduction of, by proper methods of

wound management, 63

immobilization

after resection of radial head, 129

in acromioclavicular dislocations, 204,

205, 207

in carpal scaphoid fractures, 135-138,

139, 143

in disastasis of inferior tibiofibular joint, 153

Duration of—Continued

immobilization—Continued in fractures of

bones of foot, 153-154

bones of forearm, 120

humerus, 146

radial head, 127, 128

in injuries about ankle, 151

in injuries about hip joint, 249, 260-

261, 266

in Tobruk splint, 112

skin traction after amputation, 161, 163

Dysfunction after closed plaster technique,

73

Early secondary closure. See Delayed

primary wound closure.

East Anglia, 14, 73

Eburnation after acromioclavicular dislocation, 199

Ecchymoses in—-

acromioclavicular dislocations, 198

injuries about hip joint, 293

Edema:

after delayed primary wound closure, 109

after ligation of popliteal vessels, 106

after wounding, 168

as manifestation of protein deficiency,

168

control of

by elevation of limb, 95, 105-106

by sympathetic block, 107

in vascular injuries, 86

of rectum, 291

Edinburgh, 177

Effect of

antibiotic therapy, 103-104

chemotherapy, 103-104

delay in reparative surgery, 91

high-velocity missiles, 84

land mines, 157

location of wound on healing, 102, 103

poorly fitted shoes, 187, 188

size of wound on healing, 103

Effusion into

elbow joint, 127

knee joint, 307, 310

shoulder joint, 202

Elastoplast, 205

Elbow:

ankylosis of, 77

aspiration of, 127, 128, 130, 131

coronary ligament of, 122
INDEX 369

Elbow—Continued

disability in, after acromioclavicular dislocation, 207

dislocation of, 27

exposure of, in Monteggia fractures, 119

flexion, of, in occurrence of radial-head

fractures, 121

hemorrhage into, 126, 127, 128, 130

involvement of, in fractures of humerus,

146

Election, site of, 160, 164, 165

Elective bone grafts, 185

Elective surgery, 68, 185-186, 188

Electric nerve stimulation, 104, 106

Elevation of limb

after debridement, 168

in vascular injuries, 86

Elevator, pelvic, disadvantages of, 235

Ellis, J. S., 226, 235, 239, 243

Emergency splinting, 167

Emergency surgery in transit hospitals, 55

Emotional status of orthopedic casualties,

170

Emptying of stomach before surgery, 167

Endothermy, 147

England, 36, 50, 67, 68, 121, 177, 191

Enlisted personnel as

surgical technicians, 60

ward attendants, 38

Equinus varus position, 110, 154

Equipment for care of orthopedic casualties, 42-54

Erosion of blood-vessel wall, 174

Errors

at debridement, 37, 85-87, 101-102, 174

in application of plaster casts, 110

in assignment of

orthopedic personnel, 61

soldiers for limited duty, 179, 187-188

in closure of infected wounds, 173

in delayed primary wound closure, 82

in diagnosis of carpal scaphoid fractures,

133

in evacuation practices, 8, 11, 22, 33-34,

79-80

in insertion of Kirschner wire, 115

in management of

amputation stumps, 25-26

battle casualties, 8, 19, 73

dislocations of elbow joint, 28

fractures of clavicle, 143

fractures of foot, 154

fractures of forearm, 119

fractures of leg, 33

372572° 56 25

Errors—Continued

in management of—Continued factures of long bones, 34

fractures of metacarpals, 33

injuries about hip joint, 224, 227-228

secondary hemorrhage, 175

vascular injuries, 86

wounds of knee joint, 307, 310, 314,

315, 316

in performance of elective surgery, 185

in placing of

colostomy stoma, 240

drains, 174

in rehabilitation program, 177

in splinting, 85, 174-175

in use of

internal fixation, 118

penicillin, 85

traction, 25, 148-149, 165-166

of surgical judgment, 27

Establishment of—-

clinical policies, 74-77

consultant system,

junior consultant system,

Etiology of

acromioclavicular dislocations, 191

avascular necrosis of femoral head, 245-

246, 295-296

clostridial infections, 173

injuries about hip joint, 252-253, 269

trenchfoot, 31

wounds of knee joint, 305

Evacuation;

change of casts before, 109

delay in, because of possible bleeding, 175

errors in, 8, 11, 22, 33-34, 79-80

from Continent, 22, 30, 58, 68, 70, 78

from transit hospital, 55, 56-57

hospitals, 10, 11, 13, 15-16, 29-32, 36, 38,

43, 44, 55, 68, 73, 76, 78, 79, 81, 109,

111-113, 157, 167, 169, 170, 263, 282,

307, 310

influence of tactical situation on, 260

of casualties

managed by closed plaster, 83

with fractures of clavicle, 143

with injuries about hip joint, 260, 277

with trenchfoot, 32

policies of, 8, 78-80

skin traction during, 163

to Zone of Interior, 12, 23, 26, 44, 53, 61,

83, 89, 92, 105, 109, 114, 135, 140, 142,

147, 153, 154, 170, 174, 236, 268, 277
370 INDEX

Evacuation hospitals. See Hospitals, evacuation.

Evaluation of—-

candidates for arthrotomy of knee joint,

186

damage in wounds of knee joint, 307

emotional status, 170

orthopedic personnel—-

by senior consultant, 11-14, 20

in training, 16

surgical risk in blast injuries, 166

Tobruk splint, 112-133

Evolution of

acromioclavicular joint, 195

clinical policies, 73-74

delayed primary wound closure, 81-83

management of injuries about hip joint,

226

technique of amputation, 158-165

Exchange of orthopedic personnel, 37

Exercises, 50, 114, 127, 143, 236, 237, 276,

282, 310

Experimental observations in—-

acromioclavicular dislocations, 200-201, 210

avascular necrosis of femoral head, 295

injuries about hip joint, 263, 294

wounds of hand, 27

Exploration in—-

nerve injuries, 105

secondary hemorrhage, 174

wounds of knee joint, 306

Exposure, protection from, during resuscitation, 167

Extension exercises, 127, 130

Extension, limitation of, in fractures of

radial head, 126

External fixation, 25, 63, 77, 114, 116, 154

External lateral ligament of ankle, 151

External malleolus, 162

External rotator muscles, 275, 279

Extremities:

incidence of wounds of, 10, 81

position of, in transportation splinting,

109

Face, fractures of, 95

Facilities for orthopedic care, 41-54

Factors influencing healing in carpal

scaphoid fractures, 135-142

Failure of wound healing—-

after delayed primary wound closure,

23-24, 96-97, 99, 101, 103-104

due to protein deficiency, 168

Failure of wound healing—Continued

in fractures of

bones of foot, 97

bones of leg, 97

femur, 97

pelvis, 97

Failure of conservative management in—-

carpal scaphoid fractures, 135, 138, 142

injuries about hip joint, 282

Failure of split-thickness skin grafts, 89, 96

Fascia:

inadequate removal of, at debridement,

86

transfer of, in dislocations of shoulder,

211

Fascia lata;

isograft, 211

use of, in ligamentous repair, 200

Fascial planes, opening of, at debridement,

84

Favorable factors in orthopedic injuries,

170

Femoral artery, ligation of, 106

Femur;

anatomic distribution of fractures of, 112

association of nerve injuries with fractures of, 104, 105, 291

avascular necrosis of head of, 245-247, 255, 261, 275, 289, 293-296, 301

blood loss in fractures of, 147, 167

blood supply of head of, 254, 275, 295

clostridial myositis after fractures of, 174

damage to condyles of, 307, 309

displacement of head of, 149, 150, 258,

263, 269, 275, 282, 284-288, 291

disuse atrophy of neck of, 261

drainage in fractures of, 25, 117

failure of delayed primary closure in

fractures of, 97

foreign bodies in condyles of, 308

fractures of, 22, 23, 33, 70, 95, 101, 147-

150, 239, 269, 284-288, 292, 305, 306,

312, 315

function of head of, 243

impact fracture of head of, 245

impacted fractures of head of, 284—285

indications for resection of head of, 243

internal fixation in fractures of, 27, 117

intrapelvic prolusion of head of, 262, 263,

296, 301-302

management of fractures of, 24-25, 27,

105, 114, 117, 148-149

necrosis of, in fractures about hip joint,

246
INDEX 371

Femur—Continued

position of head of, in jeep transportation, 253, 254

posterolateral incision in fractures of, 117

rarefaction of head of, 246

repeated application of skeletal traction

to, 115

resection of head of, 232, 243-244, 249

resorption of head of, 246

sclerosis of

head of, 246

neck of, 246

stellate fractures of, 287

subchondral compression fractures of,

296

subluxation of head of, 246

supracondylar fractures of, 31, 106, 115,

149-150

Tobruk splint in fractures of, 30, 33,

110-113

traction through, in pelvic fractures, 146

transportation splinting in fractures of,

76, 147-148

Ferguson, M. Sgt. Robert, 52

Fever in pyoarthrosis of knee joint, 311

Fibula;

fractures of, 24, 25, 45-49, 70, 76, 151

See also bones of leg.

Fibrocartilage, excision of, in carpal

scaphoid fractures, 141

Field hospitals. See Hospitals, field.

Fifteenth U. S. Army, 10, 70

Figure-of-8 bandage, 143

Findings at operation in fracture-dislocations of hip, 269-275, 279

Fine-mesh gauze, 84, 102, 147, 165

Fingers;

mobilization of, in splinting, 76, 120, 139

wounds of, 26, 27

First aid:

in injuries about hip joint, 223-244, 259, 263, 267

in wounds of knee joint, 307

speed of, 223

First U. S. Army, 29, 32, 86

Fissure fractures of

acetabulum, 258

acromion process, 215

Fixation of carpometacarpal joints, 120

Fixed hospitals:

mission of, 85

tented hospitals serving as, 41

See also General hospitals, Station hospitals.

Flexion;

limitation of, in fractures of radial head,

126

of elbow, in etiology of fractures of

radial head, 121

of hips in—-

fracture management, 146, 235

jeep transportation, 252, 254

plaster traction splint, 46

of knee in Tobruk splint, 30

Flexion exercise, in fractures of radial head,

127, 130

Flinn, Maj. Irvine M., Jr., 188

Fluid balance, maintenance of, 114

Foisie, Lt. Col. Philip S., 179

Followup—-

in fractures of forearm, 121

in injuries about hip joint, 296-304

of nontransportable casualties, 30

Foot:

amputation of, 26, 154

disabilities of, 68, 187-188

edema of, after wounding, 168

elective surgery on, 185, 186, 188

failure of delayed primary wound closure

in wounds of, 97

fractures of bones of, 76, 102, 153-154

malformations of, 187

position of, in splint, 76, 110

soft-tissue lesions of, 187

strain from overtraining, 187

training in disabilities of, 188

Foot drop, 291-292

Footgear, relation of, to cold injury, 31

Forearm;

edema of, after wounding, 168

fractures of bones of, 113, 114, 119-133

statistics on, 120

position of, in occurrence of fractures of

radial head, 121, 126

transportation splinting in injuries of, 76

wounds of, 102, 119

Foreign bodies:

in wounds caused by land mines, 166

management of

in joint injuries, 23-24, 37, 77, 87,

225, 227, 233-243, 305, 308, 315

in soft-tissue wounds, 84, 164, 173

retention of, as cause of

secondary hemorrhage, 174

wound infections, 173

Forward hospitals, 10, 84, 85. See also

Evacuation hospitals, Field hospitals.

Fovea capitis femoris, 285
372 INDEX

Foxhole foot, 31

Fracture beds, supply of, by British, 42

Fracture-dislocations of

ankle, 153

hip joint, 254, 269-304

Fracture Facts, 179

Fracture tables, 42, 43, 44, 60

Fractures:

associated with acromioclavicular dislocations, 215-216

associated with nerve injuries, 21, 59, 81,

83, 84, 85, 86, 104-106, 114, 144, 146,

306

associated with vascular injuries, 59, 78, 80, 81, 85, 86, 106-107, 113, 155-156,

166, 306

delayed primary wound closure in, 23-

24, 82-83

distraction of, in external fixation, 116

early management of, in Mediterranean

theater, 73

errors in management of, 79

external fixation of, 116

in transport pilots, 56

incidence of, 29, 81

instruction on, in London hospitals,

36-37

internal fixation of, 116-118

location of, in relation to management,

114

management of, 109-154

by nonorthopedic personnel, 16

by plaster techniques, 38-39

by skeletal traction, 22, 113-116

of acetabulum, 254, 276-282, 301-302

of acromion process, 191, 199, 206, 215

of ankle, 56, 76

of bones of

face, 95

foot, 76, 153-154

leg, 101, 112, 151

disadvantagesof Bohler-Braun technique in, 151

of carpal scaphoid, 28, 119, 133-143

of cervical spine, 53, 147

of clavicle, 95, 117, 143, 191, 198, 215

of condyles of

femur, 306, 307, 308, 309, 315

tibia, 309, 312

of coracoid process, 191, 206, 215

of external malleolus, 152

of femur, 22, 23, 24-25, 27, 30, 33, 70,

76, 95, 101, 104, 105, 110-113, 114,

115, 117, 147-150, 167, 174, 305, 312

Fractures—Continued

of fibula, 24, 25, 45-49, 70, 76, 151

of head of femur, 269, 284-288, 292, 296

of humerus, 24, 25, 27, 76, 95, 101, 104,

105, 106, 114, 117, 144-146

of ilium, 302

of ischium, 282, 302

of long bones, 25, 33-34, 41, 63, 100-

101, 113-116, 157

of metacarpals, 33

of neck of—-

astragalus, 153

femur, 149

of noncombat origin, 119-154

of os calcis, 153-154, 166

of patella, 34, 95, 117, 305, 309, 312

of pelvis, 26, 50-54, 146-147, 283, 289

of posterior malleolus, 152

of pubis, 302

of radial head, 119, 121-133

of radial neck, 121

of radius, 34, 70, 117, 120

of scapula, 95

of shaft of femur, 112, 149

of spine, 95, 147

of tibia, 24, 25, 33, 45-49, 70, 76, 95, 114,

117, 151, 166, 305, 312, 315

of trapezoid ridge, 215

of trochanter, 28, 247

of ulna, 34, 117, 119

of vertebrae, 95

problems of, 81

reduction of, by manipulation, 114-155

regional, 119-154

transportation splinting in, 67, 76, 84,

85, 87, 109-113, 144, 147-148, 165-

166, 222-224, 234-235, 236, 237, 259-

260, 263, 267, 309, 310

Fractures about hip joint, 221-304

adjunct therapy in, 237-238

amputation in, 244—245

antibiotic therapy in, 22, 238, 239, 245, 246, 249

arthrotomy in, 226-232, 249

association of other wounds with, 225,

239- 241, 244

bacteriology of infections of, 233, 239

blood replacement in, 223, 224, 238, 249

case fatality rate in, 221, 223, 224, 239,

240-

case histories:

avascular necrosis of femoral head,

246-247
INDEX 373

Fractures about hip joint—Continued

case histories—Continued

inadequate debridement, 228, 229, 241-243

infection from colostomy, 240

reconstructive surgery, 248-249

Smith-Petersen approach, 232-233

chemotherapy in, 238, 239, 241, 249

complications of, 236, 237, 238-247, 249-250

delayed primary wound closure in, 234,

248

disarticulation in, 244—245

errors in management of, 227-228

first-aid measures in, 223-224

history of, 221

in Mediterranean theater, 239

incidence of, 239-240

incision in, 232-233

initial wound surgery in, 224-232, 249

literature of, 226

management of, 28, 223-250

in revolving frames, 50-54

in World War I, 224, 225-226, 235,

239, 241, 243

mechanics of injury in, 225

nutritional status in, 237-238

principles of management of, 235, 291

protein deficiency in, 238

reconstructive surgery in, 247-249

results of, 221-222, 228-232, 233, 241,

248-249

roentgenologic examination in, 233, 246

saucerization in, 227, 243

shock in, 224, 227

skeletal traction in, 246, 248, 249

suppurative arthritis in, 238-245

transportation splinting in, 223-224, 234-235

France, 67, 69, 74, 78, 112, 146, 174

Frankau, C. H. S., 235, 239

Frankfurt, 191

Franz, C., 239

Free French, 21

French civilians, 56

French management of fractures about hip

in World War I, 226

French medical service, 39

French techniques in suppurative arthritis

of knee joint, 311

French use of lumbosacral splint, 236

Frenchay Park, 67

Frequency. See Incidence.

Fresh fractures of carpal scaphoid, 134-138

Full-ring leg splint, 76, 111, 112

Full-thickness skin grafts, 88, 105, 174

Function (s) of

acetabulum, 254, 262, 301

acromioclavicular joint, 201

articulations of clavicle, 210

clavicle, 212

coracoacromial syndesmosis, 195

femoral head, 243

hand, 156, 159

orthopedic surgeons in evacuation hospitals, 15-16

senior consultant, 7-8, 19

surgeons in—-

fixed hospitals, 85

forward hospitals, 85

Functional results in—-

carpal scaphoid fractures, 135, 138

closed plaster technique, 83

fractures

about hip joint, 221

of ankle, 153

of forearm, 120

of humerus, 146

injuries of

peroneal nerve, 292

radial nerve, 106

resection of femoral head, 243

wounds of knee joint, 313, 316

Fusion:

in fracture-dislocations of hip joint, 284,

302

in fractures of acetabulum, 268

of acromioclavicular joint, 212

See also Arthrodesis.

Gangrene:

as indication for amputation, 26, 159

evacuation of casualties with, 79

of circulatory origin, 113, 156, 159

Gas bacillus infection. See Clostridial infections.

Gastrocnemius muscle, 149, 150, 156

Gastrointestinal tract, injuries of, 52

Gemelli, 258, 272, 275, 279

General considerations of professional training, 35

General dispensaries:

9th—45

10th—45

General hospitals, 11, 13, 15, 16, 24, 38,

43, 44, 55-56, 57, 58-61, 73, 78, 79, 83, 87, 166, 177, 310

See also Hospital(s), general.
374 INDEX

General medical policies, 77-78

General practitioners, 113

General surgeons, 15

Genitourinary surgery, 59

Genitourinary tract, injuries of, 52

Georgia, 101

German civilians, treatment of emergency

conditions in, 70

German management of injuries about hip

in World War I, 226

German medical officers, care of protected

prisoner personnel by, 63-66

German prisoners of war, 56, 63-66, 69

German use of pelvic suspension, 236

Germany, 78, 91, 157, 191

Gerow, Maj. Gen. Leonard T., 187

Gibben splint, disadvantages of, 205

Girdlestone, G. R., 243

Girdlestone technique for resection of

femoral head, 243-244, 249

advantages of, 243-244

Glasgow, 69

Gluteal setting-up exercises, 282

Gluteus maximus, 279

Gould, Maj. Nathaniel, 121

Gout, 28

Granulation, wound healing by, 82, 83

Grasping pose of hand, 134

Gravityreduction ofdislocations of hip, 259

Great Britain. See United Kingdom Base.

Grove, Lt. Col. John A., 91, 95

Guided missiles, 166

Guillotine amputation, 159-161

Gurd, F. B., 199

Haines, H. H., 263

Haines apparatus, 63

Half-ring splint, 76

Hammertoes, 185

Hampton, Col. Oscar P., Jr., 239, 241

Hand:

function of, 156, 159

after fractures of forearm, 120

mobilization of, in wounds of forearm, 26

position of

in occurrence of fractures of radial

head, 121, 126

in splinting, 134-135, 143

Hand centers, 21

Hand grenades, 225

Hand injuries, 21, 26-27, 59, 60, 102, 168

Hanging cast, 76, 144, 145

Harnesses, 205

Hays, Maj. Gen. S. B., 43

Hayes splint, 224

Head of femur:

avascular necrosis of, 255, 275, 289,

293-296, 301

displacement of

in jeep injuries, 258, 263, 269, 275, 282,

284-288

into scrotum, 258

fractures of, 269, 284-288, 292

impact fracture of, 245

impacted fractures of, 284-285

intrapelvic protrusion of, 262, 263, 296, 301-302

necrosis of, 246

position of, in jeep transportation, 252,

254

resection of, 243-244, 249

resorption of, 246

stellate fractures of, 287

subluxation of, 246

Head of radius. See Radial head.

Head wounds, 32, 276, 290

Healing—-

after delayed primary wound closure,

23-24, 83, 91-104

by granulation, 82, 83, 99

in acromioclavicular dislocations, 199,

201, 209, 210, 217

in injuries about hip joint, 221, 260, 268

in osteomyelitis, 26

of wounds of forearm, 119

Health of troops, 170

Hemarthrosis of—-

elbow joint, 126, 128, 130

knee joint, 150, 307, 315

Hematocrit level before reparative surgery,

117, 167

Hemoglobinuria, 168

Hemolytic streptococcic infection, 239

Hemopneumothorax, 32

Hemorrhage, control of

in injuries of hip joint, 224

in injuries of knee joint, 307

on battlefield, 167

Hemorrhage, failure of resuscitation because of, 167

Hemorrhoidal veins, thrombosis of, 289,

291

Hemorrhoidectomy, 21

Hemostasis at

amputation, 160, 162

debridement, 84

Hemothorax, 81

Herniation of intervertebral disk, 185, 186
INDEX 375

Hernioplasty, 21

Hessen, 70

High altitude, wounds sustained at, 74

High-caloric diet, 238

High-velocity projectiles, 84

Hip joint:

anatomy of, 254, 276

ankylosis of, 262, 301

anterior dislocation of, 258

arthroplasty of, 254

blood supply of, 245, 255, 295

calcification of capsule of, 289, 292

degenerative arthritis of, 262

disarticulation of, 244-245, 249, 275,

283, 285

exarticulation of, 232

flexion of, in jeep transportation, 254

fractures of, 28, 37, 46, 50-54, 69, 70,

221-250

jeep injuries about, 251-304

History, clinical, in fractures of radial head,

121, 126

History of World War I, 185

Holding hospitals, 22, 32, 68

Holding period

for fractures of femur, 148

in army area, 32

in European theater, 99, 143, 154, 186,

260

in forward hospitals, 85

in relation to use of skeletal traction, 78

in station hospitals, 127

In United Kingdom Base, 78

on Continent, 68, 78-79, 113

Holland, 22, 31

Homologous serum hepatitis, 240

Hopital de la Pitie, 41, 66

Hospital center(s), 9-10, 17, 58-61

advantages of, 58

15th—23, 24, 91-100

801st—119, 188

802d—8, 9-10, 16, 42-45, 59-61, 120,

144, 147, 150, 151, 154, 178-179, 191,

221, 239, 251

803d—58-59, 119, 168, 174

804th—156

814th—69-70

Hospital trains, 22, 24

Hospitalization, duration of:

in combined bone-nerve injuries, 105-106

in fractures of radial head, 129-132

reduction of, by proper methods of

wound closure, 63

Hospitals:

arrival of—■

in United Kingdom Base, 14, 16, 17, 35

on Continent, 17

caseload of, 55

evacuation;

2d—14, 29, 30, 74, 157

41st—30, 69

44th—29, 30, 32

45th—33, 104

77th—29, 31

102d—31

111th—33

exchange of personnel between, 37

field:

8th—32, 33, 34

46th—33

51st—34

53d—29

for prisoners of war, 21

general:

19th—101-104, 150, 312

22d—9-10, 22, 24, 25, 27, 28, 45, 47, 50, 52, 115, 151, 236

23d—117

40th—33

46th—117

48th—34

50th—41, 69

62d—29, 30

67th—23, 24, 26, 27, 28

68th—42, 43, 44, 144, 155

74th—22, 25

76th—-33

79th—22

94th—86

97th—25, 45, 191

102d—21, 23, 25

103d—23, 25, 26

104th—22, 24

106th—24, 25

110th—56

112th—24

117th—21, 27

121st—22, 23, 26, 27

129th—179

140th—28

159th—25

187th—23

192d—22, 23

203d—33

216th—22, 23, 25, 26, 28, 168

217th—41, 42, 55, 66, 69-70

298th—67-69, 120, 185
376 INDEX

Hospitals—Continued

in army area, 10-11, 70

in United Kingdom Base, 9, 14, 15, 16,

17, 19-29

on Continent, 9, 17, 30, 70

orthopedic space in, 15-16, 42

professional conferences in, 39

relation of bed capacity to officers’ rank,

18

relation of timelag to location of, 78

representative experiences of, 9-10, 67-

70

staging of, 17

station:

38th—56

49th—74

65th—121-133

110th—22

168th—121-133

tented, for orthopedic casualties, disadvantages of, 41

utilization of qualified orthopedic personnel in, at invasion, 17

visits of consultants to, 8, 19-34, 73

with excess of orthopedic personnel, 15

Howard splint, 206

Humerus:

association of fractures of, with nerve

injuries, 104, 105, 106

fractures of, 24, 25, 27, 76, 95, 101, 117,

144-146

function of articulations of, 210

Hunkin cast, disadvantages of, 205

Hunts, 14

Hyperpyrexia in suppurative arthritis, 239, 311

Ideal management of fractures about hip

joint, 227-228

Identifying sutures in nerve injuries, 84

Iliac crests, traction through, 146

Iliofemoral ligaments, 262

Ilium, fractures of, 302

Immediate flap amputation, 164

Immersion foot, 28

Immobilizationafter debridement, 84

after resection of radial head, 129

after secondary resection of knee joint,

312

as cause of trenchfoot, 31

in acromioclavicular dislocations, 202,

204-210

Immobilization—Continued

in carpal scaphoid fractures, 134-135, 136-138, 139, 142-143

in diastasis of inferior tibiofibular joint,

153

in fractures of bones of—-

foot, 153-154

forearm, 120

in fractures of clavicle, 143

in fractures of external malleolus, 152

in fractures of femur, 245, 284-285, 296

in fractures of humerus, 146

in fractures of pelvis, 146

in fractures of radial head, 127, 128

in fresh fractures about hip joint, 224

in injuries about ankle, 151

in Tobruk splint, 110-113

in wounds of

knee joint, 309, 313

joints, 77, 109

Improvisations in—-

equipment, 46-54

footgear, 31

shoe corrections, 44-45

splinting, 224 Inadequate debridement, 83, 85, 86, 87, 89,

173, 174, 226-227

Incidence of—-

amputation, 157-168

among German prisoners of war, 66

avascular necrosis of femoral head, 246,

294

clostridial myositis, 26, 156, 174

complete acromioclavicular dislocations,

191

disability after acromioclavicular dislocations, 202

disability of feet, 187-188 draining sinuses, 173

failure of healing after reparative surgery, 99, 101

fractures of radial head, 126

infection after reparative surgery, 118

internal fixation, 117

jeep injuries of hip joint, 251, 252, 253,

262-263, 269, 302

nerve-bone injuries, 106, 146

noncombat injuries, 119

orthopedic injuries, 29, 41, 42, 67, 81

osteomyelitis, 26, 99, 100, 101

posterior dislocations of hip joint, 258

recurrent acromioclavicular dislocations,

202
INDEX 377

Incidence of—Continued

shortening operations in nerve-bone injuries, 106

suppurative arthritis, 238-239, 239-240

transfusion reactions, 168

trauma in youth, 252

trenchfoot, 31-32

wound infections, 74, 225

wounds of

extremities, 10, 81

knee joint, 305

Incision and drainage in clostridial infections, 156

Incision

for combined nerve-bone surgery, 105

for debridement, 84, 86

in fractures of radial head, 128-129

in injuries about hip joint, 225, 232-233, 241-243, 249, 279

in Monteggia fractures, 119

for open circular amputation, 162

forresection of femoral head, 243

for secondary resection of knee joint, 312

in wounds of knee joint, 308, 311, 312-

313

Incomplete fractures:

of carpal scaphoid, 134

use of traction cradle for, 50

Incongruous joint surfaces, 197

Indications for

amputation, 77, 113, 144, 155-157, 158,

159, 161-162, 177, 244-245, 311

aspiration-instillation penicillin therapy,

310

bone grafting in carpal scaphoid fractures, 141-142

excision of patella, 309

external fixation, 25, 116

internal fixation, 116, 118, 121, 151, 277

omission of delayed primary wound

closure, 91

penicillin therapy in German prisoners

of war, 66, 169

primary resection of knee joint 309-310

resection of

clavicle, 213-215

femoral head, 243-244

secondary resection of knee joint, 311

skeletal traction, 114, 120, 291

See also Selection of cases.

Indirect injuries of knee joint 305-306

Indirect violence in fractures of femur, 149

Infantry Division(s):

28th—31

29th—187

814th—32

Infection;

after amputation for clostridial infection,

163

after arthrotomy, 150

after debridement under local anesthesia,

87

after delayed primary wound closure, 83

after external fixation, 77

after inadequate debridement, 83

after internal fixation, 117, 118

after secondary closure of amputation

stump, 163

after skeletal traction, 211

as cause of secondary hemorrhage, 174

as contraindication to—■

delayed primary wound closure, 87

early reconstructive surgery, 247

open reduction, 89, 120

blood transfusion in, 167

due to errors at debridement, 84, 86

failure of resuscitation because of, 167

freedom from, in World War II, 169

in closed plaster technique, 73, 82

in combined bone-rectal injuries, 60

in fracture dislocations of ankle, 153

in fractures of

femur, 23, 149, 150

humerus, 146

in injuries about hip joint 70, 233, 234,

236, 237, 238, 239, 249

in prisoners of war, 73

in wounds of

buttocks, 84

knee joint, 305, 308-310, 313

thigh, 84

influence of location of fracture on, 239

protein replacement in, 168

risk of, with prolonged timelag, 49

with use of pins, 115

See also Wound infections.

Inferior tibiofibular diastasis, 153

Influence of

age on delayed primary wound closure,

100

antibiotic therapy on wound infection,

100

blood replacement in reparative surgery,

100

chemotherapy on wound infection, 100
378 INDEX

Influence of—Continued

debridement, 100

location of carpal scaphoid fractures,

135, 137, 138

reduction of carpal scaphoid fractures,

137, 138

vascular changes in carpal scaphoid

fractures, 137-138, 139

Inhalation anesthesia, 87

Initial treatment of casualties in transit

hospitals, 56

Initial wound surgery, 15, 83-87, 167, 224-

232, 249, 307-310, 312-313. See also

Debridement.

Injuries—-

associated with orthopedic injuries, 55

due to mechanized equipment, 119

due to land mines, 68

in armored units, 69

in mass combat training, 14

of gastrointestinal tract, 52, 60

of hand, 60

of head, 32, 276, 290

of sciatic nerve, 244, 245

of soft tissues of feet, 187

of spine, 42, 53

sustained on D-day, 56

See also Wounds, special wounds.

Innervation of wrist joint, 126

Inspection of wounds, 87

Instillation of penicillin into joints, 87,

169, 232, 309

Inter-Allied medical meetings, 36

Interaction of joints of hand, 120

Internal derangements of knee joint, 186

Internal fixation, 116-118

in acromioclavicular dislocations, 210,

211

in combined nerve-bone injuries, 105

in fractures of

bones of leg, 151

femur, 27, 117, 149, 150

humerus, 117, 144

neck of astragalus, 153

patella, 117

posterior malleolus, 152

radius, 117, 121

tibia, 49, 117

ulna, 119

in injuries about hip joint, 249, 262,

266-267, 269, 277, 279-282, 283-284,

292, 302, 303

in Mediterranean theater, 118

in Monteggia fractures, 119

Internal fixation—Continued

in wounds of knee joint, 310

prohibition of

in forward hospitals, 76

in prisoners of war, 66

Intertrochanteric fractures, 149

Intervertebral disk, 186

Intestine, injuries of, 97, 227, 237, 239-240,

241

Intramuscular penicillin therapy, 169, 173,

174

Intrapelvic protrusion of head of femur,

262, 263, 296

Invasion of Continent, 14, 16, 17, 55, 67, 68, 73, 143

training of personnel for, 35-39

See also D-day.

Invasion of Italy, 73

Iron salts, 238

Irreducible fracture-dislocations of hip

joint, 282-284

Irrigation at debridement, 84, 227, 249, 308

Ischemia after use of Kirschner wire, 149

Ischium:

anatomy of, 254

countertraction against, 165, 235

fractures of, 283, 302

pressure of Tobruk splint on, 234

Isograft of fascia lata, 211

Italy, 67, 73

Jacobs, Maj. Julian E., 121

Jeep dislocations of hip joint, 254-262,

297-301

Jeep fracture-dislocations of hip joint, 269-

296, 297-301

Jeep fractures

in RAMP’s, 266

of hip joint, 262-268, 297-301

Jeep injuries of hip joint, 251-304

Jeep:

position of rider in, 254—255

structure of, 252

Jergensen, Maj. Floyd H., 63, 66

Joint relationships, reconstitution of, after

acromioclavicular dislocations, 201

Joints;

elective surgery on, 185

fractures of long bones adjacent to, 116

immobilization of, in transportation

splinting, 109

mobilization of, in combined nerve-bone

injuries, 104

motion of, in skeletal traction, 114
INDEX 379

oints—Continued

of hand, action of, 120

removal of foreign bodies from, 87

wounds of, 77

See also special joints.

Jolly, Douglas W., 226

Jones abduction frame, disadvantages of,

235

Junior consultants, 8-10, 20, 21, 39, 73, 75

Keller-Blake half-ring splint, 149

Keller-Blake modification of Thomas leg

splint, 224

Kennedy General Hospital, 101

Kernodle, Capt. Harold B., 121

Key, John A., 205, 206

Kingston-on-Thames, 177

Kirschner wire(s), 27, 63, 114-116, 120,

144, 148-149, 150, 153, 267

advantages of, 114-115

use of, in treatment of decubitus ulcers,

175

Kleinberg, Samuel, 258

Knee:

fatal wounds of, 69

flexion of, in plaster traction splint, 46

mobility of, in skeletal traction, 25

motion of, in suppurative arthritis, 26

noncombat disability of, 68

position of, in—-

injuries about hip joint, 269

skeletal traction, 115

Tobruk splint, 30, 110

transportation splinting, 110

Knee joint:

anatomy of, 306

ankylosis of, in suppurative arthritis, 311

arthrotomy of, 185, 186

aspiration of, 150

blood supply of, 307

disarticulation of, 162

dislocation of, 166

effusion into, 307, 310

elective surgery on, 185

internal derangements of, 186

resection of, 309-310, 311-312

suppurativearthritis of, 26, 308, 310-312

wounds of, 150, 166, 305-317

Kocher incision, 232, 249, 279

Korean War, 155

Laboratory tests, 57

Laminectomy, 147

Landing ship tanks (LST), 55

Land mines, 32, 33, 68, 70, 157, 166, 225,

233, 305

Latent infection, 169

Lateral incision for resection of femoral

head,243

Lateral traction, 146

Lateral (Watson-Jones) incision, 232

Leg:

edema of, after wounding, 168

fractures of bones of, 101, 112

wounds of, 102, 111

Legg brachioclavicular cast, 206

Legg-Calve-Perthes disease, 296

Level of amputation, 159, 161

Levit, V. C., 226

Liaison:

between Army consultants, 10

between Mediterranean and European

theaters, 73, 82

role of senior consultant in,

Liege, 68, 112

Ligamentopexy, 211

Ligaments:

damage to, in—-

acromioclavicular dislocations, 209,

210, 216

injuries about hip joint, 234

See also special ligaments.

Ligamentum teres, 259, 269, 275, 285, 287

Ligation of

bleeding point in secondary hemorrhage, 175

femoral artery, 106

popliteal vessels, 88, 106, 113, 155-156

Lighting of tented hospitals, 41

Limitations of

chemotherapy, 173

extension in radial-head fractures, 126

external fixation, 116

flexion in radial-head fractures, 126

internal fixation, 117

motion

after acromioclavicular dislocations,

216

after resection of femoral head, 243

in fractures of radial head, 126, 130-

132

in injuries about hip, 277, 292, 293, 301

in wounds of knee joint, 306, 316

penicillin therapy, 169-170, 173

plasma, 167

Limited duty, 179

Liston splint, 224
380 INDEX

Literature of

avascular necrosis of femoral head, 295-

296

complete acromioclavicular dislocations,

194, 195, 198, 201, 210

dislocations of hip joint, 258, 260-261

fracture-dislocations of hip joint, 277,

296, 304

fractures about hip joint, 226

Litter casualties in transit hospitals, 56

Liverpool nail, 248

Local anesthesia, 87

Local chemotherapy, 74, 88, 161, 163, 165, 238, 249, 307, 316

Local penicillin therapy, 74, 150, 169, 173,

238

Localizing signs, absence of, during chemotherapy, 239

Location of

combined nerve-bone injuries, 104

fractures, relation of

to management of, 114

to wound healing, 135-137

hospitals, relation of, to timelag, 78 orthopedic wards, 42

transit hospitals, 55

wounds:

as indication for fracture management,

149

influence of, on healing, 102, 103

London, 36, 37, 39, 44, 45

Long bones:

blood replacement in fractures of, 167 fractures of, 25, 32, 41, 63, 89, 104,

113-116, 157

See also Humerus, Tibia.

Long leg cast, 47, 86, 151, 165-166

for transportation splinting, disadvantages of, 165-166

Lorient-Saint Nazaire pocket, 70

Loss of

bone substance in fractures of humerus,

146

duty days in—-

carpal scaphoid fractures, 143

fractures of radial head, 121

soft tissues in fractures of humerus, 146

position in skeletal traction, 115-116

serum via drainage, 95

skin in splints, 24

Lumbar sympathetic block, 32, 106-107,

156

Lumbosacral splint, 146, 149, 236, 249

advantages of, 236

Lunate cartilage, 263, 304

Lysis of thrombus, 174

McKee nail, 248

Maintenance of—-

fluid balance, 114

skeletal traction, 115-116

skin traction, 166

Malformations. See special types.

Malingering, 31

Malunion, 100, 101

Management of

abdominal injuries, 55, 56

acromioclavicular dislocations, 196, 199,.

202-215

amputees, 8, 165

avascular necrosis of femoral head, 296

battle casualties, 8, 19, 73, 81

bone fragments, 27, 84, 85, 102, 277

carpal scaphoid fractures, 134-135, 138,

140-143

chest injuries, 55, 56

clostridial infections, 174

combined bone-nerve injuries, 84, 104-

106, 144

combined bone-vascular injuries, 55, 86,

104-106

combined nerve-bone injuries, 104-106

decubitus ulcers, 109, 175

draining sinuses, 173

fractures, 61, 73, 76-77, 89-91, 95-100,

109-151

in Mediterranean theater, 73, 239

of bones of foot, 153-154

of bones of forearm, 114, 119-133

of bones of leg, 114, 151

of clavicle, 143

of femur, 114, 148-150

of humerus, 114, 144-146

of long bones, 89, 104, 113-116

of pelvis, 50-54

of radial head, 122, 123, 127-129

immersion foot, 29

injuries about ankle, 151-153

injuries about hip joint, 28, 50-54, 223-

250, 255, 259-261, 262, 263-268,

275-288

in World War I, 224, 225-226, 241, 243

mass casualties, 58-61

planned, advantages of, 57

orthopedic injuries, 8, 19, 78

evolution of, 81-83

in prisoners of war, 63-66

osteomyelitis, 174
INDEX 381

Management of—Continued

psychiatric complications, 170

regional injuries in relation to D-day, 119

retained foreign bodies, 233, 234, 245,

249, 308

simple fractures, 116

wound edges at reparative surgery, 88

wound infections, 89, 173

Management. See also special treatments

and techniques.

Manipulation inacromioclavicular dislocations, 203-204

fractures, 114-115, 149, 154, 235

Manning, Lt. Col. John C., 75, 111, 112,

113

Manpower losses incarpal scaphoid fractures, 143

disabilities of feet, 187

fractures of radial head, 121

Manpower, wastage of, 179

Manual of Therapy, 36, 63, 74-75, 82, 165

revision of, 36, 75, 161-165

Masking, 239, 246

Massachusetts General Hospital, 252, 296-

304

Mass admissions to general hospitals, 79

Mass evacuation, 79

Mass management of

casualties in—-

general hospitals, 58-61

hospital centers, 59-60

transit hospitals, 57-58

fractures, 11, 35, 55-61, 113-116

Massage, 127

Maxillofacial injuries, 32

Mechanics of injury in—-

acromioclavicular dislocations, 197-199

carpal scaphoid fractures, 133-134

fractures of radial head, 121, 123

injuries about hip joint, 225, 263

wounds of knee joint, 305-306

Mechanized equipment, injuries from, 68,

119, 146

Medial capsule of radial head, 122

Medial femoral circumflex vessels, 254, 255,

293, 295

Medial femoral condyle, 311

Medical Field Service School, 36

Medical Gas Treatment Battalion, 91st

32

Medical Group, 68th—-30

Medical officers:

cumulative experience of, 55

morale of, in relation to rank, 18

Medical officers—Continued with combat experience, on disposition

boards, 179

without military experience, 73, 85

without orthopedic experience, 7, 8, 13,

14, 15, 17, 19, 35, 38, 39, 61, 73, 82, 85,

110, 113, 116, 117, 119, 164, 227, 251,

260, 282, 307

response of, to training, 37

without surgical experience, 73, 74, 75

Medicine, consultants in,

Mediterranean theater, 18, 73, 118, 169

delayed primary wound closure in, 81-82,

83

evolution of management of battle casualties in, 81-82

internal fixation in, 118

management of fractures about hip

joint in, 73, 239

Meetings of

British and U. S. Army consultants, 111

British, Canadian, and U. S. Army consultants, 113

junior consultants, 39, 75

U. S. Army consultants, 112

See also Conferences.

Memphis, 101

Menisci of—■

knee joint, 186, 307, 308, 311

shoulder joint, 196, 199, 204, 219

Metacarpals:

fractures of, 33

position of, in carpal scaphoid fractures,

134-135

traction through, 120

Metal, removal of, after internal fixation,

118

Metatarsals:

congenital malformations of, 187

fractures of, 154

Midtarsal fractures, 154

Military Government in Germany, 70

Military Occupational Specialty (MOS),

rating for orthopedic surgery, 11, 16

Mines at sea, 166

Minerva jacket, 147

Minor injuries, 79, 80, 169

Mission of

evacuation hospitals, 15-16, 55, 167

field hospitals, 55

fixed hospitals, 85

forward hospitals, 84, 85

hospitals before D-day, 55

transit hospitals, 55
382 INDEX

Mobility during traction, 25, 249

Movement during treatment of

fingers, 120, 139

hands, 26, 109

joints, 77, 104, 114, 146

knees, 25, 26, 310, 313

Mold arthroplasty, 293, 302

Mongolian-Russian slave laborers, 56

Monteggia fractures, 119

Morale of

casualties, 61, 116, 130, 170

medical officers in relation to rank, 18

Morhange, 69

Morphine, 66, 167, 224

Morphogenesis of diarthrosis, 196

Motion, limitation of

after resection of femoral head, 243

in fractures of radial head, 126

in injuries about hip joint, 277

Muscle atrophy, 114, 178

Muscle spasm, 292

Muscle tissue:

inadequate removal of, at debridement,

86

interposition of, in fractures of femur, 149

loss of, in fractures of humerus, 146

transplantation of, in osteomyelitis, 174

Muscles, influence of, in function of

acromioclavicular joint, 201

femur, 148

Muscles, wounds of, 114, 258

Mushrooming of radial head, 122

Myositis ossificans, 132

Nail fixation in fractures of posterior

malleolus, 152

Nails. See special types.

Napoleonic Wars, 221

Nature of lesion in—-

avascular necrosis, 245-246

complete acromioclavicular dislocations,

197-199

fractures of radial head, 121-123

injuries about hip joint, 225, 233,

255-259, 262-263, 269-275

wounds of knee joint, 305-306

Naumburg, 157

Neck of astragalus, fracture of, 153

Neck of femur:

avascular necrosis of, 246

displacement of, 258

disuse atrophy of, 261

fractures of, 149, 239, 296

sclerosis of, 246

Necrosis

after secondary closure of amputation

stump, 163

of head of femur, 246

of muscles of leg, 156

of skin, 76, 153

Neoplasms, excision of clavicle in, 212

Nerve injuries, 21, 59, 83, 84, 85, 86, 104-

106, 114, 144, 146, 306

Nerves, protection of, during transportation, 109

Neuritis from use of Kirschner wire, 144

Neurolysis, 105

Neuropsychiatric casualties, 22

Neurosurgical centers, 21, 59, 86, 104

Neurosurgical procedures, timing of, 105

Neurosurgery, senior consultant in, 186

New-bone formation, 292

Night pain in jeep injuries of hip joint, 301

Ninth U. S. Army, 10, 29, 31, 86, 111

Nomenclature of trenchfoot, 31

Nonaffiliated hospitals, 14, 18

Nonclosure of

amputation stump, 160, 164

wound at debridement, 76, 84, 227, 309

Noncorabat disabilities, 68

Noncombat injuries, 14, 67-68, 119-154

Noncombat soldiers, arch supports for, 44

Nonpathogenic Clostridium welchii, 156

Normandy, 66, 78, 112, 157

Normandy beaches, 56, 143

Normandy campaign, clostridial myositis

in 174

North Africa, 67, 74, 110

North African Theater of Operations. See

Mediterranean theater.

Nonunion of fractures, 100-101, 135, 142,

149

Novacain (procaine hydrochloride), 29,

106-107, 127

Nurses, rotation of, 38

Nursing care

in fractures of pelvis, 146

in injuries about hip joint, 235, 237-238

in plaster traction splint, 47

in revolving orthopedic frames, 53

of mass orthopedic casualties, 59

Objectives of —-

arthrodesis of shoulder joint, 210

management of—-

acromioclavicular dislocations, 202

battle casualties, 81

reparative surgery, 37
INDEX 383

Objectives of—Continued

management of—Continued secondary resection of knee joint, 311

Oblique fractures of bones of leg, 151

Obliteration of dead space at wound

closure, 88

Obstetricians, 113

Obturator externus, 279

Obturator foramen, 258

Obturator interims, 258, 275, 279

Obturator tendons, 258

Odom, Col. Charles B., 81, 157

Old fractures of carpal scaphoid, 134, 138-

143

Olecranon process, traction through, 144

Omission of

arthrotorny of

hip joint, 226

knee joint, 312-313, 315, 316

debridement, 23, 241, 307

delayed primary wound closure, 91

quadriceps-setting exercises, 310

Onychogryphosis, 28

Oozing from aneurysm, 174

Open circular amputation, 77, 159-161, 162-163

Open fractures. See Fractures.

Open reduction of

dislocation of carpus, 28

fracture dislocations of ankle, 153

fractures, 89

See also Internal fixation.

Open wounds, evacuation to Zone of Interior with, 91, 109

Operating room;

setup of, for reparative surgery, 60

work shifts in, 55

Orbicular ligaments, 119

Order form for shoe corrections, 45

Orr-Trueta technique. See Closed plaster

technique.

Orthopaedic Section, Royal Society of

Medicine, 36

Orthopedic caseload, 14, 29, 67, 69-70

Orthopedic casualties, 7, 8, 10, 14, 15, 19,

41, 55

care of, by general surgeons, 15

collection of data on,

emotional status of, 170

evolution of management of, 81-83

facilities for care of, 41-54

in United Kingdom before D-day, 35

mass management of, 11, 35, 55-61

nursing care of, 38

Orthopedic casualties—Continued

priorities of

care of, 77-78, 81

evacuation of, 32

segregation of, 55, 57, 58, 59-60, 61

advantages of, 42, 55, 57, 58, 59-60,

61, 170

Orthopedic consultations, 70

Orthopedic experience;

gained before D-day, 37

in Zone of Interior, 35

lack of, in mass management of battle

casualties, 36

Orthopedic injuries:

association of, with

abdominal injuries, 55, 66, 59, 78, 81,

223, 276

chest injuries, 32, 55, 56, 78, 81, 223

nerve injuries, 21, 59, 81, 83, 84, 85,

86, 104-106, 114, 144, 146, 306

vascular injuries, 59, 78, 80, 81, 85, 86,

106-107, 113, 155-156, 166, 306

incidence of, 41, 42

management of, in prisoners of war, 63-

66

Orthopedic personnel:

assignment of, 7, 8, 9, 10, 11, 14-18, 58,

59, 60

economical use of, in plaster techniques,

49, 111

evaluation of, 11-14, 16, 20

excess of, on hospital staffs, 14, 15

qualifications of, 7, 11-14, 19, 20-21

rank of, 18

rotation of, 15, 16, 17-18

shortages of, 14, 16, 21, 113, 227

training of, 16, 35-39

in use of Tobruk splint, 111

Orthopedic services, administration of, 21-

22

Orthopedic surgeons:

in army areas, 18

in field hospitals, 15

in evacuation hospitals, 15-16

in general hospitals, 16

in hospital centers, 10

psychiatric therapy by, 171

rating of Tobruk splint by, 112-113

Orthopedic surgery:

concepts of, 19

spot checks of, 15

Orthopedic wards, location of, 42

Osborne incision, 279

Osborne, R. P., 279
384 INDEX

Os calcis:

fractures of, 153-154, 166

traction through, 151, 153

Osmond-Clarkb, Air Vice-Commodore, 36

Ossification of

capsule of hip joint, 261

coracoclavicular ligaments, 216, 218

periarticular structures of hip joint, 278

Osteitis, 173

fibrosa cystica of tibia, 28

Osteocartilaginousbodies in shoulder joint,

199, 216

Osteochondritis, 67, 132, 217

Osteomyelitis, 66, 67, 174

after external fixation, 116

after failure of delayed primary wound

closure, 97, 99, 100, 101

after internal fixation, 116

after use of pins and wires, 115

excision of clavicle in, 212

incidence of, 26, 99, 100, 101

of pelvis, 26

Osteotome, 43

Osteotomy, in fractures of forearm, 121

Otolaryngologists, 15

Overtreatment, risks of, 81

Oxygen, use of, during resuscitation, 167

Pacific theaters, 75

Packing of wounds at debridement, 86, 102

Packs:

as cause of secondary hemorrhage, 174

control of oozing by, 175

Padding of plaster casts, 76, 109, 110

Pain:

in acromioclavicular dislocations, 202,

207, 209, 211, 216, 217, 219

in feet after training marches, 187

in fractures of—-

foot, 154

radial head, 122, 126

in immersion foot, 29

in injuries about hip joint, 224, 268, 292,

293, 297, 301, 302

in sciatic-nerve palsy, 291-292

in suppurativearthritis of knee joint, 311

in transportation in Tobruk splint, 24, 113

referred to wrist in radial-head fractures,

126

Parachute jumps, 191

Paralysis—-

after wounds of knee joint, 306

of muscles in compound fractures, 115

Paralysis—Continued

of peroneal nerve, 283

of radial nerve in fractures of humerus,

131, 144, 146

Parapatellar incision, 308, 311, 313

Paraplegia, 53

Paratroopers, 22, 56

Paris, 39, 41, 45, 66, 69, 70, 113

Patella:

fractures of, 34, 95, 117, 305, 307, 312, 315

resection of, 309, 312

Pathologic process inacromioclavicular dislocations, 199-201

injuries about hip joint, 254

suppurative arthritis of knee joint, 311

Patients;

evaluation of Tobruk splint by, 113

morale of, 130

role of, in rehabilitation, 178

warning of, against secondary hemorrhage, 175

Pearl Harbor, 116

Pediatricians, 113

Pedicle flaps, 59

Pedicle grafts, 25, 66, 89

Pelvic abscess, 244

Pelvis:

fractures of, 26, 95, 97, 146-147, 263,

283- 289, 301

management of, in revolving orthopedic

frames, 50-54

protrusion of femoral head into, 263, 267,

296, 301-303

Penetrating wounds, 99

of knee joint, 305, 306, 308, 309, 315

suppurative arthritis after, 310-312

of popliteal artery, 106

Penicillin therapy, 26, 60, 67, 85, 87, 100,

169-170, 173

errors in use of, 85

in clostridial myositis, 156, 174

in combined nerve-bone injuries, 105

in fractures of femur, 150

in injuries about hip joint, 224, 226, 232,

238, 239, 249

in internal fixation, 117

in osteitis, 173

in osteomyelitis, 174

in suppurative arthritis, 26

in wounds of knee joint, 309, 310, 313,

315

limitation of use of, in prisoners of war, 66
INDEX 385

Penicillin therapy—Continued

limitations of, 85, 173

masking with use of, 239, 246

studies on, 74

Penicillin-resistant infections, 245

Penrose drains, 86, 241

Pentothal sodium (thiopental sodium), 114,

152, 259

Perforating wounds, 99

of knee joint, 315

of viscera, 81

omission of debridement in, 85

Perilunate posterior dislocation of carpus,

28

Perineum, pain in, with Tobruk splint, 113

Peripheral vessels, dilatation of, by whisky,

107

Peroneal-nerve damage, 283, 291-292

Personnel:

failure of, in screening for evacuation, 80

of auxiliary surgical groups, training by,

37-38

of evacuation hospitals, training of, 36, 38

Pfalz, 70

Phemister transarticular wire, 211

Physical findings inacromioclavicular dislocations, 202

suppurative arthritis of knee joint, 311

wounds of knee joint, 306-307

Physical therapists, shortages of, 178

Physician-patient relationships, 61

Physiologic salt solution for compresses,

173, 174

Physiotherapy, 52, 57, 104, 127, 128, 129,

154, 178-179, 207, 237

Picket-fence temperature, 311

Pierson attachment to Thomas splint, 27,

46-47, 145, 151, 276, 282

Pinhole osteomyelitis, 116

Piriformis muscle, 258, 275, 279

Pitney, Sgt. William, 179

Plasma protein deficits, 168, 238

Plasma transfusion, 57, 167, 168, 224

homologous serum hepatitis after, 240

Plaster, supplies of, 44

Plaster. See also Immobilization, Splints.

Plaster bandages, preparation of, 39

Plaster body jacket, 147

Plaster casts, 11, 38, 39, 50, 109

change of, before evacuation, 30, 135

constriction by, as predisposition to

clostridial infection, 173

errors in application of, 110

Plaster casts—Continued

provision of windows in, 46, 105, 109,

114, 175

record of wound data on, 109

Plaster hip spica, 24, 30, 33, 52, 76, 110, 113,

147, 148, 161, 163, 165-166, 234-235,

236, 260, 263, 267, 309, 310, 312, 313

Plaster room, 42

Plaster shoulder spica, 163

Plaster techniques, 19, 24, 30-31, 36, 37,

38-39, 63, 109-110, 165

Plaster traction splint, 45-49, 151

advantages of, 49

Plaster transportation splinting, 38, 67, 76

disadvantages of, 110

principles of, 109-110

Plaster Velpeau, 76, 144, 205, 206

Plastic centers, 25

Plastic splinting, 110

Plastic surgery, 59, 88

on hands, 27

on tendons, 59

Plating of fractures, 27, 49, 76, 105

Policies of

evacuation, 78-80

management, 7, 19, 39, 74-77, 81-83

See also Clinical policies.

Pontocaine (tetracaine hydrochloride), injection of, in immersion foot, 29

Pool, Eugene H., 225, 226

Popliteal space:

contents of, 306

protection of, in Tobruk splint, 111

Popliteal vessels;

anastomosis of, 155

damage to, 106, 166, 306

ligation of, 86, 106, 113, 155-156

Portable fracture tables, 43

Portable X-ray equipment, 41, 60

Position;

after operations on hip joint, 282

as factor in jeep injuries, 252-253

in fractures of

femur, 22

foot in plaster cast, 76, 154

loss of, in skeletal fraction, 115-116

of clavicle in acromioclavicular dislocations, 204, 206, 207

of coracoid process in acromioclavicular

dislocations, 198-199

of femoral head in jeep transportation,

253, 254

372572°—56 26
386 INDEX

Position—Continued

of forearm

in fractures of radial head, 127, 128,

129

in occurrence of fractures of radial

head, 121, 126

of fragments after internal fixation, 118

of hand in occurrence of fractures of

radial head, 121, 126

of heel inroentgenography of ankle, 152

of knees in—-

skeletal traction, 115

Tobruk splint, 110

transportation splinting, 110

of limb after vascular ligation, 106

of patient during resuscitation, 167

of scapula in acromioclavicular dislocations, 206

of sciatic nerve in fracture dislocations

of hip joint, 279

of wrist in transportation splinting, 77

Posterior dislocations of hip joint, 258. 269.

276-282

Posterior incision of hip joint, 241, 243

Posterior (Kocher) incision, 232, 249

Posterior malleolus, fractures of, 152

Posterior (Osborne) incision, 279

Posterior tibial vessels, 153

Posterior (Von Langenbeck) incision, 279

Posterolateral incision in—-

fractures of femur, 117

resection of femoral head, 243

Postoperative complications, 173-175

after resection of radial head, 131

Postoperative management in fracture-dislocations of hip joint, 282

Precautions against secondary hemorrhage,

175

Preferential care of Allied wounded, 63

Preoperative care in transit hospitals, 58

Preoperative morbidity, 70

Preoperative preparation—-

after prolonged timelag, 67

for reparative surgery, 100

in blast injuries, 166

of plaster bandages, 39

of skin for amputation, 162

of surgical field, 88

Pressure dressings, 84, 88, 89, 173, 174

control of bleeding by, 175, 224

Pressure of drains and packs as cause of

secondary hemorrhage, 174

Pressure of Tobruk splint, 111, 113, 234

Pressure sores. See Decubitus ulcers.

Prevention of—■

angulation of fractures, 89

contamination in injuries about hip joint,

241

decubitus ulcers, 175

edema of limb, 95, 105-106

infection in wounds of knee joint, 305, 309-310

scar-tissue formation, 88

shock, 268

Preventive Medicine Division, Office of the

Surgeon, Ninth U. S. Army, 31

Pridie operation, 154

Primary amputation for vascular injuries,

155-156

Primary nerve suture, 84

Primary resection of—•

hip joint, 226

knee joint, 309-310

Primary wound closure, studies of, 74

Principles of

debridement, 37, 83-85, 103-104

initial wound surgery in injuries about

hip joint, 225-226, 249

management of—•

fractures about hip joint, 235, 241, 304

nerve-bone injuries, 104—105

resuscitation, 167-168

transportation splinting, 109-110

wounds of knee joint, 315

Priorities of—-

evacuation, 32

management of fractures of hip joint, 227

Priorities of care of orthopedic injuries, 55,

57-58, 59-60, 77-78, 81, 87-88

Prisoners of war:

amputation in, 157

care of, in tented hospitals, 41

chemotherapy in, 169

fractures of femur in, 150

hospitals for, 21

management of injuries in, 63-66

penicillin therapy in, 66, 169

results of

delayed primary wound closure in,

101-104

skin grafting in, 89

wounds of knee jointin, 14, 16-19, 20, 21, 312, 313, 314, 316

See also special nationalities.

Problems of—-

blood replacement, 238

fracture management, 81
INDEX 387

Problems of—Continued

reassignment of personnel with civiliantype disabilities, 68

suspension management of fractures of

bones of leg, 151

Prodromal signs of secondary hemorrhage,

175

Professional conferences, 39

Professional Services Division, Office of

Theater Chief Surgeon,

Professional training of orthopedic personnel, 7, 10, 13, 16, 19, 35-39, 86

Profundus, ligation of femoral artery below,

106

Prognosis of

acromioclavicular dislocations, 195, 203,

207-209

carpal scaphoid fractures, 142-113

fracture-dislocations of hip joint, 303-

304

Prognostic tests in acromioclavicular dislocations, 207-209

Prohibition of

external fixation, 116

internal fixation as primary procedure,

117

local sulfonamide therapy, 88

primary nerve suture, 84

Prolongation of timelag, 49, 78, 103

Pronation in fractures of

bones of forearm, 119

radial head, 121, 122, 130

Prone position after secondary resection of

knee joint, 312

Prostheses, 162, 164, 178

Protected prisoner medical personnel, 63-

66

Protection

from exposure during resuscitation, 167

of blood supply at operation, 279-280

of bony prominences in transportation

splinting, 109

of nerves in transportation splinting, 109

of popliteal space in Tobruk splint, 111

Protein deficits, 95, 168, 249

Protein-high diet in decubitus ulcers, 175

Protein replacement, 168

Protusion of femoral head into pelvis, 263,

296, 301-303

Psychiatrists, 170

Psychologic considerations in—-

arthrotomy of knee joint, 186

trenchfoot, 32

Psychoneurosis, 67

Psychosomatic conditions, 191

Psychotherapy, 162, 165, 170-171

Pubis, fractures of, 262, 302

Pulp traction in metacarpal fractures, 33

Quadrate ligament, 122

Quadratus femoris, 258

Quadriceps exercises, 237, 276, 310

Quadriceps tendon, involvement of, in

wounds of knee joint, 306

Qualifications of

chiefs of surgical services, 19

orthopedicpersonnel, 7, 11-14, 19, 20-21

Qualified orthopedic personnel, utilization

of, 17

Questionnaire for trenchfoot casualties, 32

Quigley, Lt. Col. Thomas B., 45

Radial deviation, 120

Radial head:

anatomy of, 121-122, 128

case histories of fractures of, 132-133

fractures of, 119-133

Radial nerve;

anatomy of, 126

association of injuries of, with bone

injuries, 104, 106, 144 paralysis of, 131, 146

Radio-ulnar joint, 126

Radius;

Brodie’s abscess of, 28

fractures of, 34, 70, 117, 120, 121

See also bones of forearm.

RAMP’s, 70

Rank of orthopedic personnel, 18

Rarefaction of

clavicle, 217

head of femur, 246

Reactivation of latent infection, 169

Reassignment of soldiers, 68, 185, 188

Recommendation for limited duty, 179

Reconstitution of joint relationships, 201

Reconstructive surgery, 66, 185-186, 247—

249. See also special operations.

Record of—-

indications for amputation, 161, 162

wound data on cast, 86, 109

Recovery ward, 115

Rectum;

edema of, 291

wounds of, 60, 244

Rectus femoris, tenotomy of, 232
388 INDEX

Resection of

acetabulum, 232, 302

acromioclavicular cartilages, 210

anterior lateral muscles of leg, 106

clavicle, 185-186, 204, 209, 212-216, 217,

218, 219

femoral head, 232, 243-244, 249

fibrocartilage in carpal scaphoid fractures, 141

menisci of knee joint, 186, 308

os calcis, 154

patella, 312

radial head, 128-129, 131

ulna, 121

Reserve, evacuation hospitals held in,

15-16

Restriction of—-

surgery for ruptured lumbar disk, 186

use of penicillin in German prisoners of

war, 66

weight bearing in injuries about hip

joint, 261-262, 296, 297

Results

in acromioclavicular dislocations, 202,

204, 205, 206, 207-210, 212, 217

in carpal scaphoid fractures, 135-138,

139-142

in clostridial infections, 174

in fractures of

bones of foot, 154

clavicle, 143

humerus, 146

in injuries about hip joint, 221-222, 228-

232, 233, 238, 241, 248-249, 260, 261,

275, 282, 284, 292, 296-304

in osteomyelitis, 174

in suppurativearthritis of knee joint, 311

in wounds of knee joint, 186, 310, 315,

316

of adequate debridement, 83

of antibiotic therapy, 169, 238

of conservative management of vascular

injuries, 155-156

of delayed primary wound closure, 82, 83,

87, 91-104, 151, 313-315

of elective surgery, 185, 186

of external fixation, 116

of internal fixation, 117-118, 151

of physical therapy, 179

of plaster traction splint, 151

of protein replacement, 168

of rehabilitation, 177

of secondary resection of knee joint, 311

of shortening operations on bones, 106

Recurrence of

acromioclavicular dislocations, 202

trenchfoot, 32

Recurrent luxation of astragalus, 151

Red Cross, 57, 171

Redebridement, 173

Reduction:

in acromioclavicular dislocations, 203-

204

in fracture-dislocations of ankle, 153

influence of, in carpal scaphoid fractures,

137, 138

loss of, 148

maintenance of, 114

not function of forward hospitals, 76, 84

of fractures

by manipulation, 114-115

of bones of forearm, 119

of bones of leg, 151

of neck of astragalus, 153

of pelvis, 156

of posterior malleolus, 152

of radial head, 119, 126

of jeep dislocations about hip joint, 235,

259-260

Regional fractures, 119-154

Rehabilitation, 60, 170, 177-183

after arthrotomy of knee joint, 186

after carpal scaphoid fractures, 135

of amputees, 162

Rehabilitation centers:

advantages of, 177

in general hospitals, disadvantages of, 177

Rehabilitation Division, Office, Theater

Chief Surgeon, 7, 11, 177

Relation of—-

delayed primary wound closure to tactical situation, 79

hospital caseload to mass management of

casualties, 55

location of fractures to fracture techniques, 114

wounds to fracture management, 114

Relaxing incision, 151

Remedial exercises, 178-179

Removal of

metal after internal fixation, 118

sutures after delayed primary wound

closure, 88, 109

Reparative surgery. See Delayed primary

wound closure, Secondary debridement.

Replacement centers, 179

Replacement pools, 188
INDEX 389

Results—Continued

of skeletal traction, 114, 120, 211

of split-thickness skin grafts, 89

of surgery for ruptured lumbar disk, 186

of training of orthopedic personnel, 35, 37

Resuscitation, 167-168

Retained foreign bodies, 23-24, 77, 84, 164,

173, 174, 225, 227, 233, 234, 243, 245,

308, 315

Retinacula of hip joint, 254, 269, 275, 293

Retroperitoneal hemorrhage, 289-291

Revascularization in—-

carpal scaphoid fractures, 142

fractures of—-

astragalus, 153

femoral head, 295

Revision of amputation stump, 162, 163,

164

Revision of Manual of Therapy, 36, 75, 161

Revolving orthopedic frames, 50-54, 236-

237

advantages of, 53

Rheinprovinz, 70

Ries, Capt. Lincoln, 45

Risks of—-

internal fixation, 117

overtreatment, 81

pulp traction through fingers, 33

Roentgenologic examination, 28, 50, 57,

84, 89, 121, 126, 127, 128, 132, 135, 138,

140, 146, 149, 152, 154, 178, 186, 195-

197, 199, 202, 207, 216, 217, 219, 233,

246, 255-258, 263-264, 269, 273, 275,

276, 282, 292, 293, 295, 296, 305, 306,

307

Roger-Anderson apparatus, 25, 63

Rome, Ga., 101

Rotating Bradford frame, 27

Rotation of

nurses, 38

orthopedic personnel, 17-18

Routine of management of mass casualties,

57-61

Rouvillois splint. See Lumbosacral splint.

Royal Air Force, 36

Royal Army Medical Corps, 177

Royal Society of Medicine, 36

Rubber-tissue drains, 88

Ruhr pocket, 70

Rupture of

acromioclavicular joint, 204

coracoclavicular ligaments, 200

coronary ligament of elbow, 122

Russell apparatus, 235

Russell suspension, 261

Russian prisoners of war, 69

Russo-Japanese War, 221

Saarland, 70

Sacroiliac joint, dislocation of, 289

Sacrum:

decubitus ulcers over, 52

wounds of, 235

Saint-L6, 69, 174

Salient angle in fractures of foot, 154

Salvaged material, improvised equipment

from, 45-54

Saucerization in hip-joint injuries, 227, 243

Scanlon Morris fracture table, 43

Scaphoid, fractures of, 121

Scapula:

anatomy of, 212, 218

displacement of, 198, 199

fractures of, 95

function of, 210

manipulation of, 203

position of, in shoulder dislocations, 206

Scarification of synovial membrane of hip joint, 302

Scar-tissue formation, 38, 88

Schrivenham, 36

Sciatic nerve, damage to, in injuries about

hip, 59, 104, 113, 279, 283, 289,

291

Sclerosis of

bone in carpal scaphoid fractures, 137,

138, 141, 142

head of femur, 246

Scotland, 36

Screw-fixation technique of internal fixation, 27, 49, 105, 144, 151, 152, 266, 277

Scrotum, displacement of femoral head

into, 258

Seasonal wound contamination, 225

Secondary amputation, 156, 161

Secondary closure of

amputation stump, 163

joint wounds, 77

Secondary debridement, 22, 83, 87, 88, 150,

173

Secondary hemorrhage, 155, 174-175

Secondary resection of knee joint, disadvantages of, 311-312

Secondary shock, 70, 166

Secondary skin grafting, 96

Secondary wound closure, 96, 100
390 INDEX

Sedation, unnecessary in radial-head fractures, 128

Segregation of

amputees, 170

casualties with combined rectal-orthopedic injuries, 60

orthopedic casualties, 42, 55, 57, 58,

59-60, 61, 170

Seine Base Section, 32

Selection of cases for—-

arthrotomy of knee joint, 186

external fixation, 116

open reduction, 89

skeletal traction, 114, 146

surgery in acromioclavicular dislocations, 203

See also Indications.

Selection of transportation splinting, 84

Selection of treatment in injuries about hip

joint, 276

Senior consultant in—-

neurosurgery, 104, 186

orthopedic surgery, 7-8, 9-10, 11-14,

19-34, 35, 73, 75, 85, 102, 104, 155,

177, 186, 236

Sensitivity of organisms to penicillin, 169

Separation of symphysis pubis, 28, 289

Sepsis in—-

fractures about hip joint, 221, 227-228,

239

wmunds of knee joint, 305, 307

Sequelae of—-

acromioclavicular dislocations, 216-219

injuries about hip joint, 292, 293, 297-

301, 302-304

Sequestration

after external fixation, 115

in osteomyelitis of pelvis, 26

Shaft of—-

femur, fractures of, 112, 149

radius, fractures of, 120

tibia, fractures of, 151

ulna, fractures of, 120

Shepton Mallett, 44

Shock, 55, 81, 115, 160, 166, 167

in injuries about hip joint, 224, 227,

259, 263, 268

Shock wards, 59

Shoe corrections, 39, 44-45, 188

and repairs at disciplinary center, 44

Shoes, effect of poor fitting, 187, 188

Shortage of—-

orthopedic personnel, 14, 16, 17, 21,

113, 227

physical therapy personnel, 178

Shortening of bone in—-

combined nerve-bone injuries, 104, 105-

106

fractures of

femur, 22, 243

humerus, 144, 146

radius, 185

Shoulder;

elective surgery on, 185

spica, 144

wounds of, 102

See also Acromioclavicular joint.

Sicily, 67

Simple fractures, 116, 119, 121, 123, 128,

151

conversion of compound fractures into,

82, 88

Site of election, 160, 165

Skeletal traction, 8, 22, 24-25, 38, 59, 63,

89, 95, 100, 104, 115-116

after internal fixation, 117

application of

in United Kingdom Base, 78-79

on Continent, 79

errors in, 25

holding periods in relation to, 78

in acromioclavicular dislocations, disadvantages of, 211

in combined bone-nerve injuries, 104,

105-106

in fractures about hip joint, 235-237,

246, 248, 249, 260-261, 264, 266,

267-268, 276, 282, 283, 291

advantages of, 235

in fractures of bones of

forearm, 114, 120-121

leg, 24, 25

in fractures of femur, 25, 114, 148-150

in fractures of foot, 154

in fractures of humerus, 24, 25, 114

in injuries of hand, 27

in mass management of casualties,

113-116

in tented wards, 41, 114

in wounds of knee joint, 310

incidence of infection after, 118

indications for, 114, 120

loss of position in, 115-116

mobilization of joints in, 25

provision for, in plaster traction splint, 49
INDEX 391

Skeletal traction—Continued

shock after repeated application of, 115

techniques of, 25, 113-116, 150

Skin:

conservation of, 37, 84, 160

loss of, in Thomas leg splint, 24

necrosis of, in fracture dislocations of

ankle, 153

preparation of, at amputation, 162

record of loss of, 86

Skin coverage of capsular defects, 309,

314-315

Skin grafting, 23, 60, 63, 77, 82, 83, 95, 96,

104, 105, 151, 234, 309

Skin traction

after amputation, 25-26, 161, 163, 164,

165-166

in fractures of humerus, 144

in injuries about hip joint, 260

in wounds of knee joint, 313

maintenance of, 166

Skull, fractures of, 95

Slings, use of—•

in acromioclavicular dislocations, 205

in fractures of radial head, 127, 128

in supracondylar fractures of femur, 150

with skeletal traction, 89

Smith, Maj. Dudley W., 86

Smith-Petersen approach to hip joint,

advantages of, 232

Smith-Petersen arthroplasty of hip, 285

Smith-Petersen incision, 37, 232-233, 249

Smith-Petersen nail, 28, 43, 150, 248

Smith’s fracture, 121

Soft-tissue lesions of

feet, 187

hand, 26

Soft-tissue wounds, access to, 46, 105, 109, 114, 175

Soft tissues:

calcification of, 217 damage to, in injuries about hip joint,

113, 225, 249, 255, 269, 270, 292

paucity of, in leg, 151

Spanish-American War, 221

Spanish Civil War, 221

Special studies:

blood loss at debridement in fractures of

femur, 147

complete acromioclavicular dislocations,

191-219

debridement, 74

delayed primary wound closure, 91-104

injuries about hip joint, 221-250

Special studies—Continued

jeep injuries about hip joint, 251-304

management of compound fractures, 73-

74

penicillin, 74

primary wound closure, 74 Tobruk splint, 111-113

wounds in prisoners of war, 14, 16-19,

20, 21, 312-316

Specifications for plaster, 44

Spica. See Plaster hip spica, Plaster

shoulder spica.

Spinal-cord injuries, 95, 147 Spine:

elective surgery on, 185, 186

fractures of, 42, 53, 69, 95, 147

Spiral fractures of femur, 149

Splinting—•

after delayed primary suture, 109-110

after open circular amputation, 161, 163

in acromioclavicular dislocations, 204

in combined bone-nerve injuries, 105

in vascular injuries, 86 See also special types

Splints, vascular damage caused by, 174- 175

Splints. See also special types.

Split-thickness skin grafts, 88, 89, 105, 151,

164, 174

Splitting of circular plaster casts, 33-34,

76, 84, 85, 87, 109, 110

Spondylolithesis, 185

Spontaneous reduction of dislocations of

hip joint, 259

Spontaneous wound closure, 23, 97

Spot checks of orthopedic surgery, 15

Sprains of

acromioclavicular joint, 207

ankle, 151

coracoclavicular ligaments, 199

elbow, misdiagnosis of, 121

feet, 187

noncombat type, 67

Spur formation, 199

Stab-wound drainage, 88

Staging of hospitals, 17

Staphylococcic infection, 97, 239

Station hospitals, 11, 13, 14, 15, 29, 55, 56,

57, 67, 68, 70, 73, 83, 127, 177. See also

Hospital(s), station.

Statistics:

amputations, 157-158

battle casualties, 14

blood loss at debridement, 147
392 INDEX

Statistics—Continued

blood replacement, 102

carpal scaphoid fractures, 134-143

chemotherapy, 74

combined bone-nerve injuries, 104, 106

complete acromioclavicular dislocations,

200-201

debridement, 74

delayed primary wound closure, 23, 91-

104

in unfavorable cases, 101-104

fractures of—-

femur, 150

forearm, 120

humerus, 144—146

radial head, 121-133

injuries about hip joint, 221-304

internal fixation, 117-118

management of fractures, 73-74

nonbattle casualties, 14

orthopedic casualties, 14

penicillin, 74

plaster traction splint, 47

regional distribution of battle fractures,

95

Tobruk splint, 111-113

timelag, 102, 103-104

transfusion reactions, 168

wound infection after reparative surgery,

102

wounds of extremities, 81

wounds of knee joint, 312-317

in prisoners of war, 14, 16-19, 20, 21,

312, 313, 314, 316

Zone of Interior hospitals, 100-101

See also Incidence, Case fatality rates.

Steinmann pins, 63, 77, 114-115, 154, 287

advantages of, 115

Stellate fractures of head of femur, 287

Stereoscopic films, 282

Stewart, Lt. Col. Marcus J., 75, 134, 187

Stimson technique, 259

Stockinet in skin traction, 32

Stomach, emptying of, before surgery, 167

Streptococcic wound infection, 173

Stryker frame, 52

Styloid process of radius, 120

Subastragalar arthrodesis, 153, 154

Subchondral compression fractures of

acetabulum, 275

acromioclavicular joint, 203

clavicle, 199, 215

femur, 296

head of femur, 284

Subdiaphragmatic hemorrhage, 289

Subluxation of—-

acromioclavicular joint, 202, 207, 209

femoral head, 246

Subtrochanteric fractures, 247

Sulfadiazine, 57, 156, 174, 288, 249, 809,

313,315

Sulfonamides, 60, 100, 224, 239, 307

local use of, 88, 161, 163, 165, 168

undue reliance on, 85

Superficial tissues, erroneous excision of, 37

Superficial wound infection, 173

Superior gemellus, 279

Supination of forearm in fractures of radial

head, 121, 122, 126, 130

Supply, difficulties of, 43

Suppression of virulent microorganisms by

chemotherapy, 239

Suppurative arthritis: of hip joint, 231, 233, 237, 238-245

of knee joint, 305, 308, 310-312

penicillin therapy in, 26

Supracondylar amputation, 156

Supracondylar fractures of femur, 31, 106,

112, 115, 149-150

Suprapatellar pouch, 306

Suprapubic cystostomy, 52, 289

Surgeon General of the Army, 100, 114, 118,

227

in World War I, 226

Surgery, timing of, 60, 105, 106, 166

Surgical consultant, 7, 10

First U. S. Army, 29

Ninth U. S. Army, 29

Surgical field, preparation of, 88

Surgical judgment, errors in, 27

Surgical risk, evaluation of, in blast

injuries, 166

Surgical teams, 55

Suspension;

duration of, 175

management of decubitus ulcers by, 175

techniques of, 205, 236-237

See also Skeletal traction.

Suspension management of

fractures of bones of leg, disadvantages

of, 151

limb for control of edema, 95, 106, 168

Sutures: placing of, 173

removal of, 88, 109

Sympathectomy, 107

Symphysis pubis, separation of, 28, 289
INDEX 393

Symptoms of

complete acromioclavicular dislocation,

202

suppurative arthritis of knee joint, 311

trenchfoot, 32

Syndesmoplasty, 210-211

Syndesmosis, 195

Synostosis, 195, 211, 218

Synovial membrane:

closure of, 77, 208-309, 314

damage to, in wounds of knee joint, 305,

307

scarification of, 302

Synovitis, 67

in acromioclavicular dislocation, 202, 219

in injuries about hip joint, 289, 292-293

Tables of organization, 13, 16

Tachycardia, 239

Tactical situation, influence of, on medical

policies, 63, 77, 79, 227, 260

Taunton, 177

Tears of ligaments of ankle, 151

Technicians, use of, in fracture management, 38-39, 60, 115-116

Techniques of

amputation, 77, 158-165

application of

plaster, 36, 37, 38-39, 109-110

plaster Velpeau, 144

Tobruk, splint, 110-111

traction, 148-149

arthrotomy, 308-310

aspiration of elbow, 127

closure of capsule of knee joint, 309

conservative management of acromioclavicular dislocations, 203-210

debridement, 84-85, 249, 308-310

delayed primary wound closure, 87-89,

102, 173

excision of retained foreign bodies, 233

fracture management, 19, 101-102, 109-

118

immobilization

in acromioclavicular dislocations,

204-210

in carpal scaphoid fractures, 131-135

of joints, 77

insertion of Kirschner wire, 114-115

internal fixation, 266, 279-282, 283-284

reconstructive surgery of hip joint, 248

reduction of dislocations of hip joint,

259-260

Techniques of—Continued

resection of

clavicle, 212-213

femoral head, 243

radial head, 128-129

roentgenologic examination, 199, 276

secondary resection of knee joint, 312

skeletal traction, 25, 113-116, 150, 154,

211, 236-237, 267

skin closure of capsule of knee joint

314-315

skin traction after amputation, 163

Smith-Petersen incision, 232

syndesmoplasty, 211

wound closure

after secondary debridement, 88-89

in fractures about hip joint, 234

See also special techniques.

Temporary skeletal traction, 115

Tenderness in—-

acromioclavicular dislocations, 207

fractures of radial head, 127

suppurative arthritis of knee joint, 311

wounds of knee joint, 306

Tented wards, 41, 114

Tendinous structures of fingers, 27

Tendon repair, 43, 59

Tendon transplantation, 11, 12, 106

Tennessee, 101

Tenosynovitis of feet, 187

Tenotomy of rectus femoris, 232

Tension:

avoidance of, at wound closure, 88

relief of, by incision of fascial planes, 84

Tetanus toxoid, 105

T-fractures of femur, 105

Theater Chief Surgeon, 7, 8, 87, 102, 104,

112, 118

Theater Surgeon, Mediterranean theater,

82

Therapy, adjunct, 167-171

Thigh, wounds of, 84, 111

Third U. S. Army, 69, 75, 77, 81, 86, 157

Thomas arm splint, 145

Thomas leg splint, 24, 30, 49, 76, 110, 151,

161, 165, 235, 236, 259, 267, 276, 282, 307

advantages of, 49

Keller-Blake modification of, 224

Thoracic spine, fractures of, 147

Thoracobrachial spica, 24, 145, 205

Thrombophlebitis, 289, 291
394 INDEX

Thrombosis of—-

hemorrhoidal veins, 289, 291

medial circumflex vessels, 293

Thrombus, lysis of, 174

Through-and-through drains, 101

Thumb, position of, in splinting, 135

Tibia:

as site of autogenous bone graft, 27

damage to condyles of, in wounds of knee

joint, 307, 309, 312, 315

fractures of, 24, 25, 33, 45-49, 70, 76, 95,

114, 117, 151, 166, 305

osteitis fibrosa cystica of, 28

traction through, 146, 148

See also Bones of leg.

Time element in carpal scaphoid fractures,

134

Time of development of

avascular necrosis, 294

suppurative arthritis, 240, 311

Timelag:

before debridement, 22, 70, 78, 103-104

before delayed primary wound closure,

56, 67, 95, 102

in acromioclavicular dislocations, 191

prolongation of, 49, 78, 103

Timing of

amputation, 245

debridement, 167, 249

delayed primary wound closure, 82, 310

movement after operation in wounds of

knee joint, 310

secondary resection of knee joint, 311

surgery in—-

blast injuries, 166

combined nerve-bone injuries, 105

combined vascular-bone injuries, 106

Tincture of metaphen (nitromersol), 88

Tobruk splint, 24, 30-31, 33, 76, 110-113,

234-235, 309, 310

advantages of, 111-113, 234

disadvantages of, 112-113, 234, 235

Toenails, onychogryphosis of, 28

Tourniquet;

application of

at amputation, 162, 164

at operation, 308, 312

on battlefield, 159

use of, under plaster, 175

Torso cast, 205, 206

Toxemia in clostridial myositis, 174

Traction:

after amputation, 77

in fracture management, 60, 66, 88

Traction—Continued

in fractures

about hip joint, 224, 260-261, 266

of ankle, 153

of bones of leg, 151

of clavicle, 143

of humerus, 144-146

of pelvis, 147

in Tobruk splint, 30, 235

through metacarpals, 120

through os calcis, 151

See also special types.

Traction cart, 57

Traction cradle, 27, 50

advantages of, 50

improvised, advantages of, 50

Traction equipment in operating room, 60

Traffic accidents, 68, 69, 70, 119, 146, 191,

251-304

Training marches, 187, 188

Training;

of enlisted men

as ward attendants, 38

in special techniques, 25, 36

of general surgeons, 37

See also Professional training.

Transcondylar amputation, 156

Transfusion reactions, 113, 168

Transit hospitals, 8, 29, 36, 38, 41, 42, 55-58

Transportability, 56

Transportation:

of amputees, 32

relation of, to timelag, 78

Transportation splinting, 67, 76, 84, 85, 87,

109-113, 144, 147-148, 165-166,222-224,

234-235, 236, 237, 259-260, 263, 267, 307,

309, 310

Trauma, as indication for amputation, 157,

158-159

Traumatic amputation, 32, 77, 155

Traumatic arthritis, 289, 293, 296

Trapezoid ligaments, 198, 200, 201, 211, 217

Trapezoid muscle, 199, 201, 204, 206

Trapezoid ridge, 215

Treatment. See Management, Technique.

Trenchfoot, 31-32, 33, 170

Triage, 55, 57, 59, 77

Triple arthrodesis, 154

Triplett, Col. W. H., 187

Trochanter, fractures of, 28, 247

Troop strength, 13, 177

Trueta, J., 226

Twin Bradford frame, 53
INDEX 395

Ulceration after

external fixation, 77

pulp traction, 33

Ulna:

fractures of, 34, 117, 119, 120, 121

Monteggia fractures of, 119

traction through, 146

See also bones of forearm.

Ulnar deviation, 120

Ulnar nerve, protection of, in fractures of

humerus, 144

Unciform bone, 28

Undisplaced fractures:

about hip joint, 246

use of traction cradle for, 50

Union

in fractures of—-

bones of leg, 151

carpal scaphoid, 138

humerus, 144

of fractures after reparative surgery,

100-101

United Kingdom Base, 9, 44, 58, 73, 79, 89,

114, 157, 165

arrival of hospitals in, 14, 16, 17, 35

caseload of hospitals in, 22

delayed primary wound closure in, 23

elective surgery in, 185

equipment in, 42-43

evacuation to, 22, 30, 78

holding period in, 79

hospitals in, 9, 14, 15, 17, 41

junior consultants in, 8-9, 39, 75

management of British battle casualties

in, 36-37

neurosurgical centers in, 104

rehabilitation in, 177

shortages of orthopedic personnel in, 20

training of orthopedic personnel in, 35-

39, 67

visits of senior consultant to hospitals in.

19-29

wound infection in, 173-174

United States. See Zone of Interior.

United States Navy Medical Corps, 235

United States prisoners of war, 66

Unreduced fractures, evacuation of patients

with, 79

Upper extremity;

amputation of, 156, 159, 166

splinting of, 76

Uremic syndrome, 70

Urethra, wounds of, 289

Urethrostomy, 146

Urgent surgery in transit hospitals, 56

Urist, Maj. Marshall R., 27, 45

Urist splint, 206-210, 219

disadvantages of, 206

Utah Beach, 69

Utilization of—•

hospitals at invasion, 17

orthopedic personnel, 17, 57-58

V-l bombs, 69

Vacuolization of bone, 137-142

Variations in—-

acromioclavicular joint, 195-197

holding period on Continent, 78-79

Vascular changes in carpal scaphoid fractures, 137-138, 139

Vascular damage:

as indication for amputation, 144, 155-

156, 157, 159, 161, 166

associated with fractures, 78, 80, 81, 85,

86, 106-107, 144, 155-156

errors in management of, 86

secondary hemorrhage after, 174

Vascular spasm, 107

Vascular tissue, loss of, in fractures of

humerus, 146

Vaseline-impregnated gauze, 84, 86, 89,

161, 165, 173, 241

V-E Day, 9, 19, 39, 91, 168

Vertebrae, fractures of, 95

Vertical acromioclavicular joints, 203

Vertical fractures of radial head, 121

Vertical traction, 28, 236, 260, 267

Veterans’ Administration, 20, 21, 293

Visceral injuries, 146, 225

Visceral wounds. See wounds of special

organs.

Visits of

junior consultants to hospitals, 8,

senior consultant to hospitals, 7, 8, 19-34, 73

Vitallium screws, 27

Vitamin therapy, 168, 238

Volkmann’s ischemia, 153

Von Langenbeck, Bernhard, 279

Von Langenbeck incision, 279

Walking wounded, 56

War of the Rebellion, 221, 239

Ward, exercises on, 127

Ward attendants, enlisted men as, 38

Ward discipline, 170
396 INDEX

Ward officers;

caseload of, 60

in transit hospitals, 57, 58

use of protected prisoner medical personnel as, 66

Ward rounds, 8, 178

Wardmaster, supervision of exercise by, 178

Wastage of—-

manpower, 179

orthopedic personnel, 22

Wasting, due to protein deficiency, 168

Watson-Jones, Reginald, 36, 212

Watson-Jones incision, 232

Weight bearing—■ after injuries about hip, 261-262, 276,

296, 297

after resection of femoral head, 243

in injuries of os calcis, 154

in trenchfoot, 29

Wheeler, W. I. de Courcy, 226, 235, 243

Whirlpool treatments, 127

Whisky, use of, for dilatation of peripheral

vessels, 107

Wild West era, 221

Windows, provision of, in casts, 46, 52, 105,

109, 175, 309

Wire ladder loop in skin traction, 32

Wire ladder splints, 66, 166

Wiring of fractures of humerus, 144

Working hours of surgical teams, 55

World War I:

adjunct therapy in, 238

amputation in, 157

arthrotomy of hip joint in, 225

history of, 185

management of fractures about hip

joint in, 221, 224, 225-226, 235, 239,

241, 243, 311

orthopedic surgery in, 35

use of Thomas leg splint in, 224

Wound closure after circular incision at debridement, 85

Wound closure. See also Delayed primary

wound closure.

Wound excision in neglected fractures of

femur, 150.

Wound healing, 73, 74, 87, 114, 118, 146,

150, 168, 174

Wound infection, 67, 86, 89, 102, 144, 173-

174, 225, 316

redebridement in, 173

Wounding:

conditions of, 74

edema after, 168

protein depletion after, 168

Wounds:

access to, in plaster for dressing, 46, 52, 105, 114, 175

caused by guided missiles, 166

exploration of, in secondary hemorrhage,

175

exposure of, at debridement, 84

of abdomen, 276

of ankle, 102

of bladder, 34, 97, 227, 233, 237, 289

of buttocks, 34, 84, 111, 157, 235

of chest, 32

of extremities, 10, 27, 81

of foot, 102, 156

of forearm, 102, 119

of hand, 102

of head, 32, 276, 290

of intestine, 97, 227, 237, 239-240, 241,

244

of joints, 77

of knee joint, 305-317

in prisoners of war, 14, 16-19, 20, 21,

312, 313, 314, 316

of leg, 102, 111

of muscles, 114

of rectum, 244

of sacrum, 235

of shoulder, 102

of thigh, 84, 111

of urethra, 289

status of, after debridement, 83

Wrist joint:

function of, after fractures of forearm,

120

innervation of, 126

pain referred to, 126

position of, in transportation splinting,

77

Y-ligament, 260

Youth:

incidence of trauma in, 252

of soldiers, 170
INDEX 397

Zone of Interior:

arrival of hospitals from, 55

bone grafting in, 121

definitive surgery in, 26

development of suppurative arthritis in,

240, 241

evacuation to, 22, 23, 26, 44, 53, 61,

83, 89, 92, 105, 109, 114, 135, 140, 142,

147, 153, 154, 170, 174, 236, 268, 277

hospitals of, 114

Zone of Interior—Continued

limitation of elective surgery to, 185

management of jeep injuries in, 261

mission of hospitals of, 66

orthopedic experience in, 35

restriction of —-

arthrotomy of knee joint to, 186

surgery for ruptured lumbar disk to, 185

study of results of reparative surgery

in, 100-101

U. S. GOVERNMENT PRINTING OFFICE; 1956

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