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Specific Considerations in Primary Surgery of the Extremities

Medical Science Publication No. 4, Volume 1

SPECIFIC CONSIDERATIONS IN PRIMARY SURGERY OF THE EXTREMITIES*

COLONEL JOHN M. SALYER, MC
CAPTAIN JOHN O. ESSLINGER, MC

Fifty-six percent of the last 7,200 United Nations troops injured during the Korean war sustained wounds of extremities. This percentage, which all will agree is quite considerable, is somewhat lower than was anticipated in view of past statistics on the anatomical location of war wounds and by virtue of the fact that a significant number of those wounded were wearing protective nylon vests which have so often afforded protection to the extent that potential death-dealing missiles have been deflected by or retarded in the nylon armor plates, thus often sparing the upper abdomen and chest of any injury or permitting relatively minor wounds beneath the protective vest. Nevertheless, a paradox has arisen in that the incidence of extremity wounds has not increased over those percentages determined prior to the present armor designed to offer such encouraging and proven protection to the upper torso.

It would seem reasonable to assume that other body areas, apart from the head and chest, will be provided with protective devices in future wars. It is predicted, although to my knowledge no official overtures have been forthcoming, that the next anatomical areas to be given armor coverage will be the lower half of the lower extremities. Surgeons trained and experienced in the field of traumatism, not to mention orthopedists who are even more aware of the danger to this area, view with grave concern and consternation the surgical and therapeutic problems imposed when open fractures of the lower third of the tibia and fibula are encountered. The relatively poor blood supply and paucity of soft tissues for subsequent bone and tendon coverage are deterrent factors which spell out an ominous warning that occasional serious complications may be expected and the final functional results may not always be ideal.

With such traumatic problems the nonambulatory phase, as well as total periods of hospitalization, will of necessity be prolonged, although such unfortunate patients are given the most detailed and


*Presented 22 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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expert surgical and orthopedic care at an early hour and under the best of professional circumstances. Unduly delayed and/or inadequate débridement of such wounds that confronts the military surgeon during periods of military conflict may result in significant infections that may require an amputation or even cost the patient his life. Credit is given to rapid methods of evacuation, in most instances detailed and meticulous débridements by competent surgeons, whole blood in adequate quantities, specific and broad-spectrum antibiotics, and a stringent policy regarding the proper application of, and the early splitting of, plaster casts and all underlying circular dressings down to skin level.

The remainder of this discussion will deal with the forward surgical care of extremity wounds-the initial phase in the divisional area; this includes care forward to and at first priority hospitals (Surgical Hospitals, Mobile-so called during Korean war). Not all, but most surgeons who have had experience in the evaluation and surgical care of war wounds will agree that the professional care given forward to the mobile surgical and evacuation hospitals, i. e., in the battalion aid stations, collecting companies and clearing stations, should provide wound care essentially as follows: Control hemorrhage; apply temporary splints and first aid dressings; evaluate the patient as a whole, as well as specific injuries-wound shock being foremost in mind; clear and maintain airway; provide adequate initial shock therapy; control apprehension and pain with barbiturates and narcotics-if wound shock is evident or impending, narcotics are given intravenously and in small doses; administer tetanus toxoid, institute antibiotic therapy; render transportable; triage as to type of selective evacuation; and, last but not least in importance, make initial entries in the Field Medical Record-these concise full-coverage entries will be of inestimable value to medical officers providing professional care throughout the chain of evacuation and hospitalizations.

All but the most minor of wounds of the extremities, as well as war wounds elsewhere, should only be given initial definitive surgical care where the following types of personnel and facilities are available:

    1. Surgeons well versed and trained in the care of war wounds.

    2. Anesthesiologists and anesthetists available in adequate numbers and provided with proper equipment and anesthesia agents.

    3. Whole blood provided in ample quantities.

    4. Roentgenographic facilities for wound evaluation and localization of radiopaque foreign bodies. A small missile producing an apparent minor wound of the thigh has been found to traverse the thigh, peritoneal cavity and terminate above the leaf of the diaphragm, not to mention other bizarre missile phenomena such is intravascular migration.


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    5. Ample surgical supplies processed and sterilized as required; suitable dust-protected operating space or rooms, sufficient operating tables, and other essential equipment to perform large numbers of aseptic surgical procedures satisfactorily.

The above minimal requirements are not available in advance of the Mobile Surgical Hospital.

Early First-Aid Splinting of Extremities

The Army half-ring leg splint has been employed with very satisfactory results during the Korean war. We in the Army have had little experience with the "light beaverboard trough-type" splint presently used to some extent by some Navy medical installations. This linear fenestrated splint would appear suitable in most instances but would seem not to be quite as suitable when traction should be employed, which is frequently so necessary. The wooden trough does not appear to be as adaptable for counter-traction apposition to the ischial tuberosity and pelvis as the Keller half-ring splint. Traction "Army style" is effected by applying traction straps over laced shoes. Only rarely has traction been improperly applied or maintained for sufficient periods to produce blisters and superficial areas of necrosis about the foot and ankle. Well-padded wire ladder splints are employed for foot and ankle injuries. Adequate splinting is our primary concern when preparing those with upper extremity fractures for transport to forward hospitals where the first phase of definitive wound care is provided. The arm can be immobilized by bandaging it to the chest with a Velpeau-type dressing. Wire ladder splints are frequently of value for fractures of the upper extremity.

Forward Evacuation

The transport of the wounded to the rear or laterally proved to be very successful during the Korean conflict. Ambulances much improved as to comfort over those employed in World War II were employed around the clock, almost entirely at night, when helicopters were employed only on rare occasions. Helicopter and light plane transport for any and all types of battle injured was successful to an extent that may never again be realized in future conflicts-in Korea the United Nations had air supremacy south of the main line of resistance throughout the entire war. Periodic air raids by the enemy would have made forward air evacuation much less successful as well as very costly in life and aircraft. It is doubtful if any better method or mode of forward evacuation will ever be devised for transport of patients with severely wounded extremities than that afforded by a helicopter ambulance.


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Early Care of Extremity Wounds

Simple and Mixed Soft Tissue Injuries

This implies surgical débridement and complete hemostasis without any attempt at primary wound closure. After careful evaluation of the extremity for possible artery, nerve and bone damage, the extremity is shaved, prepared and draped in accordance with good current operating principles. Compromise or deviation from such technics should never be condoned. As a general rule, extremity wounds are extended by adequate longitudinal incisions. Oblique or transverse incisions are only employed on flexion surfaces overlying joints. Only a small amount of skin beyond the primary wound should be removed, as it is vascular, resistant to infection, and should be retained to facilitate delayed primary closure a few days hence.

Devitalized fascia and muscle are excised as completely as can be determined after the deep fascia is incised even beyond the limits of the skin incisions. Metallic foreign bodies are removed as encountered but extensive exploratory probing and dissection for purposes of removal of small metallic bodies is not warranted. Other foreign matter, such as soil, gravel, bits of clothing, boot leather and splinters, is carefully removed with all devitalized tissues. Inadequate surgical care of significant extremity wounds such as not conforming to the above-mentioned concepts of surgical care will result in a wound pabulum most ideal for the growth of virulent bacteria and almost 100 percent of troublesome wound infections. However, a very low percentage of wound sepsis, none of which is likely to be threatening to life or limb, can be anticipated when such extremity wounds are provided early care by surgeons well indoctrinated in the care of wounds produced by war missiles and other types of destructive forces, be they explosive in nature or inflicted by odd forces of nature. Instillation of antibiotics and chemotherapeutic agents into extremity wounds is almost never recommended.

Mixed Soft Tissue, Joint, Nerve and Vessel Wounds

In addition to the débridement steps listed above, the following specific surgical measures are recommended:

Joint Wounds. Massive injury near and involving joints presents distinct surgical problems which deserve comment. The joint is irrigated with sterile saline solution; foreign matter and devitalized tissue such as detached cartilage and bone are removed. The synovial membrane and/or joint capsule should be closed if possible with absorbable suture material and the remainder of the wound left open. Antibiotics (penicillin and streptomycin) are injected into the joint cavity.


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Nerve Wounds. It is obvious that all structures such as nerves and blood vessels are given the most detailed anatomical consideration during any type of surgical procedures on extremities. A careful and detailed clinical record is made of the nerve injured or severed and the exact level or site of injury is accurately recorded. Early primary suture of major nerves is never attempted; neither is it necessary to mark the ends of nerves as they are readily found at the time of delayed repair by exposing their proximal and distal portions beyond the confines of the original wound and tracing them to the site of injury.

Major Vessel Wounds. This important and interesting problem will be discussed in detail at this meeting by military surgeons who have made immeasurably valuable contributions in this field during the Korean war. It can be stated that when ligation of a severed artery is not indicated, early establishment of the major arterial blood flow to the distal portion of the extremity is attempted as soon as the débridement is completed. End-to-end anastamosis is desired and considered ideal if feasible. Autogenous vein grafts and homologous arterial grafts have likewise given very encouraging results. The site of repair or vascular graft should be covered with viable muscle or subcutaneous tissue and the remainder of the wound left open.

Wound Dressing. One layer of fine-mesh dry gauze is employed to cover the entire raw surface of the débrided wound. Fluffed coarse-mesh gauze is loosely placed to fill in and extend well above the level of the wound defect. Circular bandages are so arranged that tourniquet-like constriction will not result.

Hand Wounds. Early in the Korean conflict, hand wounds were closed primarily if remaining tissues permitted. This method of management resulted in an infection rate of approximately 90 percent of such wounds. Two years before the end of the war, it was deemed advisable to advocate a nonclosure policy which gave much more encouraging results. Débridement should be performed with the most meticulous care-rash excision of questionably viable important structures and tissue is not advocated. The retention of avulsed skin is highly desirable and it should be loosely tacked down by spaced sutures and immobilized by the wound dressing. Such attached skin will often provide cover for exposed nerves, tendon sheaths, tendons and other hand structures.

Forward Amputations. Under war conditions, the guillotine, or open-type amputation, is the procedure of choice as well as the method that has given the most satisfactory results. It was indorsed through-out the Korean conflict. The guillotine, or open, amputation implies a total débridement of an extremity hopelessly destroyed by trauma


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or infection or both. Even today it is often a lifesaving procedure regardless of the etiological trauma producing a mangled extremity. It has been common surgical knowledge since World War I that the end of the amputation stump must be left open in order to control infection, just the same as following the débridement of any war wound of an extremity. As ideal as antibiotics are, they have not provided sufficient bacteriostasis to cause military surgeons to alter this policy.

Technic. A tourniquet is always used. The amputation is done at the lowest possible level consistent with the total removal of devitalized tissue and without regard to so-called elective sites of operations. Reamputation or revision of the stump is always necessary. Such revisions can be performed in the Zone of Communications or Zone of Interior where surgery can be accomplished under ideal conditions. The skin incision may be roughly circular or oblique. The subcutaneous tissue and deep fascia are cut at the level of the retracted skin. Proximal retraction allows the muscle to be severed at a slightly higher level. All structures are again retracted and the bone is sawed without stripping the periosteum. If the lower leg is being amputated, the fibula is amputated about 11/4 to 11/2 inches above the stump of the tibia. All major vessels are ligated and the tourniquet removed, after which complete hemostasis is accomplished. The nerve is pulled down, divided and allowed to retract into the stump. Sterile stockinette is fashioned over much of the remaining extremity and fixed by means of skin glue. Minimal gauze dressing is applied to the raw stump surface, and sufficient traction is maintained to cause the stump end to appear as an inverted cone, the bone being at the apex. Constant elastic traction is maintained from the end of extension splint bars incorporated in a well padded plaster cast fashioned to allow the very necessary and only safe method of bony prominence counter-traction. Injudicious counter-traction applied to the soft tissues above the amputated stump will almost always result in an impairment of the normal venous return and subsequent arterial insufficiency.

References

1. Bolibaugh, O. B.: Treatment of Gunshot Wounds of the Extremities. Symposium on Military Medicine in the Far East Command, September 1951.

2. Bolibaugh, O. B.: Personal communication.

3. Churchill, E. D.: Management of Wounds (Initial and Reparative Surgery). Symposium on Treatment of Trauma in the Armed Forces. Army Medical Service Graduate School, Walter Reed Army Medical Center, March 1952.

4. Hagman, F. E.: Notes on the Care of Battle Casualties. Symposium on Military Medicine in the Far East Command, September 1951.