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ORTHOPEDIC SURGERY IN VIETNAM

MEDICAL DEPARTMENT, UNITED STATES ARMY
SURGERY IN VIETNAM
ORTHOPEDIC SURGERY Editor for Orthopedic Surgery

Colonel WILLIAM E. BURKHALTER, MC USA (Ret.)

Colonel ANTHONY BALLARD, MC, USA (Ret.)
Colonel PAUL W. BROWN, MC, USA, (Ret.)
Colonel WILLIAM E. BURKHALTER, MC, USA, (Ret.)
Colonel WILLIAM W. EVERSMANN, Jr, MC, USA, (Ret.)
Colonel JOHN A. FEAGIN, Jr, MC, USA, (Ret.)
Colonel GERALD W. MAYFIELD, MC, USA, (Ret.)
Colonel GEORGE E. OMER, MC, USA, (Ret.)

OFFICE OF THE SURGEON GENERAL AND CENTER OF MILITARY HISTORY

UNITED STATES ARMY
WASHINGTON, D.C., 1994

MEDICAL DEPARTMENT, UNITED STATES ARMY
The volumes comprising the official history of the Medical Department of the United States Army in Vietnam are prepared by the U.S. Army Center of Military History and published under the direction of the Surgeon General and the Chief of Military History. These volumes are divided into two groups, (1) the professional, or clinical and technical, and (2) medically related subjects. This is the third volume of the former group; the first two volumes are entitled "Skin Diseases in Vietnam, 1965-72," and "General Medicine and Infectious Diseases."

Contents
Chapter

1 The Soldier and His Wound in Vietnam
(Colonel John A. Feagin, Jr., MC, USA (Ret.))

The Milieu
    Care of the Wounded Soldier
    Care of the Soldier's Wound
    Wound Infection and Antibiotics
    MEDCAP Activities

2 Penetrating Injuries of the Thigh With Associated Femoral Fracture
(Colonel William E. Burkhalter, MC, USA (Ret.))

Practices During the Vietnam Conflict
Treatment in Japan
Treatment in CONUS--Ambulation in the Cast Brace
Lessons Learned

3 Penetrating Wounds of the Leg With Associated Fractures of the Tibia
(Colonel William E. Burkhalter, MC, USA (Ret.))

Historical Background
Treatment in Vietnam
Treatment After Vietnam
Recommendations

4 Wounds of the Hand
(Colonel William E. Burkhalter, MC, USA (Ret.))

Development of Army Hand Surgery
Conclusions

5 Wounds of the Foot
(Colonel Anthony Ballard, MC, USA (Ret.))

Treatment Principles
Specific Injuries
Recommended Operative Approach to Deep Compartments of the Wounded Foot
Summary

6 Wounds of Joints
(Colonel Anthony Ballard, MC, USA (Ret.))

Historical Background
Overall Policy in the Treatment of Joint Wounds
Wounds of the Knee
Wounds of the Hip
Wounds of the Shoulder

7 Vietnam War Amputees
(Colonel Gerald W Mayfield, MC, USA (Ret.))

Wounds and Wounding Agents
Management of Patients With Amputations
Management of Amputations Classified by Anatomical Site
Special Prosthetic Considerations
Lessons Learned

8 Peripheral Nerve Problems
(Colonel George E. Omer, Jr., MC, USA (Ret.), and Colonel William W. Eversmann, Jr., MC, USA (Ret.)

Initial Surgery
Spontaneous Recovery
Management of Painful Neuroma in Continuity and Causalgia
Surgical Techniques
Extremity Reconstruction
Long-Term Follow-up of Combat-Incurred Peripheral Nerve
Injuries at Fitzsimons Army Medical Center
Summation

9 Rehabilitation of the Combat-Wounded Amputee
(Colonel Paul W. Brown, MC, USA (Ret.))

Historical Background
Evacuation Policies and the Patient in the Vietnam War
Care in CONUS Hospitals
Rehabilitation: The Challenge
Motivation and the Rehabilitation Program
Lessons Learned and Recommendations

10 Epilogue: General Thoughts on the Management of Orthopedic Casualties
(Colonel William E. Burkhalter, MC, USA (Ret.))

Lessons Learned and Unlearned
Communication and Consultants
Continuity of Care and Rehabilitation

Illustrations
Figure

1 The MedEvac "Huey" helicopter
2 Evacuation of a wounded soldier
3 High-velocity gunshot wound of the humerus
4 Examples of patient-care facilities
4 Examples of patient-care facilities cont'd
5 Elevation to allow circumferential extremity surgical preparation
6 Tobruk splint used with femoral fractures
7 Ipsilateral femoral and tibial fracture with contralateral below-knee amputation in continuous traction
8 Cast brace to allow stabilization and use of limb musculature
9 Moderate soft tissue injuries with femoral fracture and bone loss
10 Severe soft tissue injury with bone loss
10 Severe soft tissue injury with bone loss cont'd
11 Use of an air splint
12 Example of poor debridement which resulted in below-knee amputation
13 Treatment of tibial shaft fracture with long-leg and Delbet casts
14 Open fracture with exposed bone and contralateral above-knee amputation
14 Open fracture with exposed bone and contralateral above -knee amputation cont'd
15 Middle one-third tibia bone loss
15 Middle one third tibia bone loss cont
16 Blast injury to hand with skin and bone loss
16 Blast injury to hand with skin and bone loss cont'd
16 Blast injury to hand with skin and bone loss cont'd
17 Through-and-through high-velocity wound of a hand with previous index ray excision
17 Through-and-through high-velocity wound of a hand with previous index ray excision cont'd
17 Through-and-through high-velocity wound of a hand with previous index ray excision cont'd
18 Multiple open fractures with skin loss
18 Multiple open fractures with skin loss cont'd
18 Multiple open fractures with skin loss cont'd
19 Viable but unstable index finger following blast injury
19 Viable but unstable index finger following blast injury cont'd
20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb
20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb cont'd
20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb cont'd
20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb cont'd
21 Severe explosive injury to the wrist with bone, tendon, and skin loss
21 Severe explosive injury to the wrist with bone, tendon, and skin loss cont'd
21 Severe explosive injury to the wrist with bone, tendon, and skin loss cont'd
22 Necrosis of the forefoot following crush injury
23 Medial plantar wound from bamboo stake penetration into deep plantar compartments
24 Skin incision for exploration of plantar foot compartments, avoiding primary weightbearing prominences
25 Retracted laciniate ligament, exposing posterior tibial
26 Shotgun wound of the ankle with destruction of the talus and fracture of the calcaneus
26 Shotgun wound of the ankle with destruction of the talus and fracture of the calcaneus cont'd
27 Longitudinal heel-splitting incision to debride infected calcaneus and plantar heel wounds
28 Perforating gunshot wound of the heel
29 Gunshot wound to the hindfoot with severe damage to the calcaneus and nerves and arteries of the heel pad
30 Chopart amputation with common equivinorus deformity of the hindfoot
31 Loss of lateral rays, compatible with fair foot function
32 Loss of medial rays, resulting in poor foot function
33 Use of skin of toes 2-4 to resurface plantar area over metatarsal heads
34 Transection of origins of abductor and flexor digitorum brevis muscles
35 Willem's technique of active joint motion in the presence of open wounds applied to the elbow
35 Willem's technique of active joing motion in the presence of open wounds applied to the elbow cont'd
36 Treatment of infection following penetrating injuries of the knee without significant fractures
36 Treatment of infection following penetrating injuries of the knee without significant fractures cont'd
37 Saggital diagram of a knee in partial flexion, showing spaces that sequester effusion and purulent material
38 Arthrodesis of the shoulder without humeral head
39 Continuous distal skin traction in open amputations
40 Severe mid-tarsal gunshot wound converted to Chopart following debridement
41 Temporary plaster blow-knee prosthesis
42 Use of elastomer foam insert, allowing early prosthetic training
43 Bent-knee pylon, allowing early ambulation
44 X-ray evaluation to allow improved prosthesis fabrication
45 Method of managing painful neuroma in continuity and causalgia
45 Method of managing painful neuroma in continuity and causalgia cont'd
46 Surgical scar following surgical sympathectomy
47 Epineurial repair by freeing and transposing the ulnar nerve
48 Fascicular bundle nerve grafts of ulnar nerve
49 Extensor indicis proprius transfer
50 Tendon transfer of long or ring flexor digitorum superficialis
51 Application of von Frey monofilament to a digit
52 Transfer of double neurovascular cutaneous island from ring-little web space to thumb-index web space
53 Amputee ski program, Arapahoe Basin, Colorado
54 Three-track skiers
55 Bilateral above-knee amputee skier with "stubby" prostheses
56 Bilateral above-knee amputee with improvised swim fins
57 Triple amputee in riding saddle
58 Amputees at a gallop

Tables

Number

1 Mechanism of injury of 300 patients with fractured femurs
2 Location and type of femoral fracture
3 Amputations during first hospitalization for midfoot metatarsal injury, Fitzsimons General Hospital, 1966-70
4 Amputations or revisions at subsequent hospitalization for midfoot or metatarsal injury, Fitzsimons General Hospital, 1966-70
5 Results after first hospitalization, open injuries of the foot, Brooke Army Medical Center, 1966-69
6 Final disposition of patients with knee wounds
7 Influence of intra-articular fractures on final results
8 Interval between injury and spontaneous recovery in gunshot wounds
9 Time scale in months for spontaneous recovery in gunshot wounds
10 Summary of upper extermity nerve injuries at Brooke Army Medical Center
11 Causalgia: Nerves involved (1966-70) during Vietnam War
12 Causalgia: Time of onset of symptoms (1969-70) during Vietnam War
13 Causalgia: Causative agent (1966-78) during Vietnam War
14 Causalgia: Results of treatment (1966-70) during Vietnam War
15 Vietnam neurorrhaphy related to etiology and level of injury
16 Vietnam neurorrhaphy secondary suture-specific nerves
17 Vietnam cases with external neurolysis
18 Autogenous grafts of major nerves-Vietnam War
19 Early tendon transfers as internal splints
20 Median nerve palsy
21 Radial nerve palsy
22 Ulnar nerve palsy
23 Combined low median-low ulnar palsy
24 Combined high median-high ulnar palsy
25 Combined high median-radial palsy
26 Combined high ulnar-radial



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	ACCESS TO CARE HISTORY OF THE OFFICE OF MEDICAL HISTORY ANC HISTORY AMEDD BIOGRAPHIES AMEDD CORPS HISTORY BOOKS AND DOCUMENTS HISTORICAL ART WORK & IMAGES MEDICAL MEMOIRS AMEDD MEDAL OF HONOR RECIPIENTS ORGANIZATIONAL HISTORIES THE SURGEONS GENERAL ANNUAL REPORTS OF THE SURGEON GENERAL AMEDD UNIT PATCHES AND LINEAGE		Contents

			Books and Documents ORTHOPEDIC SURGERY IN VIETNAM MEDICAL DEPARTMENT, UNITED STATES ARMY SURGERY IN VIETNAM ORTHOPEDIC SURGERY Editor for Orthopedic Surgery Colonel WILLIAM E. BURKHALTER, MC USA (Ret.) By Colonel ANTHONY BALLARD, MC, USA (Ret.) Colonel PAUL W. BROWN, MC, USA, (Ret.) Colonel WILLIAM E. BURKHALTER, MC, USA, (Ret.) Colonel WILLIAM W. EVERSMANN, Jr, MC, USA, (Ret.) Colonel JOHN A. FEAGIN, Jr, MC, USA, (Ret.) Colonel GERALD W. MAYFIELD, MC, USA, (Ret.) Colonel GEORGE E. OMER, MC, USA, (Ret.) *OFFICE OF THE SURGEON GENERAL AND CENTER OF MILITARY HISTORY* UNITED STATES ARMY WASHINGTON, D.C., 1994 MEDICAL DEPARTMENT, UNITED STATES ARMY The volumes comprising the official history of the Medical Department of the United States Army in Vietnam are prepared by the U.S. Army Center of Military History and published under the direction of the Surgeon General and the Chief of Military History. These volumes are divided into two groups, (1) the professional, or clinical and technical, and (2) medically related subjects. This is the third volume of the former group; the first two volumes are entitled "Skin Diseases in Vietnam, 1965-72," and "General Medicine and Infectious Diseases." Authors Foreword Preface Introduction Contents Chapter 1 The Soldier and His Wound in Vietnam (Colonel John A. Feagin, Jr., MC, USA (Ret.)) The Milieu Care of the Wounded Soldier Care of the Soldier's Wound Wound Infection and Antibiotics MEDCAP Activities 2 Penetrating Injuries of the Thigh With Associated Femoral Fracture (Colonel William E. Burkhalter, MC, USA (Ret.)) Practices During the Vietnam Conflict Treatment in Japan Treatment in CONUS--Ambulation in the Cast Brace Lessons Learned 3 Penetrating Wounds of the Leg With Associated Fractures of the Tibia (Colonel William E. Burkhalter, MC, USA (Ret.)) Historical Background Treatment in Vietnam Treatment After Vietnam Recommendations 4 Wounds of the Hand (Colonel William E. Burkhalter, MC, USA (Ret.)) Development of Army Hand Surgery Conclusions 5 Wounds of the Foot (Colonel Anthony Ballard, MC, USA (Ret.)) Treatment Principles Specific Injuries Recommended Operative Approach to Deep Compartments of the Wounded Foot Summary 6 Wounds of Joints (Colonel Anthony Ballard, MC, USA (Ret.)) Historical Background Overall Policy in the Treatment of Joint Wounds Wounds of the Knee Wounds of the Hip Wounds of the Shoulder 7 Vietnam War Amputees (Colonel Gerald W Mayfield, MC, USA (Ret.)) Wounds and Wounding Agents Management of Patients With Amputations Management of Amputations Classified by Anatomical Site Special Prosthetic Considerations Lessons Learned 8 Peripheral Nerve Problems (Colonel George E. Omer, Jr., MC, USA (Ret.), and Colonel William W. Eversmann, Jr., MC, USA (Ret.) Initial Surgery Spontaneous Recovery Management of Painful Neuroma in Continuity and Causalgia Surgical Techniques Extremity Reconstruction Long-Term Follow-up of Combat-Incurred Peripheral Nerve Injuries at Fitzsimons Army Medical Center Summation 9 Rehabilitation of the Combat-Wounded Amputee (Colonel Paul W. Brown, MC, USA (Ret.)) Historical Background Evacuation Policies and the Patient in the Vietnam War Care in CONUS Hospitals Rehabilitation: The Challenge Motivation and the Rehabilitation Program Lessons Learned and Recommendations 10 Epilogue: General Thoughts on the Management of Orthopedic Casualties (Colonel William E. Burkhalter, MC, USA (Ret.)) Lessons Learned and Unlearned Communication and Consultants Continuity of Care and Rehabilitation Illustrations Figure 1 The MedEvac "Huey" helicopter 2 Evacuation of a wounded soldier 3 High-velocity gunshot wound of the humerus 4 Examples of patient-care facilities 4 Examples of patient-care facilities cont'd 5 Elevation to allow circumferential extremity surgical preparation 6 Tobruk splint used with femoral fractures 7 Ipsilateral femoral and tibial fracture with contralateral below-knee amputation in continuous traction 8 Cast brace to allow stabilization and use of limb musculature 9 Moderate soft tissue injuries with femoral fracture and bone loss 10 Severe soft tissue injury with bone loss 10 Severe soft tissue injury with bone loss cont'd 11 Use of an air splint 12 Example of poor debridement which resulted in below-knee amputation 13 Treatment of tibial shaft fracture with long-leg and Delbet casts 14 Open fracture with exposed bone and contralateral above-knee amputation 14 Open fracture with exposed bone and contralateral above -knee amputation cont'd 15 Middle one-third tibia bone loss 15 Middle one third tibia bone loss cont 16 Blast injury to hand with skin and bone loss 16 Blast injury to hand with skin and bone loss cont'd 16 Blast injury to hand with skin and bone loss cont'd 17 Through-and-through high-velocity wound of a hand with previous index ray excision 17 Through-and-through high-velocity wound of a hand with previous index ray excision cont'd 17 Through-and-through high-velocity wound of a hand with previous index ray excision cont'd 18 Multiple open fractures with skin loss 18 Multiple open fractures with skin loss cont'd 18 Multiple open fractures with skin loss cont'd 19 Viable but unstable index finger following blast injury 19 Viable but unstable index finger following blast injury cont'd 20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb 20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb cont'd 20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb cont'd 20 Bone loss injury to first metacarpal with resultant adduction contracture of the thumb cont'd 21 Severe explosive injury to the wrist with bone, tendon, and skin loss 21 Severe explosive injury to the wrist with bone, tendon, and skin loss cont'd 21 Severe explosive injury to the wrist with bone, tendon, and skin loss cont'd 22 Necrosis of the forefoot following crush injury 23 Medial plantar wound from bamboo stake penetration into deep plantar compartments 24 Skin incision for exploration of plantar foot compartments, avoiding primary weightbearing prominences 25 Retracted laciniate ligament, exposing posterior tibial 26 Shotgun wound of the ankle with destruction of the talus and fracture of the calcaneus 26 Shotgun wound of the ankle with destruction of the talus and fracture of the calcaneus cont'd 27 Longitudinal heel-splitting incision to debride infected calcaneus and plantar heel wounds 28 Perforating gunshot wound of the heel 29 Gunshot wound to the hindfoot with severe damage to the calcaneus and nerves and arteries of the heel pad 30 Chopart amputation with common equivinorus deformity of the hindfoot 31 Loss of lateral rays, compatible with fair foot function 32 Loss of medial rays, resulting in poor foot function 33 Use of skin of toes 2-4 to resurface plantar area over metatarsal heads 34 Transection of origins of abductor and flexor digitorum brevis muscles 35 Willem's technique of active joint motion in the presence of open wounds applied to the elbow 35 Willem's technique of active joing motion in the presence of open wounds applied to the elbow cont'd 36 Treatment of infection following penetrating injuries of the knee without significant fractures 36 Treatment of infection following penetrating injuries of the knee without significant fractures cont'd 37 Saggital diagram of a knee in partial flexion, showing spaces that sequester effusion and purulent material 38 Arthrodesis of the shoulder without humeral head 39 Continuous distal skin traction in open amputations 40 Severe mid-tarsal gunshot wound converted to Chopart following debridement 41 Temporary plaster blow-knee prosthesis 42 Use of elastomer foam insert, allowing early prosthetic training 43 Bent-knee pylon, allowing early ambulation 44 X-ray evaluation to allow improved prosthesis fabrication 45 Method of managing painful neuroma in continuity and causalgia 45 Method of managing painful neuroma in continuity and causalgia cont'd 46 Surgical scar following surgical sympathectomy 47 Epineurial repair by freeing and transposing the ulnar nerve 48 Fascicular bundle nerve grafts of ulnar nerve 49 Extensor indicis proprius transfer 50 Tendon transfer of long or ring flexor digitorum superficialis 51 Application of von Frey monofilament to a digit 52 Transfer of double neurovascular cutaneous island from ring-little web space to thumb-index web space 53 Amputee ski program, Arapahoe Basin, Colorado 54 Three-track skiers 55 Bilateral above-knee amputee skier with "stubby" prostheses 56 Bilateral above-knee amputee with improvised swim fins 57 Triple amputee in riding saddle 58 Amputees at a gallop Tables Number 1 Mechanism of injury of 300 patients with fractured femurs 2 Location and type of femoral fracture 3 Amputations during first hospitalization for midfoot metatarsal injury, Fitzsimons General Hospital, 1966-70 4 Amputations or revisions at subsequent hospitalization for midfoot or metatarsal injury, Fitzsimons General Hospital, 1966-70 5 Results after first hospitalization, open injuries of the foot, Brooke Army Medical Center, 1966-69 6 Final disposition of patients with knee wounds 7 Influence of intra-articular fractures on final results 8 Interval between injury and spontaneous recovery in gunshot wounds 9 Time scale in months for spontaneous recovery in gunshot wounds 10 Summary of upper extermity nerve injuries at Brooke Army Medical Center 11 Causalgia: Nerves involved (1966-70) during Vietnam War 12 Causalgia: Time of onset of symptoms (1969-70) during Vietnam War 13 Causalgia: Causative agent (1966-78) during Vietnam War 14 Causalgia: Results of treatment (1966-70) during Vietnam War 15 Vietnam neurorrhaphy related to etiology and level of injury 16 Vietnam neurorrhaphy secondary suture-specific nerves 17 Vietnam cases with external neurolysis 18 Autogenous grafts of major nerves-Vietnam War 19 Early tendon transfers as internal splints 20 Median nerve palsy 21 Radial nerve palsy 22 Ulnar nerve palsy 23 Combined low median-low ulnar palsy 24 Combined high median-high ulnar palsy 25 Combined high median-radial palsy 26 Combined high ulnar-radial

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