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MEDICAL DEPARTMENT UNITED STATES ARMY IN WORLD WAR II

SURGERY IN WORLD WAR II

ORTHOPEDIC SURGERY in the MEDITERRANEAN THEATER OF OPERATIONS

Editor in Chief

Colonel JOHN BOYD COATES, Jr., MC

Editor for Orthopedic Surgery

MATHER CLEVELAND, M. D.

Associate Editor

ELIZABETH M. McFETRIDGE, M. A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D.C. 1957


SURGERY IN WORLD WAR II

Prepared under the direction of
MAJOR GENERAL S. B. HAYS
The Surgeon General, United States Army

Historical Unit, Army Medical Service

Colonel JOHN BOYD COATES, Jr., MC, Director
Major I. H. AHLFELD, MSC, Executive Officer
Captain J. K. ARIMA, MSC, Special Projects Officer
DONALD O. WAGNER, Ph. D., Chief, Historians Branch
WILLA B. DIAL, Chief, Editorial Branch
JOSEPHINE P. KYLE, Chief, Archives and Research Branch
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. D.
FRANK GLENN, M.D.
J. BARRETT BROWN, M. D.
M. ELLIOTT RANDOLPH, M. D.
STERLING BUNNELL, M. D.
ISIDOR S. RAYDIN, M. D.
NORTON CANFIELD, M. D.
ALFRED R. SHANDS, Jr., M. D.
B. NOLAND CARTER, M..D.
HOWARD E. SNYDER, M. D.
EDWARD D. CHURCHILL, M. D.
R. GLEN SPURLING, M. D.
MATHER CLEVELAND, M.D.
BARNES WOODHALL, M. D.
DANIEL C. ELKIN. M. D.
ROBERT M. ZOLLINGER, M. D.

Colonel JOSEPH R. SHAEFFER, MC (ex officio)
Colonel JOHN BOYD COATES, Jr. MC (ex officio)


ORTHOPEDIC SURGERY

in the

MEDITERRANEAN THEATER
OF OPERATIONS

by

OSCAR P. HAMPTON, Jr., M. D., F. A. C. S., Colonel, MC, USAR

Assistant Professor of Clinical Orthopedic Surgery
Washington University School of Medicine, St. Louis, Mo


Contents

FOREWORD
PREFACE
ACKNOWLEDGMENTS
PROLOGUE

Chapter

I    Introduction

II   Administrative Considerations
        Evolution of the Consultant System   
        Visits to Medical Installations
        Assignment of Personnel
        Facilities
        Hospital Administration
        Graphic Records
        Accumulation of Data

III  Splinting in the Combat Zone
        Classification of Military Splinting
        Emergency Splinting
        Transportation Splinting

IV  The Management of Compound Battle Fractures 

Part I. The Evolution of the Program of Staged Management

Concepts and Practices Before World War II
United States Experiences With the Closed Plaster Method
Development of the Program of Reparative Surgery
Application of the Reparative-Surgery Program to Compound Fractures

Part II. The Initial Surgery of Compound Fractures

Surgical Timing
First Aid
Preparation for Initial Wound Surgery
Appraisal of the Wound
General Principles and Practices
Technical Considerations
Management of Bone Fragments
Fracture Management
Postoperative Regimen
Evacuation

Part III. The Reparative Surgery of Compound Fractures

Preoperative Preparation
Technical Considerations
Postoperative Management
Results

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

General Considerations
Problems of Management
General Principles of Management
Compound Fractures of the Humerus
Compound Fractures of the Radius and Ulna
Conclusions

Part II. Compound Fractures of the Femur

General Considerations
Survey of Results, Spring 1944
Source Material
The Program of Reparative Surgery
Technical Considerations
Appraisal of Results
Conclusions

Part III. Compound Fractures of the Tibia and Fibula

The Reparative-Surgery Program
Analysis of Cases, 1944-45
Wound Management
Fracture Management
Evaluation of Results

Part IV. Compound Fractures of the Foot

Wound Management
Fracture Management
Postoperative Management

VI Delayed Internal Fixation of Compound Battle Fractures - A Followup Study in the Zone of Interior  
Technical Considerations
Survey of Results
Conclusions of the Survey
Analysis of Unfavorable Results 

VII External Skeletal Fixation of Fractures in the Communications Zone
Analysis of Cases

VIII Wounds of Joints
Historical Note
General Considerations
Wounds the Knee Joint
Wounds of the Hip Joint
Wounds of the Smaller Joints

IX Amputations
Indications
Technical Considerations
Analysis of Cases

X Noncombat Orthopedic Lesions
General Principles of Management
The Management of Painful Backs and Feet
Surveys of Management of Noncombat Orthopedic Lesions
Internal Derangements of the Knee
Noncombat Orthopedic Lesions - Continued
Joint Mice (Osteochondritis Dissecans)
Recurrent Dislocations of the Shoulder
Fractures of the Carpal Scaphoid Bone

XI Disposition of Patients From Orthopedic Services of General Hospitals
General Principles of Disposition
A Sample hospital Experience

APPENDIX

Table

Number
1 Timing of splinting of compound battle fractures in relation to objectives and facilities
2 Relationship of shock and blood loss in 67 battle casualties
3 Blood replacement before and during initial surgery in 100 compound fractures
4 Results in relation to procedure and wound healing in 147 compound fractures of humerus
5 Results in relation to technique and status of fractures in 147 compound fractures of humerus
6 Results in relation to technique, wound healing, and status of fracture in 147 compound fractures of humerus
7 Location of Kirschner wire for skeletal traction in 613 compound fractures of femur
8 Methods of fracture management in 1,063 compound fractures of femoral shaft
9 Techniques of internal fixation in 284 fractures of femoral shaft
10 Appraisal of wound healing in 825 compound fractures of femoral shaft
11 Fracture management in 622 compound fractures of tibia and tibia and fibula
12 Fracture management in relation to level of tibial injury in 621 compound fractures of tibia and tibia and fibula
13 Severity of injury in relation to location of fracture in 132 compound fractures of tibia and 80 of tibia and fibula
14 Results in relation to severity of injury and technique of wound management in 132 compound fractures of tibia and 80 of tibia and fibula
15 Results in relation to severity of injury and technique of fracture management in 132 compound fractures of tibia and 80 of tibia and fibula
16 Combined results of wound and fracture management in relation to severity of injury in 132 compound fractures of tibia and 80 of tibia and fibula
17 Results of internal fixation on obligate indications in 135 compound fractures
18 Results of internal fixation on elective indications in 165 compound fractures
19 Results of internal fixation in relation to indications in 67 compound fractures of humerus
20 Results of internal fixation in relation to indications in 31 compound fractures of radius and ulna
21 Results of internal fixation in relation to indications in 146 compound fractures of femur
22 Results of internal fixation in relation to indications in 88 compound fractures of tibia and fibula
23 Composite results of internal fixation in relation to technique and location of fracture in 332 compound fractures of long bones
24 Results of internal fixation in 29 compound fractures with established wound infection
25 Essential data on 14 fractures treated by external skeletal fixation
26 Essential data on 27 fractures treated by external skeletal fixation
27 Essential data on 25 fractures treated by external skeletal fixation
28 Sites of amputation in 1,379 separate operations on United States Army troops
29 Sites of amputation in 1,389 separate operations on German prisoners of war
30 Agents of wounding and causes of amputation in 1,271 United States Army troops
31 Agents of wounding and causes of amputation in 1,332 German prisoners of war
32 Complicating injuries in 1,000 United States Army amputees
33 Indications for amputation in 1,344 operations following wounds or injuries in United States Army troops
34 Indications for 843 primary and 243 secondary amputations in United States Army troops
35 Indications for 962 primary and 427 secondary amputations in German prisoners of war
36 Combinations of levels in 85 multiple amputations in United States Army casualties

Illustrations

Figure

1 First aid in field
2 Scenes at first-aid stations
3 Scenes at collecting station
4 Arrival of casualty at admission tent of clearing station
5 Ambulance transportation of wounded
6 Scenes in field hospital
7 Scenes in evacuation hospital
8 Evacuation hospital
9 General hospital
10 Improvised battlefield splinting for fracture of femur
11 Emergency splinting for fractures of forearm and about elbow and wrist
12 Emergency splinting for fracture of humerus
13 Emergency splinting for fractures of lower third of leg and ankle
14 Emergency splinting for injuries of thigh, knee joint, and leg
15 Improvised techniques of splinting after initial wound surgery
16 Modification of elephant-tusk splint for fractures about shoulder joint and elbow
17 Plaster Velpeau bandage for injuries of shoulder joint, arm, or elbow
18 Shoulder spica for injuries about shoulder joint and of arm
19 Transportation splinting of compound fracture of femur with hip spica
20 Modified Tobruk splint
21 Transportation splinting for fractures of lower extremities
22 Staged surgery of wound of calf
23 Staged surgery of wound of right arm
24 Reparative surgery of wound of left axilla and shoulder
25 Initial wound surgery of soft-part wound
26 Staged surgery of wound of thigh
27 Initial surgery of wound of thigh
28 Appearance of wound at completion of initial surgery
29 Correct excisional surgery in infected compound comminuted fractures of left tibia and right femur
30 Management of compound comminuted fractures of femur and patella by delayed internal fixation
31 Reparative management of wound of thigh with associated compound fracture of femur
32 Management of compound comminuted fractures of right tibia and fibula by delayed internal fixation
33 Staged management of compound comminuted fracture of femur
34 Management of compound comminuted fracture of femur by delayed internal fixation
35 Staged surgery of bilateral compound fractures of shaft of femur 
35-1  Figure 35  C and  D continued
35-2  Figure 35  E and F continued
35-3  Figure 35 G and H continued
35-4  Figure 35 I, J and K continued
35-5  Figure 35 L and M continued
35-6  Figure 35 N and O continued
36 Management of compound fractures of tibia and fibula by internal fixation
37 Comminuted compound fracture of right humerus with radial-nerve paralysis
38 Compound comminuted fracture of right humerus with loss of bone 
38-1 C, D, E and F continued
38-2 G and H continued
39 Staged management of associated humeral-radial fractures and nerve injury by shortening of bone
40 Reparative management of fracture of tibia
41 Management of compound comminuted fracture of femur by balanced-suspension skeletal traction
42 Management of compound fracture of right tibia by staged surgery and modified closed plaster technique
43 Management by delayed internal fixation of compound comminuted fracture of humerus, with loss of bone and laceration of median and ulnar nerves
43-1 E and F continued
44 Management by delayed internal fixation of compound comminuted fracture of humerus with segmental loss of bone and laceration of radial nerve
45 Splinting for paralysis of radial nerve
46 Comminuted fracture dislocation of right shoulder, comminuted fractures of humerus and both bones of forearm, with injuries of median and radial nerves
47 Hanging cast for fracture of humerus
48 Shoulder spica cast for fracture about shoulder joint
49 Unsuccessful management of compound comminuted fracture of right radius and ulna
50 Management of compound comminuted fracture of radius and ulna by delayed internal fixation
51 Suspension traction in 90-90-90 position for compound fracture of femur
52 Management of compound oblique fracture of femur by delayed internal fixation  
52-1 F, G, H, I, J and K continued
53 Internal fixation of displaced fracture of medial femoral condyle
54 Two-wire skeletal traction for battle fracture of femur
55 Balanced-suspension skeletal traction by half-ring leg splint and Pierson attachment
56 Navy traction for fracture of femur
57 Modlin modification of Navy traction for fracture of femur
58 Linch modification of Navy traction for fracture of femur
59 Skeletal traction by 90-90-90 suspension method for fracture of femur
60 Anteroposterior and lateral roentgenograms showing fracture of tibia with loss of bone
61 Skeletal traction in fractures of both bones of leg
62 Roentgenologic results of skeletal traction in cast
63 Management of compound comminuted fractures of tibia and fibula by delayed internal fixation
64 Management of compound comminuted fractures of tibia and fibula by delayed internal fixation
65 Management of compound comminuted fractures of tibia and fibula
66 Management of comminuted fracture of tibia and fibula, by plating of fibula
67 Management of fractures of fibula and tibia, with loss of bone, by plating of fibula
68 Management of compound comminuted fracture of radius, with loss of bone and median-nerve palsy, by external skeletal fixation
69 Management of segmental compound comminuted fractures of tibia and fibula by external skeletal traction
70 Staged management of wound of left knee joint
71 Staged management of penetrating wound of knee joint with comminuted fracture of femur
72 Management of early suppurative arthritis of knee joint
73 Management of early suppurative arthritis of knee joint 
73-1 C, D, E and F Management of early suppurative arthritis of  knee joint
74 Management of suppurative arthritis of knee joint
75 Management of suppurative arthritis of knee joint
76 Management of suppurative arthritis of knee joint
77 Management of suppurative arthritis of knee joint 
77-1 B, C and D continued
77-2 E, F, G and H continued
78 Management of suppurative arthritis of hip joint
79 Management of suppurative arthritis of hip joint
80 Management of suppurative arthritis of hip joint
81 Destructive injury of entire left leg
82 Bilateral traumatic amputations of legs
83 Bilateral injuries of lower extremities
84 Traumatic amputation of right leg, multiple penetrating wounds of left leg
85 Amputation stump of left forearm
86 Technique of open circular amputation
87 Application of skin traction after amputation of leg
88 Plaster cast with elastic traction
89 Traumatic amputation of right leg, compound fracture of bones of left leg
90 Open circular amputation through middle third of forearm
91 Healed stumps after amputation by open circular technique
92 Closure of amputation stumps
93 Closure of amputation stump
94 Closure of amputation stump
95 Amputation by open flap technique, with closure of flaps at reparative surgery
96 Amputation through leg near site of election, with preservation of posterior viable flap of skin