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Chapter IV

Contents

CHAPTER IV

The Management of Compound Battle Fractures

Part I. The Evolution of the Program of Staged Management

CONCEPTS AND PRACTICES BEFORE WORLD WAR II

Orthopedic practices in general use at the end of World War I called for the management of most compound battle fractures in splints or appliances based on the general principles of splinting. Skin traction was used for continuous traction. Only occasional fractures were put up in skeletal traction, and plaster was not generally used because freedom of joint movement was considered desirable.

In the management of compound fractures, great emphasis was placed upon the sterilization of the wound. Infection was combated by local applications of such agents as BIP (bismuth subnitrate, iodoform, and paraffin) or by the elaborate irrigation ritual of the Carrel-Dakin method. Evaluation of the results accomplished during the last months of the war, when these methods had become fairly well stabilized, showed a high incidence of infection, which was likely to run a prolonged course; a high incidence of malunion and nonunion; and rates for amputations and for fatalities which exceeded reasonable expectancies.

After the war, the Carrel-Dakin method continued to be used in the management of civilian compound fractures and joint injuries, at first enthusiastically, then with increasing dissatisfaction. It was tedious and troublesome to apply, and the end results left much to be desired. Gradually, for these reasons, it fell into disuse. Meantime, a method usually credited to H. Winnett Orr was increasing in popularity. This method had been devised to meet the dual problems of an infected wound and a fractured bone. The wound was left open, to secure drainage, and the fracture was managed by skeletal fixation in a plaster cast. One objective of the method was the prevention of the trauma and reinfection which experience had shown was likely to occur with frequent dressings.

The first wartime test of the closed plaster technique (which, incidentally, was a revival of the "occlusive" method described by Ollier in 1872) came during the Spanish Civil War, when it was employed by Trueta1 and others with

1 Trueta, J.: Treatment of War Wounds and Fractures With Special Reference to the Closed Method as Used in the War in Spain. New York: Paul B. Hoeber, Inc.


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a number of modifications. It was eventually used in some 20,000 cases. In 1,073 open fractures personally treated by Trueta, the reported results were excellent. There were only 6 deaths, and only 2 of these, both after operations for gangrene, were directly related to the compound fractures. Results were classified as poor in 91 other cases, in 4 of which amputation was necessary. As these results became generally known, the closed plaster method became increasingly popular, and, when World War II broke out in 1939, it was natural that it should be employed in the Allied armies, as well as in the German and the Russian Armies.

The steps of the closed plaster technique were described by Trueta as follows:

2. Once the patient is anesthetized, thoroughly wash the entire extremity and the wound with water, soap and a nail brush, until the whole is completely clean and the wound itself is bleeding; shave all hair. Paint the surrounding skin with a weak alcoholic solution of iodine, Without touching the wound in any circumstances.

3. Excise the skin edges of the wound, remove all contused tissue and widen the wound as much as may be required. Excise carefully and unhesitatingly all nonviable muscular and cellular tissues, noting in particular the colour of the injured muscles, their contractility on stimulation with forceps, and their capacity to bleed.

4. Open up the neighbouring cellular spaces affected by the contusion and, where necessary, incise the soft tissues, following up the cellular spaces in the depths of the wound. always keeping in mind the need for adequate drainage. Remove any haematoma present.

5. Remove the majority of bone fragments that are completely denuded of periosteum or displaced, and all foreign bodies found at the site of fracture. There is no need to be concerned much about any pieces of bullet that are difficult to locate; but it is most important to excise carefully all foreign organic matter (pieces of clothing, wood, etc.). The procedures described above--namely, the removal of all foreign matter, the excision of all the tissues immediately surrounding the wound, including devitalized soft parts in the vicinity, and the opening up of cellular spaces--is known technically as debridement.

6. If the thigh, knee joint or leg is fractured, reduce the fracture by traction on an orthopaedic table or by hand. In arm fractures which require traction or abduction, apply the appropriate apparatus. Details may be found in the chapters dealing with wound of the different regions.

7. Once the fracture is reduced firmly dress the wound with sterile gauze and immediately immobilize with plaster, including the two adjoining joints if possible.

8. Give an injection of tetanus antitoxin.

Drainage and Suture

In cases in which deep cavities are present drainage must be arranged by opening up the aponeurotic planes and the intermuscular spaces; this drainage can generally be maintained by the insertion of sterile gauze, but in some cases no inconvenience results from the insertion of a rubber tube which may be buried under the plaster and retained until the first change of the cast. No complication of any kind can be attributed to drainage; on the other hand, retained discharge, the result of bad drainage, may bring about disaster.

The immediate reaction to this method of treatment was sometimes severe. The temperature might rise to 104° F., and the axillary or inguinal lymph nodes might become enlarged. These phenomena were not regarded by Trueta as indications, in themselves, for the premature removal of the cast or for cutting windows into it. The only indication for removal of the plaster


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ahead of the time determined upon--from 10 days to a month after operation, depending upon circumstances--was the appearance of such symptoms and signs as edema of the distal portion of the extremity; inability to move the toes or fingers; and evidences of progressive infection, including lassitude, a progressive increase in the intensity of the pain, and a rising pulse rate. As a rule, the cast was kept in place without change for 10 to 15 days in summer and for a month in winter. The seasonal distinction was explained by the fact that the strong odor which emanated from the wound in this method of treatment was not well tolerated during the summer by the patients associates in the ward.

UNITED STATES EXPERIENCES WITH THE CLOSED PLASTER METHOD

Since United States experiences with the closed plaster method had been reasonably good in civilian practice and since British and other European surgeons had apparently had good results with it in the first months of World War II, it was natural that United States Army medical officers should be prepared to use it in the North African invasion. The circumstances early in the invasion were not conducive to a coordinated plan of timed surgery such as was developed later. Evacuation hospitals were widely separated, and often the medical officers in them had no knowledge of what hospitals were behind them. The situation, in short, was an invitation to the one-stage management of compound fractures which was offered by the closed plaster method.

In the early experience in North Africa, the general plan of management, although it was not really official, was as follows: After debridement in a forward hospital, the wound was dressed with vaseline gauze; the fracture was reduced; and a plaster cast was applied, in which skeletal transfixion pins were sometimes incorporated. The patient was then transferred to a general hospital where, in the absence of specific indications to the contrary, the cast was left in place for 4 to 6 weeks. At the end of this time, it was assumed, wound healing would be progressing satisfactorily by granulation, and the fracture would also be well on its way toward healing.

In theory, this was not an unsound policy. In practice, it proved unworkable, and the results were poor. Patients were frequently febrile when they were received in general hospitals; often the temperature was very high. If the casts had been split or bivalved, as theater regulations required (p. 40), the plaster was often disintegrating and ineffective. If the casts had not been split, the circulation was sometimes threatened. Transfixion pins were often broken, and infection about them was frequent. Even when the fracture had been adequately reduced in the forward hospital, position was likely to be lost in transit over long distances and rough roads, and a second reduction was necessary at the general hospital. Finally, when the casts were left in situ the theoretical length of time, blister formation, excoriations of the skin, and pressure sores were frequently present when they were removed.


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Because of the poor condition in which so many casualties were received in general hospitals, it was found inadvisable to allow the casts to remain in place for the specified length of time, and they were usually changed at once. Inspection was likely to reveal two reasons for the infection: (1) Devitalized tissue had not been completely excised, and (2) the wound was actually plugged by the pack of vaseline-impregnated gauze. Displacement of fractures was frequent, but, if only a week or two had elapsed since wounding, the displacement could usually be corrected by manipulation or skeletal traction. If 2 weeks or more had elapsed, in many cases this was not possible, and faulty reduction had to be accepted.

Even in the relatively small number of cases in which conditions appeared to be favorable when the casualties were received at the general hospital, surface impressions were not always correct. When the cast was finally removed, at the end of several weeks, unsuspected infectious processes were often revealed. In many cases, purulent exudate had been dammed back by the dressings which plugged the wound, and the infection had been buried beneath the closed plaster. Moreover, reduction of the fracture was often lost as the cast became loose as a result of atrophy of the musculature as well as decreased swelling.

These observations in the first months of the North African invasion made it clear that. a strict application of the closed plaster regimen was not practical in the circumstances which then prevailed. Initial surgery was often inadequate, perhaps because it was, of necessity, performed by surgeons without previous experience in military surgery.

By the early spring of 1943, the closed plaster method had been modified to meet these circumstances. All casts applied after initial surgery in the forward area were removed at the fixed hospital not later than the 15th day after wounding. The surgeon who assumed charge of the patient thus had an opportunity to inspect and appraise the wound when the dressings were removed and before it was re-dressed. It was also possible to manipulate the fracture, institute traction, or carry out whatever other measures of fracture management the particular case required. Finally, the wound was covered with an occlusive dressing, and, if traction had not been instituted, a fresh plaster cast was applied.

The 15th day after wounding was arbitrarily set as the upper time limit for these manipulations. It is true that some fractures were reducible after longer time lapses but most of them were not, and additional postponement of attempts at correction would have introduced the risk of serious trauma to the soft parts, which in turn was conducive to infection.

At this period in the war, the attention of surgeons in general hospitals was chiefly concentrated on the reduction of fractures. It was believed that an open wound was necessary to permit prolonged drainage and that interference with the wound would reactivate infection. Secondary surgery, when


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the cast was removed, was therefore Limited to the unroofing of areas of dead tissue and the excision of presenting and protruding tags of similar tissue. The depths of the wound were seldom investigated. Slow healing of the wound by granulation, with resultant scar formation, was accepted as the best that could be expected in the circumstances.

As the months passed and experience increased, concepts of wound management and fracture management began to alter. It began to be realized, as later experience amply proved, that, if devitalized tissue was not completely excised at the first surgical attack on the injury, infection was a likely outcome. If large hematomas remained in undrained dead space, they were likely to undergo purulent decomposition. If dead tissue were allowed to remain in the wound, neither systemic nor local chemotherapy nor a combination of these methods could prevent wound infection. Once wound infection had developed, local necrosis of living tissue would follow, and a vicious circle was likely to be established.

Several clinical observations of considerable importance, as follows, were made during this period of the war:

1. Although the sulfonamides had no ability to prevent local infection, invasive infection was extremely infrequent when they were used, and infected wounds seldom manifested the cardinal signs of inflammation.

2. Systemic chemotherapy, though it could not prevent local infection, was apparently extremely effective in preventing the type of invasive infection of streptococcic origin which had been associated with so many compound fractures in World War I.

3. Unreduced fractures which required repeated manipulations or whose position in traction required repeated readjustments were peculiarly likely to become infected.

4. Infection was also likely to occur in injuries in which the fracture was exposed in the wound and dead space was difficult to obliterate. This was particularly true of fractures of such bones as the tibia, the ulna, and the tarsus, all of which lie immediately beneath the skin.

The significance of these various observations was not immediately realized. The fear of reactivating infection persisted, and wounds containing grossly devitalizing tissue continued, for the most part, to be managed in the general hospitals by a hands-off policy, in anticipation of the spontaneous sequestration of dead tissues. Delayed surgical excision was thought to be neither feasible nor safe. For the same reason, inadequate reduction of many fractures, particularly of the tibia, the fibula, and the bones of the forearm, and fractures about the joints, continued to be accepted because it was feared that infection would follow operative manipulation and reduction. As the result of these concepts and practices, the incidence of malunion and nonunion of compound fractures continued too high through most of 1943, and wound healing was prolonged and sometimes was not obtained at all.


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DEVELOPMENT OF THE PROGRAM OF REPARATIVE SURGERY

The closed plaster method of management of compound fractures was for all practical purposes written off early in 1944 because, even with the modifications which had been introduced, the results were not satisfactory. Analysis of the results, furthermore, showed that improvement could be accomplished only by a fundamental change in surgical concepts. Superficial alterations of technique would not accomplish the purpose. In particular, it would be necessary to discard the concept that surgery in an infected field could not be performed because of the risk of precipitating a limb-endangering osteomyelitis if not a life-endangering generalized infection.

The changed approach to battle-incurred compound fractures and the revised concept of their management were both embodied in the reparative-surgery program which had been instituted in the Mediterranean Theater of Operations late in 1943. At this time, the delayed closure of clinically clean wounds of the soft parts began to be practiced by a number of surgeons and was enthusiastically encouraged by the consultant in surgery for the theater. Though this story is told in detail in another volume of the clinical series of this history, it must be briefly summarized here, because it provides the background for the experience in the reparative surgery of compound fractures.

It was always a general principle of military surgery in World War II that wounds should be left open following debridement. The wartime experience with primary closure of soft-tissue wounds was brief and unhappy. Wound healing by granulation, however, had not provided the answer to the problem, and, as just indicated, delayed closure of soft-tissue wounds began to be practiced late in 1943, at first occasionally, then more frequently, and with informal official encouragement.

This was not a new idea. It had been practiced to some extent in World War I, with, however, one essential difference. No matter at what time delayed primary closure was to be instituted, cultures were taken from the wound when it was exposed for dressings, and closure was not scheduled if the bacterial count was high. In effect, this meant that the wound must be dressed one or more times to obtain the material for culture. It meant, further, that each of these dressings offered fresh opportunities for infection. Finally, it meant that a considerable amount of laboratory work was prerequisite to the closure of any wound. For two reasons, therefore, the policy of delayed primary wound closure had only a limited application in World War I: (1) If bacterial counts were high, as they frequently were, the optimal time for wound closure was missed, and healing by granulation had to be accepted. (2) Multiple dressings and extensive laboratory studies were so time consuming as to be completely impractical when the flow of casualties was heavy.

In World War II, delayed primary wound closure was based upon an entirely different concept. It was preferably accomplished within 4 to 7 days


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after wounding if the wound looked clinically clean and if surgical limitations (that is, loss of tissue, dead space, or excessive tension if the wound were to be sutured) did not contraindicate it. Bacterial counts were not made. The decision to close the wound or leave it open longer was based entirely on very careful inspection and clinical appraisal. If tags of devitalized tissue could be excised and hematomas and dead space could be eliminated, wound closure was not regarded as contraindicated. If skin deficits prevented closure by suture, reparative surgery was still performed if closure could be effected by rotation or advancement of flaps of skin or by the use of split-thickness skin grafts. In other words, the criteria for closure were not bacteriologic but clinical. The requirements were (1) a clean wound, either present on inspection in the general hospital or secured by some additional excisional surgery; and (2) freedom from the surgical limitations just listed.

Even if the casualty was not seen in the general hospital until 10 days or more after wounding, delayed closure of clean wounds was still practiced. Granulation had usually begun in such cases, and closure involved, just as in World War I, actual excision of the wound. Even after this lapse of time, cultures and bacterial counts were omitted. The decision for or against closure was based on the clinical impression that invasive wound infection was or was not present. If it was not present, closure was accomplished after what amounted to a second debridement.

The extensive bacteriologic studies carried out by Lyons and Rustigian, which are also reported in detail in another volume of this clinical series, completely confirmed the soundness of these practices. These observers were able to demonstrate that cultures taken from blood clots and from bits of devitalized tissue removed from an otherwise clean wound which healed after delayed closure with no evidence at all of infection exhibited bacterial flora entirely comparable to that found on cultures of similar material secured from wounds in which infection was established. The mere presence of these bacteria, therefore, was obviously not the cause of wound infection.

From these observations, the following concepts were derived:

1. Wound suppuration becomes established as the result of the decomposition of devitalized tissue and hematomas in dead space.

2. Pathogenic bacteria are present in all war wounds, but they are unlikely to survive if the tissue from which they secure their nutriment is eliminated at debridement.

3. If this pabulum is removed and if living tissue is protected from invasive infection by an effective antibacterial agent, then the bacterial flora of clinically clean wounds can be disregarded, infection or sepsis is not a complication to be feared, and whatever reparative surgery may be indicated can be performed on established surgical principles and will be followed by sound wound healing in the great majority of cases.

By the time of the fall of Rome, in June 1944, the consultant in surgery for the Mediterranean theater was able to report that up to that time at least


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FIGURE 22. - Staged surgery of wound of soft tissue of calf.  A. Appearance of wound before initial wound surgery.  B. Appearance of wound at completion of initial surgery. Note exposed fascia and tendon in wound. Note also extent of resection of damaged muscle tissue.  C. Wound healing after closure by suture at reparative surgery 6 days later. Split-thickness relaxing incisions have been made to avoid excessive tension on the suture line.

25,000 soft-tissue wounds had been closed by delayed primary suture on the indication of their gross appearance alone. Bacterial counts were not made in any of these injuries, partly because identification of species and tests for pathogenicity would have required weeks of arduous laboratory work and partly because preliminary qualitative or quantitative bacteriologic analysis of the flora of the wound by smear and culture would not have provided information of either diagnostic or prognostic value. In at least 95 percent of the soft-tissue wounds managed by these principles, healing occurred with no loss of life or limb and without serious complications (figs. 22, 23, and 24). The most usual explanation in the 5 percent of unsuccessful closures was failure to remove residual dead tissue in the deep recesses of the wound before the wound was sutured.


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FIGURE 23. - Staged surgery of wound of soft tissues of right arm.  A. Appearance of wounds of entry and exit before initial wound surgery in operating tent of evacuation hospital.  B. Appearance of wound of entry (the smaller of the wounds shown in view A) after excisional surgery. Exploration disclosed that the median and ulnar nerves and the profunda brachii artery had been severed. Considerable muscle tissue was devitalized. The artery was ligated, and the damaged muscle tissue excised. The severed nerves were merely identified.  C. Healed incision 3½ weeks after delayed closure at reparative surgery.  D. Healed wound of exit (shown in view A) after coverage by split-thickness skin grafts.

APPLICATION OF THE REPARATIVE-SURGERY PROGRAM TO COMPOUND FRACTURES

The writing off of the closed plaster management of compound fractures, even with its modifications, occurred, as already noted, early in 1944. By this time, the effectiveness of the reparative-surgery program for wounds of the soft parts had become fully established. It was logical to extend this program, which had proved so eminently successful, to the management of compound fractures, in which results, to date, had often left a great deal to be desired.

The program had already been applied, informally, to small groups of cases in half a dozen hospitals, with generally good results. Its expansion into a


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FIGURE 24. - Reparative surgery of wound of left axilla and shoulder.  A. Appearance of wounds in operating room of base hospital just before reparative surgery. Note axillary artery and severed nerve trunk visible in axillary wound.  B. Appearance of wounds at conclusion of reparative surgery. By extending the axillary wound with an incision along the posterior margin of the chest wall, it was possible to advance and rotate a flap of skin, after which it was possible to cover the axillary contents and close the wound without excessive tension on the suture line. C. Healed wounds 15 days after delayed closure.

theaterwide program of management in the late spring of 1944 could not have occurred under more propitious circumstances, for the following reasons:

1. The educational program in forward hospitals concerning standardized principles of excisional surgery and transportation splinting had begun to bear fruit, and debridement, as a general rule, was now being performed completely and correctly.

2. The chain of evacuation from Cassino, by ambulance and train, to


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general hospitals in Naples and Caserta was relatively short. After 23 May 1944, air evacuation from the Anzio area was also functioning well.

3. The functions of forward and general hospitals in the management of compound fractures had been completely clarified. The mission of forward hospitals was the salvage of life and limb by initial wound surgery, together with the application of transportation splinting, without effort at definitive reduction. The mission of fixed hospitals in the rear was the prevention of infection or its treatment, closure of the wound, and reduction of the fracture. It was recognized, in short, that the management of compound fractures in overseas theaters was a two-stage procedure. The mission of forward hospitals did not include fracture management, and the splinting applied in them was designed primarily for transportation and not to maintain precise alinement of bones.

4. A bed status had been established in general hospitals which permitted patients to be held the length of time necessary for the employment of reparative surgery and fracture management.

5. Supplies of blood had become available in sufficient quantities to permit transfusions in more liberal amounts than had previously been possible or than had been regarded as necessary.

6. Penicillin had become available in sufficient quantities for general use.

The extension of tile reparative-surgery program to the management of compound fractures was intimately related to the availability of penicillin. The original plan had been to establish an orthopedic center in the theater to test the surgical possibilities of this new agent as soon as it could be supplied in sufficient quantities for this purpose. This plan was later discarded. Instead, Maj. Oscar P. Hampton, Jr., MC, theater consultant in orthopedic surgery, and Maj. Champ Lyons, MC, who had done much of the original work with penicillin in the Zone of Interior, were constituted a team to be attached, in turn, to each of five general hospitals in the Naples area, for periods of 1 to 2 weeks, to initiate in them a program of reparative surgery under penicillin protection for compound fractures.

This project was set up with no preconceived notions. No effort was made to prove anything at all about penicillin. It was merely used as a probable safeguard while surgical eradication of an infectious process was undertaken. The first cases selected for treatment in each hospital were invariably infected compound fractures. Surgery was aggressive. It included not only the drainage of abscesses but also the excision of devitalized tissue, foreign bodies, and sequestra; freshening of wound edges; reduction of fractures, with, if necessary, stabilization by internal fixation; and closure of wounds by suture about 7 days after this operation. Liberal blood transfusions were an essential part of the program.

Within a few weeks, the soundness of these new policies had become so apparent that the program was extended to include all fractures and all joint injuries. Subsequent appraisal of results showed that when the original injury did not make prolonged drainage inevitable and reduction of fractures impos-


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sible, the reparative-surgery program was found to be capable of accomplishing, in large measure, its original objectives; namely, (1) elimination of wound infection; (2) rapid wound healing, with minimal scar formation; (3) optimum reduction and stabilization of fractures; and (4) maximum functional restoration of the wounded part. These objectives were achieved by a three-point plan of management consisting of (1) adequate blood replacement, to overcome anemia, permit the prolonged anesthesia so often necessary in compound fractures, and aid in wound healing and in the defense against infection; (2) antibiotic therapy, to protect living tissue against invasive infection; (3) precise surgical therapy, designed to repair defects caused by the missile or resulting from initial wound surgery and planned, at the same time, to prevent infection or to control it if it was already present.

Blood replacement and antibiotic therapy, valuable as they were proved to be, were recognized from the beginning as merely adjunct measures. Good surgery was the keystone of the reparative-surgery program for compound fractures. Wound healing by granulation was inevitable and had to be permitted in a certain proportion of all compound fractures, but it was no longer accepted in any instance in which the program of delayed closure of wounds by suture or skin graft was applicable.

Part II. The Initial Surgery of Compound Fractures

SURGICAL TIMING

The surgery of wounds involving bones and joints was ideally rendered in three phases, initial wound surgery in the combat zone and reparative surgery in the communications zone, with reconstructive surgery, if it was necessary, a function of hospitals in the Zone of Interior. One of the most important medical developments in World War II was the perfection of surgical timing, by which hospitalization, evacuation policies, and the scheduled transportation of patients from one medical installation to another were progressively correlated with the temporal necessities of surgical management. As always in warfare, tactical circumstances and the maintenance of combat efficiency required the evacuation of the injured soldier who was not to return to duty within the theater farther and farther away from the battlefront, both to remove him from the combat zone and to leave hospital facilities near the front available for the freshly wounded, whose need for care was urgent. This military necessity required, in turn, that medical care be rendered in phases, by different surgeons, at different times and in different places. Professional and logistic considerations were problems which could be solved only in relation to each other.

The pattern of wartime surgical care is thus radically different from the pattern of civilian care. This is one of the things that makes their introduc-


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tion to military surgery so difficult for medical officers, however competent they may be, who are fresh from civilian practice. It is a matter of the first importance that they learn and adhere to the prescribed routine, and it is here that the educational efforts of consultants have a particularly wide field of usefulness.

Because of their character, bone and joint injuries lent themselves particularly well to surgical timing. In them, as in other wounds of the extremities, surgical care was rendered in phases, in installations equipped and staffed to supply the special phases of care required at the time after wounding when the casualty reached them. It cannot be too strongly emphasized that it was the timing of each phase of management, not the location of the installation in which the surgery was performed, which was of supreme importance.

As the consultant in surgery for the Mediterranean theater, Col. Edward D. Churchill, MC, repeatedly emphasized, surgical considerations established the necessity for (1) as short a timelag as possible between wounding and initial wound surgery; (2) an optimum 4- to 7-day delay between excisional initial surgery and reparative would revision and closure; and (3) suitable holding periods in hospitals coincident with those stages of wound management. 2

The timelag between wounding and the institution of first-aid measures, although it was often lengthened by the intensity of combat, seldom exceeded a few hours. The timelag between the institution of first-aid measures and initial wound surgery for bone and joint casualties was influenced by a variety of factors, including the intensity of combat, the numbers of casualties, the distance of the evacuation hospital from the frontline, the condition of the roads, the availability of transportation, and the delay required for resuscitation. As a rule, it did not exceed 12 to 16 hours.

From the standpoint of reparative surgery, it was preferable that casualties reach a general hospital in the communications zone by the 4th day after the first operation and essential that they reach it not later than the 7th to the 10th day. Since the majority of casualties with injuries limited to the bones and joints became transportable from forward hospitals within 2 to 3 days after initial wound surgery, this requirement could usually be met without difficulty. Hospitalization for periods varying from 2 to 12 weeks, depending upon the nature and location of the fracture, was necessary after reparative surgery.

The chief thing that an inexperienced medical officer had to learn, whether or not he had had experience in orthopedic surgery in civilian practice, was that battle-incurred compound fractures are materially different from those resulting from traffic and other civilian accidents. For example-

1. Battle-incurred fractures in World War II were usually produced by high-velocity missiles or shell fragments which had, for all practical purposes, the effect of an internal explosion. The shattering effect of the energy imparted by the missile produced both fragments which frequently themselves acted as

2 Churchill, E. D.: The Surgical Management of the Wounded in the Mediterranean Theater at the Time of the Fall of Rome. Ann. Surg. 120:269-283, September 1944.


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secondary missiles, being driven into the muscle tissue and adding greatly to the original soft-tissue damage. These fragments, like the original missiles, had a tearing, disruptive action which led to extensive damage in multiple directions, often far from the site of injury.

2. Battle-incurred compound fractures were always compounded from without in. The missiles passed through clothing which was often soaked with the mud, grime, and filth of the battlefield. They often blasted or carried fragments of the clothing and other material into the wound with them.

3. The timelag from wounding to operation, which is usually minimal in civilian injuries, while very occasionally as short as 3 to 4 hours, not infrequently was as long as 12 to 24 hours. The mere lapse of many of these periods of time implies that at operation the wounds had passed beyond the stage of simple contamination and were potentially infected.

Convalescent hospitals in either the combat or communications zone played little part in the management of casualties with bone and joint injuries. The mission of these hospitals was to receive lightly wounded men after their professional care had been completed at evacuation hospitals and to prepare them for return to combat duty after a short period of what amounted to rehabilitation. Very few soldiers with injuries of the bones and joints had injuries whose care could be completed within the holding periods permitted at evacuation or convalescent hospitals. In the great majority of instances, for that matter, care could not be completed at general hospitals in the communications zone, and evacuation to the Zone of Interior was necessary.

FIRST AID

The preliminary management of compound fractures is briefly summarized in this chapter, to make the record complete. The only measures employed on the battlefield and in the battalion aid stations and collecting and clearing stations were those necessary to check hemorrhage, prevent further damage to soft tissues, relieve pain, avert or control shock, and prevent further contamination of the wound while the wounded soldier was being evacuated from the frontline to a hospital staffed and equipped to perform initial wound surgery. These steps included -

1. The application of sterile occlusive dressings. These dressings were inspected at each of the echelons of the division medical service but were removed and replaced only for cause, which was chiefly the suspicion of fresh or recurrent hemorrhage.

2. The control of hemorrhage by compression dressings. If they were not effective and if the bleeding vessel could not be visualized and controlled by the application of a hemostat, a tourniquet was used. Casualties with bone and joint injuries became first-priority cases once a tourniquet was applied.

3. The administration of morphine, in limited doses, if the pain was too severe to be controlled by simpler measures. The routine administration of


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morphine in the large doses given early in the war was later replaced by a more discriminating use of morphine, in smaller doses, and of sedatives, according to the requirements of the individual patient. Actually, a man who had suffered a compound fracture was frequently promptly relieved of pain by the correct application of emergency splinting (p. 32).

4. Plasma transfusion. Transfusions of plasma while the casualty was in one of the stations en route to an evacuation or field hospital had a single objective, to provide lifesaving resuscitation and make him transportable. Plasma was administered as necessary in the battalion aid station, the collecting station, or the clearing station. Blood was not available in these medical echelons of the Mediterranean theater during World War II. If, however, the blood pressure was found to be critically low in the clearing station, experienced medical officers, instead of holding the patient there to administer plasma, frequently transferred him to the adjacent field hospital, where whole blood was always available.

5. Emergency splinting, which was an essential step in all bony and massive soft-tissue injuries of the extremities. This subject is discussed in detail in a separate chapter (p. 31).

6. Other measures. These included the administration of a booster dose of tetanus toxoid and the institution of chemotherapy. Until near the end of the war, chemotherapy included the local use of sulfonamide powder or crystals.

PREPARATION FOR INITIAL WOUND SURGERY

The routine preoperative management of casualties with bone and joint injuries in a forward hospital consisted of the following steps:

1. A rapid examination, after the clothing had been cut away, to determine the location and extent of the injuries and to evaluate the soldiers general condition.

2. Inspection of the dressings and of the emergency splinting. If resuscitation occupied any considerable time or if operation was delayed for other reasons, the inspection was repeated at regular intervals. It was frequently necessary to reinforce the splinting or to adjust it when the patient was first examined. If the lower extremity was in a half-ring leg splint, the traction hitch was examined, to be certain that pressure on the dorsum of the foot was not excessive. Careful attention to splinting frequently eliminated the necessity for the administration of morphine or other drugs to control pain.

3. Conservation of body warmth, by the use of blankets under the patient as well as over him. Excessive covering and external heat, which would cause sweating with loss of body fluids, were avoided.

4. The prompt use of a tourniquet if there was evidence of bleeding. Patients with tourniquets already in situ were, as already noted, first-priority cases.


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5. Roentgenologic examination, which was an essential part of the preoperative routine in all bone and joint injuries. Roentgenograms, which were made in the usual anteroposterior and lateral views, were planned to include not only the known area of damaged bone and retained foreign bodies but also as large a portion of the surrounding areas as possible.

6. Induced vomiting or gastric lavage, unless the stomach had already been completely emptied by vomiting or more than 12 hours had elapsed since intake of food.

7. Withholding of food and fluids by mouth. If the patient complained of thirst, he was permitted to rinse his mouth or to suck a moist sponge.

Resuscitation. - Many casualties were in moderate or severe shock and required some resuscitation as part of the preoperative preparation. The measures employed to combat shock included -

1. The use of the Trendelenburg position unless complicating chest or head wounds contraindicated it. The patient was very gradually restored to a level, recumbent position when the systolic blood pressure reached 80 mm. Hg.

2. Oxygen administration by nasal tube if cyanosis was present.

3. Blood and plasma transfusions according to the indications of the special case. The necessity was determined entirely by clinical findings (table 2). Detailed laboratory studies were impractical in the preoperative wards of an evacuation hospital, and medical officers, as their experience increased, became more and more skilled in the interpretation of clinical observations in terms of blood replacement.

In practice, the liberal use of whole blood proved the most effective single measure of resuscitation for casualties in actual or impending shock. Most. men with compound fractures required some replacement of lost blood before and during operation. Often they required large quantities.

In at least. half of all cases, patients with fractures of the femur required a minimum of 1,000 cc. of blood before they could be subjected to initial wound surgery. Studies in the 16th Evacuation Hospital showed that 28 of 1 00 casualties with fractures of the femur required between 1,500 and 2,000 cc. of blood before and during operation and that only 9 required no blood at all. Of 100 patients with compound fractures of the radius, ulna, or both bones of the forearm, in contrast, only 3 required between 1,500 and 2,000 cc. of blood, and 63 received no blood at all before and during operation. Patients with compound fractures of the humerus and of the tibia, fibula, or both bones of the leg formed an intermediate group in respect to the need for whole blood. Of the 400 patients with compound fractures of the bones included in this survey (table 3), only 110 (27.5 percent) required no blood at all before and during operation, while 48 (about 12 percent) required between 1,500 and 2,000 cc.

Blood could not be administered by any rule of thumb. The individual man's condition determined how much he needed and when he was fit for surgery. Enough had to be given to overcome the most severe symptoms and signs of shock, plus enough to prepare him for the additional strain of anesthesia and operation and to compensate for the estimated blood loss on the operating


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TABLE 2. - Relationship of degree of shock and average blood loss in 67 patients with all types of wounds


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table. It was a very easy matter to underestimate the amount of blood lost at wounding and during transportation, as well as later at operation.

TABLE 3.- Blood replacement before and during initial surgery in 100 consecutive compound fractures of each of the long bones 1

In most of the casualties with bone and joint injuries, systolic blood pressures could be restored to 100 mm. Hg before operation. If this level could be attained without too much delay, that was naturally desirable. If it could not be, experience showed that operation should be undertaken only (1) after a combination of blood replacement and other measures had raised the blood pressure to 50 mm. Hg, which was a safe and satisfactory level for men of military age; (2) when the trend of the pulse rate was downward and the trend of the quality upward; and (3) when other symptoms and signs of shock were decreasing or had disappeared. It was not safe, however, to undertake operation until a sufficient quantity of blood was available to cover possible losses at operation.

Plasma transfusion was stopgap therapy and was eventually used only for that purpose; that is, to elevate the blood pressure to a level compatible with life and to maintain it at that level until transfusions of whole blood could be given and operation undertaken. The chief usefulness of plasma was in the echelons of the division medical battalion, but it was also used as indicated in evacuation and field hospitals.

Another important clinical fact which was eventually confirmed during World War II was that the wounded man did best if he was resuscitated as rapidly as possible and operated on with equal promptness. A wounded man who had been brought out of shock could readily slip back into it. The second attempt at resuscitation was always more difficult than the first and was sometimes not as effective. This was as true of patients with extensive compound fractures as of those with injuries of the chest or abdomen. The aim of resuscitative therapy was not to restore the casualty to his normal status nor to repair the organic damage caused by even a brief period of depressed blood pressure. Both of these objectives, in fact, were unattainable within a limited time and without the corrective effect of operation, which was itself a part of


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the resuscitative procedure. The aim of resuscitation in an evacuation hospital was merely to make the patient fit for initial wound surgery, and his best interests were served if he was operated on as soon as that objective had been achieved.

Objectives of initial wound surgery. - This objectives of initial wound surgery (debridement), regardless of the type of injury, were threefold: (1) To save life, (2) to save limb, and (3) to prevent or eradicate infection. The attainment of these objectives was accomplished by (1) the arrest of hemorrhage; (2) the removal of foreign bodies and foreign material within the wound; (3) the excision of tissues which had been destroyed by the missile (missiles) or devitalized by the impairment or destruction of the blood supply to the part; (4) the provision of drainage, which was accomplished by nonclosure of the wound; and (5) transportation splinting. Transportation splinting is discussed in detail under a separate heading (p.39). When these objectives had been accomplished, the result was a wound easily managed at reparative surgery.

APPRAISAL OF THE WOUND

After the wounded man with an injury or injuries of an extremity had been adequately treated for shock in the shock or preoperative tent of the evacuation hospital, he was transferred to the operating tent, accompanied by the roentgenograms which had been taken of the injured area.

Only occasionally was the soldier removed from the litter on which he had been transported and placed on an operating table. As a general rule, the litter was placed on the table or was supported by its handles on boxes or sawhorses, and itself served all the purposes of a standard operating table. This plan had a number of advantages. It conserved the time and effort of the operating-room personnel. More important, it spared the patient the move from the litter to the operating table before operation, and from the table to the litter at the end of the procedure. This was highly desirable, because casualties who had previously been in shock were likely to suffer recurrent shock if they were moved about.

Examination in the admitting tent of an evacuation hospital (p. 67) was essential to identify the wounds and determine the patients status. A detailed examination, however, was impossible under the circumstances which prevailed in that area, and it was therefore deferred until he had reached the operating room. It was, as a matter of fact, to the advantage of a patient in shock not to disturb him for such an examination until lie had been properly prepared for operation. When he was placed on the operating table, under a good light, with the emergency splinting and dressings removed, and with roentgenograms available for reference, it was possible to make a thorough examination and complete appraisal of the injuries. The routine was as follows:

1. The site of entry of the missile (missiles) was determined, and the site of exit was sought for.


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2. When the sites of entry and exit had been identified, the course of the missile was determined. If a site of exit was not found, the course was postulated from the site of entry to the point at which the retained missile was demonstrated by roentgenograms. After this information had been secured, it was possible to plan the incision or incisions which would provide most convenient and most satisfactory access to the devitalized tissue and retained foreign material which had to be removed, as well as to whatever nerve or vascular injuries might be present.

3. Determination of the presence or absence of arterial pulsations distal to the wound (wounds) of an extremity was an essential part of preoperative appraisal. If pulsations could not be obtained, the major blood vessels which might be damaged had to be visualized and treated according to the indications.

4. Function of major nerve trunks also had to be investigated, though this was not always an easy matter, since damage to bone and muscle might prevent active movement of the digits of the hand or foot, even when the motor nerve supply remained intact. On the other hand, careful investigation of the status of motor function and sensory supply usually permitted the surgeon to arrive at some definite conclusion concerning the integrity of the major nerve trunks. By observation of only the motions of the thumb, for example, it was possible to decide whether or not there had been functional damage to each of the three major nerve trunks of the upper extremity. If the distal phalanx of the thumb could be extended or if the entire thumb could be abducted and extended, it could be assumed that the radial nerve was intact. Active flexion of the thumb against the side of the hand established the integrity of the ulnar nerve. When there was evidence of loss of function in the supply of a major peripheral nerve, the nerve was usually exposed during initial surgery to permit an accurate estimate of the degree of damage.

GENERAL PRINCIPLES AND PRACTICES

Initial wound surgery, whatever modifications might be necessary in individual wounds, was ideally conducted on the basis of certain principles and practices, as follows:

1. The length of the timelag from wounding to operation was of no importance in the decision whether, or when, to perform initial wound surgery. Fresh wounds were operated upon as promptly as possible. Old wounds (that is, wounds of more than 48 hours duration) were managed in the same manner except that invasive spreading infections, with cardinal signs of inflammation such as cellulitis and lymphangitis, were best managed by antibiotics, immobilization, and the application of warm wet dressings until an optimum time for surgery could be selected. There was no hesitation, however, in draining septic hematomas, fascial-plane abscesses, and large masses of dead, autolyzing tissue when the casualty was first seen.


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2. A precise knowledge of regional anatomy was essential. Indeed, the initial surgery of war wounds of the extremity amounted to a postgraduate course in surgical anatomy. The surgeon had to know the location of the nerve and blood supply of every muscle and had to respect blood vessels and nerves in his dissection. This was particularly important when there were large wounds in the region of heavy muscles, such as the gastrocnemius-soleus group in the calf and the rectus femoris in the thigh. The technique had to be both careful and precise, for irreparable damage could be done if major blood vessels and nerve trunks were damaged in the course of the operation.

3. Roentgenograms were made routinely in two views, so as to cover as broad a field as possible about the wound or wounds. They were available for use in the operating tent.

4. An adequate light and a competent assistant were basic requirements.

5. A wide field was prepared, to allow for extension of the original incision or for counterincision as might be necessary.

6. The operative procedure was carried out in an orderly manner. There was no place in initial wound surgery for haphazard, bloody, cut-and-slash techniques.

7. Adequate exposure was essential for the complete excision of devitalized tissue. Bold incision was therefore the first step at operation. As a general rule, the line of incision was placed parallel to the long axis of the limb, though on the hand, the foot, or the buttock the incision might follow the natural hues of the skin. The creation of circular skin defects had to be avoided, though excision of a small area (2 to 3 mm.) of devitalized skin on the margins of the wound might be indicated.

8. Dead and devitalized tissues had to be completely excised. This was the most important single step in preventing infection. Failure to excise devitalized muscle seeded with pathogenic bacteria led to the sepsis for which combat-incurred wounds are notorious. If tissue devitalized by the missile or produced by the surgeon in the course of operation was left in situ, wound healing would not occur until it had sloughed away. The fascial layers had to be incised as freely as the skin, since free access to devitalized muscle is necessary for thorough excisional surgery.

9. Retained foreign bodies, especially if they were of any considerable size, were best removed at initial surgery. It was important that they be identified and, if possible, removed, because the path which led to them was the track along which devitalized muscle would be found. Moreover, foreign bodies, especially high-explosive shell fragments, were likely to carry into the wound bits of clothing, shoe leather, or other foreign material, which would be removed when the fragments themselves were removed. Deep recesses containing foreign bodies might be approached by counterincisions planned anatomically over fascial planes rather than by cutting through normal muscle structure.

10. Fine hemostats were used whenever they were available, and only the smallest possible amount of tissue was ligated. Structures within the wound


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were not traumatized more than was necessary by the use of tissue forceps. Sponging was done very gently.

11. Ligatures for the control of bleeding vessels were as fine as possible. They could be either absorbable or nonabsorbable, but the young surgeon found his operating time shortened when nonabsorbable sutures were used because they were bulkier and therefore easier to handle.

12. Incisions and counterincisions were left open, and no sutures were used following the excisional phase. The provision of drainage, which was inherent in this policy, was a cardinal principle of the management of such injuries. There were only two exceptions to this rule: The synovial membrane was closed in wounds of the joints (p.216), and flaps of skin were tacked loosely in wounds of the hand to cover cartilaginous surfaces and tendons which would otherwise be left exposed.

13. The unsutured wound was carefully dressed with fine-mesh gauze so that all raw surfaces were covered. The purpose of the dressing was merely to hold the raw surfaces of the wound apart and permit drainage from its depths. The portion of the dressing placed in the depths of the wound always had to be placed loosely. Otherwise, as the wound and the area about it began to swell, the dressing would become dangerously tight.

TECHNICAL CONSIDERATIONS

The wide variation in the location of battle injuries of the extremities and in the extent of the damage to the deeper structures required variations in the surgical procedure which made it impossible to outline the step-by-step technique for initial surgery which could be outlined for an appendectomy, for instance, or the repair of an inguinal hernia. The principles and policies just listed served as a guide to what had to be done. Certain technical considerations, however, were applicable to all types of wounds (fig.25).

Incision. - The location of the wound usually, though not always, determined the location of the surgical incision. Wherever it was located, care was taken to make it of adequate length. It was always better to make it too long rather than too short; the unnecessary length did no harm, since an incision heals from side to side, not from end to end. It was also desirable that the surgeon, at the initial operation, plan the skin incision so as to expose the devitalized deeper structures.

Instead of an incision through the wound, a standard longitudinal incision was frequently used, so placed as to open into muscle planes and offer a better access to devitalized muscle tissue. It was never wise to extend an incision proximally and distally from the center of a wound which ran in the opposite direction, or from the center of a circular wound. These practices created a crucial type of incision, which handicapped the closure of the operative incision at reparative surgery and might even prevent closure entirely, particularly at the point at which the wound of entry was crossed by the surgical incision. If an incision had to be extended proximally and distally from the wound pro-


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FIGURE 25. - Technique of initial wound surgery of soft-part wound.  A. Incision of skin, in long axis of extremity and excision of the traumatized skin border.  B. Exposure of depths of wound, excision of devitalized fascia. Damaged muscle in depths of wound is visualized.  C. Saucerized wound. Debridement is almost completed. The last of the devitalized muscle is being cut away with scissors.


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FIGURE 26. - Staged surgery of wound of thigh.  A. Anterior wound of thigh compounding fracture of femoral shaft. Appearance 3 weeks after reparative surgery.  B. Lateral wound of soft parts 4 weeks after reparative surgery. Note that in these wounds the proximal and distal incisions extending from the transverse wounds of entry were correctly made at initial wound surgery. Z-plasty incisions, which can be closed without difficulty, were thus obtained, rather than cruciate incisions, difficult to close, which would have resulted had the surgical incisions been made across the center of the transverse wounds. (These wounds were debrided by Maj. Howard B. Shorbe, MC, 2d Auxiliary Surgical Group.)

duced by the missile, it was best to begin each limb at an opposite corner of the wound, so as to leave, in effect, a Z-shaped incision (fig.26). This kind of incision was particularly desirable in areas in which the skin was normally tight, as over the anterior surface of the leg.

Skin devitalized by the entrance of the missile had to be excised, but as little as possible was removed and no normal skin was sacrificed. The skin incision was made with a knife, and surgical perfectionists demanded that a knife also be used for the excision of the skin edges about the wound. Experience showed, however, that, when this practice was followed, there was usually a tendency to excise more skin than was necessary. If the surgeons technique was such that the excision could be limited to removal of 2 to 3 mm. of skin, then the scalpel was preferable, since its cutting edge was sharper than the cutting edges of scissors. On the other hand, the advantages of excision by scalpel were more theoretic than real, and trimming of the skin edges of a wound with scissors was easier and generally more rapid.

Excisional surgery. - Once the skin incision had been made and the wound laid fully open, there was no objection to tine careful use of a pair of sharp scissors for excision of devitalized fascia and muscle. Strong encircling fascia, such as the fascia lata, was opened widely, and all grossly traumatized areas were excised.


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FIGURE 27 - Initial surgery of large, ragged wound of anterior surface of right thigh. A. Appearance of wound before initial surgery. B. Wound of devitalized tissue.

The decision as to just what muscle tissue should be excised was decidedly less simple, because devitalization was not so easily determined. A time-honored criterion of death of muscle is its failure to contract when it is pinched with thumb forceps, and this test was frequently used. Muscle which contracted when pinched was unquestionably viable, but the reverse was not true; failure of contraction did not necessarily mean that the muscle was dead and should be excised. Muscle which bled freely when it was cut, even if it did not contract when it was pinched, was probably still viable.

If bleeding did not occur, then the muscle was definitely not viable and the excision had to be carried back until muscle which bled on section was reached. On the other hand, even though there was some bleeding when damaged muscle was cut, it was always best to carry out excisional surgery if the tissue appeared macerated or the muscle bundles were separated (fig. 27). In other words, while it was essential that excisional surgery be thorough, it was the responsibility of the military surgeon to be certain that the incision he undertook was justified and that he was not extending it beyond indicated limits.

The wound, as has been repeatedly emphasized, was left open when initial wound surgery was concluded. A saucerized type of wound was generally desirable, though there were exceptions, particularly when the original injury was of the through-and-through variety. Large dead spaces, in which serum and wound exudate could collect, were eliminated by counterincisions and dependent drainage. Rubber-tissue drains were not used after initial wound surgery except when they were essential to insure dependent drainage of residual dead space.

Dressing of the wound. - The raw surfaces of the wound were covered with fine-mesh gauze. After the program of reparative surgery was in effect


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at the fixed hospitals in the theater, dry gauze was regarded as best for this purpose, since drainage of wound exudate was provided by capillary attraction when it was used. When the gauze was removed, several days after the first operation, a clean, relatively dry surface was usually found. Petrolatum-impregnated gauze could also be used, but capillary attraction was not provided through its meshes and when it was removed the surface of the wound was likely to have a slimy and less healthy appearance than when dry gauze was used.

Whether dry or petrolatum-impregnated gauze was used, the wound was dressed in the following manner: Single strips of gauze were arranged side by side around the perimeter with the ends of the strips in the depths of the wound, until all raw surfaces had been covered (fig. 28). It was not the intention to

FIGURE 28.- Appearance of wound after strips of dry or petrolatum-impregnated fine-mesh gauze had been loosely introduced into depths at completion of initial surgery.

pack the wound. The purpose of the dressing was merely to hold the raw surfaces apart and provide drainage from the depths of the wound. Inexperienced military surgeons, partly because of their inexperience and partly because of a desire to reduce the oozing of blood from the raw surfaces, were inclined to pack the wound tightly. When this was done, there was no provision for the swelling which normally follows an operative procedure, and the tightly packed dressings became even more undesirably tight.

After the fine-mesh gauze strips had been placed in the wound, they were covered with standard gauze dressings.

MANAGEMENT OF BONE FRAGMENTS

It was impossible to avoid moving bony fragments about during the debridement of compound fractures, and it was easy, unless great care was taken, to tear them away from attached soft tissue. All manipulations of fragments


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therefore had to be very gentle. Sponging had to be done carefully in the region of the fractures, for jagged fragments could become entangled in the meshes of the gauze and could be avulsed from their remaining attachments, especially when the sponge was removed from the wound.

To the end of the war, there was no universal agreement in the Mediterranean theater as to the management of bone fragments. A few surgeons believed that all fragments should be allowed to remain in situ or should be replaced after they had been removed and cleansed, on the ground that segmental bone defects would thus be avoided and the chances of union increased. The background of this policy was the concept that these fragments were, in effect., bone grafts, which could be expected to participate in the process of healing.

The majority of surgeons took the opposite point of view. They willingly admitted that the removal of bone fragments introduced the risk of segmental defects and that segmental defects, in turn, militated against the union of fractures. In their opinion, however, these fragments should be removed because, since they were totally devoid of soft-tissue attachments and were therefore without blood supply, they were, in effect, devitalized tissue, which might serve as a means of infection and prevent healing of both the injured bone and the compounding wound.

The whole disagreement was, to a certain extent, academic. Surgeons of both schools of thought naturally left in situ all fragments with any sort of soft-tissue attachments, regardless of their size, since it could be assumed that some degree of vascularization would persist through these connections. Fragments totally devoid of soft-tissue attachments were usually small (three-fourths inch in diameter or less), and their removal seldom created defects of sufficient size to prevent good contact between major bone fragments.

The policy therefore evolved of removing all small fragments of bone totally devoid of soft tissue and of leaving in situ those with even the smallest amount of attachment to the soft parts. If a large fragment was totally detached and its removal would create a segmental bony defect, the chance of leaving it in place was usually taken, even thought it had no soft-tissue attachment. Fragments of bone totally devoid of soft tissue were, as a rule, small fragments of cortical bone, which made up only a relatively minor portion of the bony circumference at the level of the fracture.

The policy of removing totally separated fragments of bone from the wound had a sound basis. It was repeatedly observed in general hospitals in the earlier months of the war that when compounding wounds, without soft-tissue deficits, failed to heal within a few weeks, exploration of the depths of the wound was likely to reveal totally loose fragments of bone which were acting as sequestra. For this reason, delayed healing and nonhealing were particularly frequent in compound fractures of the tibia, in which filaments of cortex were often indriven into the medullary canal and remained in that location until they were removed surgically.


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FRACTURE MANAGEMENT

The management of compound fractures at initial wound surgery was limited to the correction of gross malposition. Splinting was applied only for transportation purposes (p. 39). Definitive reduction was postponed until the reparative stage of surgery, which was carried out in the fixed hospital. There were the following sound reasons for this policy:

1. Initial wound surgery was usually performed in an operating tent in a forward hospital, often with the wounded man lying on the same litter on which he had been brought into the hospital (p. 71). Neither environment nor circumstances were conducive to the accurate reduction of fractures.

2. Roentgenologic controls, which are essential for accurate fracture reduction, were not feasible in evacuation hospitals.

3. Even if precise fracture reduction could have been obtained under these unfavorable circumstances, reduction would likely have been lost during application of the plaster cast.

4. Even if precise reduction could have been maintained during the application of the cast, displacement of the fragments would have been almost inevitable after the cast had been split or bivalved, as was required in forward areas, to guard against circulatory impairment during transportation.

5. The early experience in the North African theater had shown that the use of internal fixation and of skeletal fixation in casts as primary procedures in forward hospitals was attended with a high incidence of infection and extremely unsatisfactory end results.

6. The limited personnel in forward hospitals did not warrant the expenditure of time and effort which would have been required to reduce compound fractures properly. The delays thus entailed, in fact, might have put other wounded men awaiting surgery in jeopardy of life as well as of limb.

POSTOPERATIVE REGIMEN

The postoperative regimen after initial wound surgery consisted of standard measures, with additional blood replacement as necessary. Casualties with compound fractures of the femur and other serious injuries often required additional transfusions. The fingers or toes were inspected at regular, frequent intervals, to evaluate the circulatory status of the injured part, so that bandages and casts could be loosened if any vascular impairment became evident. Repeated inspection was also necessary to detect early signs of gas-bacillus infection, which readily developed in limbs which were the site of compound fractures associated with vascular damage. Finally, repeated inspections were necessary to detect early evidence of continuing or recurrent hemorrhage.

EVACUATION

The soldier with a compound fracture was held in the evacuation hospital after initial wound surgery only long enough for him to recover from the


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immediate effects of operation and for the surgeon who had operated on him to be certain that he could be transported safely to the rear. A casualty with an injury of a bone or joint generally became transportable within 24 to 48 hours. His transportability was determined not only by his actual status but also by certain external considerations, such as the tactical situation, the mode of transportation available, the distance to be traversed, and the number of casualties to be moved. If there was any doubt at all about the soldiers status, it was usually the policy to keep him in the forward hospital a day or two longer, particularly if it seemed that the transportation time might be unduly prolonged by delays at airfields or other holding points or for other reasons.

Part III. The Reparative Surgery of Compound Fractures

Under the concept of reparative surgery as it developed in the Mediterranean theater, surgery of some kind was indicated on every casualty with a compound fracture as soon after his arrival at a fixed hospital as he could be properly prepared for the operation. The procedure, depending upon the necessities of the special case, was excisional, reparative, or both. This concept represented an entirely new development of World War II.

Four to seven days after wounding was regarded as the optimum time for the reparative stage of wound surgery, and particularly for the closure of a compounding wound, though a maximum of 10 days was still within permissible limits. Operation within these time limits was a perfectly practical objective. It gave time for the transfer of the patient from an evacuation to a fixed hospital; for the proper evaluation of his status after he had arrived; and for preoperative preparation, including roentgenologic examination and blood replacement. In a series of 188 compound fractures treated during a push period at the 23d General Hospital during the breakout from the Anzio beachhead, the average time between wounding and reparative surgery was 8.3 days. This was a usual, not an exceptional, accomplishment.

From the physiologic standpoint, the time lapse of 4 to 7 days between initial and reparative surgery allowed for the sequestration of bits of residual devitalized tissue which had been overlooked or which could not be excised at initial wound surgery. By the end of this interval, it was possible to make a decision concerning the viability of questionably devitalized tissue which had been deliberately left in situ at the first operation. It was not too long a time to permit further debridement, if it should be indicated, before infection could become established. Purulent exudate formed by the decomposition of dead tissue would not yet have had time to exert a locally necrotizing action, and heavy granulation tissue would not yet have formed and fixed in position the deep and superficial soft parts. Finally, this interval was within the golden period for the management of fractures. It was too soon for them to have become fixed by callus formation, and they were still amenable to closed or open manipulation.


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PREOPERATIVE PREPARATION

Roentgenologic examination. - New roentgenograms were made as soon as this casualty was admitted to the general hospital. The films made in the evacuation hospital were supposed to travel with the patient, but this rule was not always observed. Even when they were available, however, they were used only for comparison, as they had been made before initial wound surgery, during and after which conditions were likely to have changed. More recent roentgenograms permitted an accurate appraisal of the position of bony fragments, the precise loss of bone, and the location of any retained foreign bodies.

Blood replacement. - Secondary anemia, often of a considerable degree, was present in a large number of the casualties with bone and joint injuries when they were received at fixed hospitals. This was in spite of the generally adequate use of blood in the forward hospital. A series of 138 fractures of the long bones treated at the 23d General Hospital well illustrates this point. Thirty-three patients (24 percent) had hematocrit values under 30. Eighty others (58 percent) had values between 31 and 40, and only 25 (18 percent) had values of 40 or higher, the desirable level for the reparative operation. Only 2 of the 38 patients with fractures of the femur fell into the 40 or higher group. In another series of 166 fractures of the long bones observed at the 21st General Hospital, the proportions were substantially the same: 37 casualties (22 percent) had hematocrit readings under 30, and only 31(19 percent) fell into the group with readings regarded as safe for operation without further preparation.

Since operation with low hematocrit levels would have introduced a completely preventable risk, the correction of secondary anemia was this first step in preoperative preparation. Transfusions were given, as a rule, until the desired level of 40 or better was reached. The copper sulfate falling-drop technique proved a simple and satisfactory method of determining this value as well as the total serum-protein value.

Preoperative requirements were roughly calculated as 500 cc. of whole blood for each 3 to 4 points of deficit on the hematocrit reading or for each 0.9-gm. percent deficit in hemoglobin. Except when hemorrhage created an emergency, which was not often in a fixed hospital, the total volume of blood administered in a 24-hour period did not exceed 1,000 cc.

Additional blood was also given as indicated while the reparative operation was in progress as well as during the postoperative period. The principles of administration were the same, regardless of the location of the injury. On the other hand, the necessity for blood replacement was usually far greater in certain fractures, especially fractures of the femur (p. 68), than in others.

No absolute proof can be adduced to show that such intensive blood replacement was necessary for good results. There is, however, a good deal of indirect proof. More liberal transfusions became the practice at about the


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same time that penicillin became available and the program of reparative surgery in compound fractures came into general use. Results in these injuries were greatly improved after this threefold plan of management was instituted, though it is naturally impossible to assign credit for the improvement to any single phase of the program. The risk of prolonged anesthesia and of a long and taxing operation was naturally far less in a patient whose anemia had been corrected. It was also the general impression that casualties who had received liberal blood transfusions were much less likely to suffer from chronic wound infections and much more likely to show prompt healing of wounds than those in whom this measure had been omitted. The postoperative course was also always much smoother in patients who had received ample transfusion therapy.

Antibiotic therapy. - Before the spring of 1944, when penicillin became generally available, it was the policy to continue in the fixed hospital the sulfa drug which had been given in the forward hospital. The same policy was followed with penicillin. The surgeons in the general and station hospitals had had the benefit of the teachings of Maj. Champ Lyons, MC, in the proper use of penicillin after it had become available for use in battle casualties. As a result, this agent was always used as an adjuvant to surgery in an effort to provide a wider margin of safety for the aggressive surgical measures of reparative surgery.

Penicillin therapy initiated in a forward hospital was continued in the general hospital in all wounds involving the bones and joints. It was also used after operation until wound healing was well on the way to completion. This was usually 5 to 10 days after the reparative operation. If drainage from the wound persisted, penicillin was usually given for a longer period.

TECHNICAL CONSIDERATIONS

Reparative surgery could not be undertaken unless holding policies were such that the casualty could be kept at bed rest in the same hospital until healing of the wound was complete. When the injury was a compound fracture, this requirement also implied healing of the fracture to a stage at which transportation could safely be permitted. The early experience in the theater had shown that the transfer of the wounded from one hospital to another while sutures were still in place after delayed wound closure and while the wound was still unhealed, was always hazardous and could be attended with serious complications.

All reparative surgery was performed under general anesthesia, in an operating room set up for any type of surgery which might be indicated. This meant that instruments and equipment were available for skeletal traction and internal fixation, as well as for the repair of soft-tissue defects by suture or by graft.

The plaster cast and dressing applied after initial wound surgery were not removed until the patient was on the operating table and fully anesthetized.


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This practice was an important feature of the reparative stage of military wound surgery for several reasons, as follows:

1. A fundamental concept of the staged management of combat-incurred injuries was that every wound required some additional surgery, either further debridement or closure of the wound by suture or skin graft, after initial surgery. Reduction of the fracture was also necessary, since fracture management was not a function of forward hospitals (p. 80).

2. Since these procedures had to be carried out in the operating room, under anesthesia, there was no reason to subject the patient to painful dressings on the ward or to the risk of hemorrhage.

3. The risk of secondary contamination on the ward was avoided by the practice of removing in the operating room the cast and dressings applied after initial surgery in a forward hospital.

4. This practice conserved the time and effort of medical and ward personnel.

Because of the varieties of injuries encountered, it was not possible to recommend a step-by-step technique for the reparative surgery of compound fractures. The operation, however, always followed a definite plan.

Appraisal and Revision of the Wound

Wound revision was conceived of as an extremely careful completion of excisional surgery, to remove tissue that might lead to suppuration. The entire wound, including the fracture site, was exposed by gentle retraction and explored to verify the adequacy of initial surgery. Incisions were enlarged, if necessary, to facilitate exposure. Any remaining foreign material, accessible foreign bodies, totally detached fragments of bone, or devitalized soft tissue was removed. Old blood clot was cleaned out. Means of obliterating or draining dead space were considered.

In the clinically clean case, wound revision consisted, at the most, of the excision of remaining tags of devitalized tissue. In compound fractures, however, further excisional surgery was not infrequently indicated. This was particularly true of large, deep wounds, such as wounds of the thigh associated with a compound fracture of the femur.

Reduction to a minimum of residual devitalized tissue was the keystone of the staged plan of management of battle-incurred compound fractures. Failure to explore the depths of the wound and to follow up the exploration with the necessary excisional surgery was repeatedly shown to account for many of the failures to obtain wound healing when the program of delayed primary wound closure was being tested in the Mediterranean theater late in 1943 and early in 1944. Adequate excisional surgery usually resulted in the prompt subsidence of infection (fig. 29). To perform the kind of surgery necessary, the formerly accepted concept--that operation in an infected field would not only fail in its objectives but might be followed by serious consequences--had to be discarded.


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FIGURE 29. - Control of infection in compound comminuted fracture of upper half of left tibia and upper third of right femur by correct excisional surgery.  In this case, when the cast on the left leg was changed for the second time in the fixed hospital 18 days after wounding, purulent, foul-smelling drainage suggested an incipient osteomyelitis.  Twelve days later, the wound was explored, and several dead, totally detached, indriven fragments of bone were removed.
A. Roentgenograms of left leg made when patient was received in fixed hospital 5 days after wounding; initial wound surgery had been performed 2 ½ hours after wounding.
B. Roentgenograms made 5 days after the reparative operation. Although further sequestration seemed probable at this time, it did not occur; when the cast was changed 4 weeks later, the wound was clean, drainage had ceased, and there was clinical evidence of bony stability. If this fracture site had been explored when the patient was received in the general hospital, and if the totally detached bone fragments which were acting as devitalized tissue had then been removed, osteomyelitis of the tibia might have been prevented.


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Fracture Management

Thorough visualization of the depths of the wound to determine its clinical status permitted full view of the fracture site. Reduction could therefore, for all practical purposes, be conducted, at least in part, as an open operation. Direct inspection was supplemented by study of the roentgenograms taken just before operation. It was thus possible to decide, with all the evidence at hand, the best means of obtaining and maintaining reduction.

The method of fracture management depended upon the circumstances of the special injury. Whenever possible, the ends of the fragments were adjusted under direct vision, after they had been freed from intervening soft parts. Twisted and rotated fragments were alined. In most cases, the decision was to accomplish reduction either by manipulation and plaster immobilization or by skeletal traction. Internal fixation was employed only under special circumstances.

Internal fixation. - Internal fixation, per se, was by no means an objective of the reparative-surgery program. It was usually neither advisable nor possible because of severe comminution. The program permitted its use, however, with the limitations to be outlined below, when it was indicated to maintain fracture reduction. Fixation was obtained by plating, multiple screws, or wire sutures.

Rigid stabilization of the fracture in reduction by a plate or by multiple screws offered certain advantages: (1) Anatomic apposition and alinement were secured, in anticipation of faster bony union with no deformity; (2) dead space was obliterated and the traumatizing manipulations just mentioned were avoided (fig. 30); (3) handling of the extremity for necessary subsequent wound care was facilitated (fig. 31); (4) early joint motion and muscle exercise, in anticipation of a more rapid return to function, could be permitted; and (5) the management of concurrent injuries which precluded traction and required repeated trips to the operating room was facilitated.

The use of internal fixation was, however, limited by three factors other than comminution. These were (1) the desire to minimize intrawound trauma caused by the operative procedure, which could produce additional devitalized tissue; (2) interference with the covering of all exposed bone cortex with vascular soft parts (fig. 32); and (3) the desire to avoid the periosteal stripping which may be necessary to permit the application of a bone plate and which carries the danger of massive sequestration (fig. 33). Periosteal stripping, which deprives the outer cortex of bone of its nourishment, is an important consideration in surgery in a field known to be contaminated and potentially infected, and this consideration therefore always had to be recognized in the reparative surgery of compound fractures. Practically, if the wound was regarded as clean and if the other factors were favorable, especially the availability of vascular soft parts for covering bone, as in the arm or thigh, there was less hesitancy in stripping sufficient periosteum to permit the required surgery.


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If, on the other hand, the wound was regarded as dirty or doubtful, stripping was restricted or avoided.

When the factors that might restrict its use were not unfavorable and the contour of the fracture permitted, rigid internal fixation was frequently employed in order to gain the advantages of a well-reduced and stabilized fracture. Fixation through the compounding wound was at times practical but had the disadvantages of retraumatizing tissue. It also had the disadvantage of placing the metal on bone usually devoid of periosteum, as well as at the bottom of dead space created by excision of devitalized muscle. For plating, therefore, a separate standard approach to the fracture was advisable, to permit covering of the bone and metal by periosteum and vascular soft parts (fig.34).

In actual practice, when internal fixation was indicated, multiple-screw fixation (by 2 or more screws) was frequently used (figs. 35, 36, and 31). Many fractures by their obliquity lent themselves to this technique. Little or no additional periosteal stripping was required to permit placement of the screws, and intrawound trauma was not excessive. If the fracture, because of comminution, did not permit rigid fixation, one or more wire sutures were sometimes used to hold major fragments in approximation. These could usually be placed without additional periosteal stripping, a factor of particular importance in a wound with recognized established infection. In comminuted fractures with segmental bone loss, wire sutures permitted approximation of the major fragments.

Bony union is a prime consideration in any fracture, and contact of the fragments greatly enhances the chances of union. The shortening of an extremity to overcome segmental loss and obtain contact of fragments by internal fixation of some kind was therefore often a justifiable and indicated procedure that was permissible under reparative fracture surgery (figs. 37 and 38). A nerve-trunk or a muscle-group deficit associated with a fracture at times was the indication for the deliberate removal of attached bone fragments and shortening of the extremity. In this way, continuity of all the severed major structures was achieved, with the objective of maximum functional restoration of the extremity instead of merely a good fracture result as demonstrated by roentgenograms (fig. 39).

There were a number of special types of fractures in which internal fixation was frequently employed at the first operation of reparative surgery, to achieve special objectives. Among them were (1) fractures about joints, such as fractures of the condyles of the femur or the humerus, to permit anatomic replacement of articular surfaces; (2) fractures of long bones deep in muscle tissue, such as fractures of the femoral shaft and upper radius, in which circumstances favored early reattachment of soft parts to the bone; (3) fractures which experience had shown were difficult to hold in reduction by other means, such as fractures of the olecranon and fractures associated with massive loss of soft tissue (fig. 38); and (4) fractures with segmental loss of bone, to achieve contact of the fragments and prevent nonunion (fig. 32).


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FIGURE 30. - Compound comminuted fractures of left femur and patella, multiple penetrating wounds of knee, thigh, and buttock. Inadequate initial surgery; additional excisional surgery 5 days later, with both femoral and patellar wounds left open. Septic course; failure of reduction by skeletal traction in 90-90-90 position. Final management by delayed internal fixation.  A. Extremity in skeletal traction 1 month after injury; femoral fragments distracted, gas-abscess formation.  B. Drainage of fascial-plane abscess by posterolateral fasciotomy 21 days later.  C. Plating of fractured femur at same operation after removal of totally separated bone fragments.  D. Partial suture of wound.  E. Instillation of penicillin into knee joint at same operation. Arthrotomy through transverse wound and connecting lateral parapatellar incision revealed dead, detached patellar cartilage amid autolysis of femoral and tibial cartilage at contact points and points at which patella had rested upon condyles. Curettage of raw condylar areas, excision of patella, and closure of synovial membrane and skin.


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FIGURE 30 - Continued.  F. Staged closure of compounding wound of femur over small drain, 6 days after operation shown in views B, C. and D.  G. Appearance of wound 13 days after reparative surgery and 7 days after staged closure shown in view F. Healing has been obtained, except for small granulating areas in old compounding wound and at proximal end of drainage incision.  H. Roentgenograms made 5 months after wounding. It was thought that a small area of sequestrum formation might be present at this time.  I. Roentgenograms showing solid bony union and excellent anatomic alignment of femoral fracture, 13 months after wounding. The metal was later removed because of some absorption about one of the screws. Granulation tissue present under plante was curetted.  J. healed wounds of knee and thigh, 13 months after wounding.

This patient, 4 weeks after wounding, presented septic knee joint, grossly septic wound of thigh, unreduced fracture of femur, and gas abscess which could have been mistaken for gas gangrene. He could logically have been considered a candidate for amputation. This gloomy out look was altered by complete excisional surgery, closure of dead space, fracture stabilization, adequate drainage, and staged wound closures, together with adequate blood replacement and protection of living tissue front invasive infection by systemic therapy. End result was control of septic process in knee amid thigh and union of fracture in anatomic alinement.


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FIGURE 31. - Reparative management of massive wound of left thigh with associated compound fracture of femur.  A. Massive wound of thigh compounding fracture of femur shown at reparative surgery, 6 days after wounding, with the extremity in the 90-90-90 position. Note the distal end of the proximal bony fragment projecting in the wound.  B. Anteroposterior and lateral views of fracture before reparative surgery. The patient was transported in a Tobruk splint.  C. Exposure of fracture site by gentle retraction, after which the fracture was stabilized by multiple-screw fixation with minimal periosteal stripping.  D. Partial closure of wound, with drainage established by dry fine-mesh gauze inserted into residual dead space about fracture site. The remaining defect probably represents the skin loss at wounding. Ten days later, coverage was successfully effected with a split-thickness skin graft.  E. Anteroposterior and lateral roentgenograms made in Zone of Interior hospital 3 months after reparative surgery. The fracture is uniting in excellent position and almost in anatomic alinement.

Internal fixation by multiple screws was selected in preference to other methods in this injury because the huge compounding wound of the thigh would probably have decreased the effectiveness of skeletal traction. Staged operative procedures were necessary to obtain complete wound healing. The contour of the fracture permitted satisfactory stabilization with screws without additional periosteal stripping. (This patient was managed by Maj. Charles M. Henry, MC, 36th General Hospital.)


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Internal fixation was preferably avoided when the disadvantages exceeded advantages, as in fractures of the tibia, in which periosteal stripping was hazardous because overlying skin is not a sufficiently vascularized soft part and in which the presence of metal may interfere with even skin closure.

When the indications and advantages were not clear cut, it was thought best to perform wound closure and attempt reduction of the fracture by manipulation or traction. If the attempt was unsuccessful, a planned open reduction and internal fixation could be carried out later, perhaps after healing of the compounding wound. The important point was that if poor anatomic results could be prevented by surgical measures performed on sound principles, results of this kind were no longer accepted for fear of lighting up infection.

Wound Closure and Drainage

The hazards of an open wound in a compound fracture are the sequestration and sloughing of exposed bone cortex, tendon, and fascia; reinfection at dressings; and slow wound healing by granulation. The advantage of an open wound is continuing drainage from the depths of the wound until healing by granulation has sealed off the fracture site. The gaping wound forms a natural channel for drainage. When the wound is not dependent, however, and infection intervenes, there may be pocketing, puddling, or pooling of purulent exudate in the fracture site or adjacent fascial planes with continuing local necrosis of the collagenous tissues.

In reparative surgery of compound fractures, the hazards of an open wound were recognized, and an attempt was made to overcome them by wound closure. The need was also recognized for providing a means of egress for the possible breakdown of any residual devitalized tissue not yet separated and of a


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FIGURE 32. - Management of compound comminuted fracture of middle third of right tibia and fibula, with multiple penetrating wounds of left leg, by delayed internal fixation.  A. Wounded left leg prepared for reparative surgery in fixed hospital 5 days after wounding and initial wound surgery. Note the multiple wounds.  B. Stabilization of fracture of tibia through incision connecting anterior wounds. After an unsuccessful attempt to fix the fracture by multiple screws, the periosteum was stripped over a long middle fragment, and stabilization was accomplished by the anteromedial application of a long plate to strut the comminuted fragments.  C. Closure of surgical wound. Note that two posteromedial wounds have been connected to form a relaxing incision, to permit closure of the surgical wound and also to provide for drainage.  D. Roentgenograms made in fixed hospital before and after reparative surgery. Note hairline reduction of tibia in postoperative films.  E. Roentgenograms made in Zone of Interior hospital 3 months after wounding. Stabilization of the fracture had been accomplished, but the plate, with some cortical bone, was still exposed, although there was 11 evidence of infection. A week later the plate, screws, and four sequestra were removed firm union of the fracture was found at operation.  F. Roentgenograms made 11 months after wounding, showing solid union of fracture.

In retrospect, this fracture of the tibia might have been adequately stabilized by plating the fibula or might have been managed by skeletal traction in a cast. Either of these methods would have avoided periosteal stripping and the application of metal at a point at which it was likely to interfere with the healing of soft parts over bone. The anteromedial surface of the tibia is not a good location for plating if there is any question of wound healing, though in this case the location of the wounds determined the location of the incision and of the site on which the metal had to be placed.


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contaminated hematoma in unobliterated dead space. In the light of these facts, the complete closure of wounds compounding fractures was justified only when the pabulum for wound infection was nil. A deep abscess about a fracture site underneath a sutured or healed epithelial bridge could produce nothing but irreparable damage. An increased margin of safety was obtained, therefore, by providing drainage, dependent if possible, by utilizing wounds or counter- incisions as indicated. Drains were carefully inserted, so as not to cause tissue necrosis, and were removed between the 3d and 10th day, depending upon the indications, before rigid sinus formation had occurred.

The problem of closure of the compounding wound was approached with the major objective of covering exposed bone cortex, tendon, and fascia with healthy soft parts, and with the minor objective of reducing skin defects to a size compatible with adequate drainage. Closure was accomplished, whenever possible, by simple, loosely tied, interrupted sutures. Sliding or rotation of flaps often permitted closure of the wound (fig.36). It was recognized that soft parts must adhere to the bony cortex to permit revascularization, whereby the dying bone could be absorbed and replaced by new living bone (fig. 40). Otherwise, sequestration was inevitable. Wound closure, therefore, was


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FIGURE 33. - Staged management of compound comminuted fracture of left femur, reparative phase. In this case, because of the tactical situation, initial surgery for a very large posterior wound compounding the fracture had to be delayed until 60 hours after wounding. In spite of the long timelag, excisional surgery at the initial operation was thorough, and the wound was quite clean when it was observed in the operating room at the general hospital 9 days later.
A. Drawing of compounding wound at this time.  B. Closure of wound with drainage of residual dead space by dry fine-mesh gauze.
C. Appearance of wound 9 days Healing is now practically complete.  D. Firmly healed wound 1 month after reparative surgery.  E.  Reduction of fracture by two-wire skeletal traction.  Wire lifting distal femoral fragment is visualized, but wire inserted in tibial tubercle for longitudinal traction is not seen.  The fracture united in good apposition. length, and alinement.  (This patient was managed by Lt. Col. Roderick E. Begg, MC, and Capt. John E. Manning, MC, 46th General Hospital.)


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FIGURE 34. - Management of compound comminuted fracture of middle third of left femur by delayed internal fixation.  A. Anteroposterior and lateral roentgenograms of left femur before reparative surgery.  B. Anteromedial wound exposed in operating room. The extremity is in the 90-90-90 operating position.  C. Stabilization of fracture in reduction through posterolateral incision by bone plate. An additional screw was inserted through the compounding medial wound.  D. Closure of surgical incision with drainage.  E. Closure of compounding medial wound with drainage.

After operation, the extremity was placed in skeletal traction in a Thomas splint with Pierson attachment. Active and passive knee motion and quadriceps exercises were instituted promptly. When the patient reached the Zone of Interior 8 weeks after wounding, the wounds were well healed, the fracture had united in anatomic alignment, and a full range of knee motion was possible. He was returned to duty in a motor pool in a general hospital 12 months after wounding.

The approach to the fractured femur via a standard anatomic plane permitted the bone which was exposed by surgery to be covered by healthy soft parts and also permitted dependent drainage. The fracture was reduced anatomically arid was stabilized, so that the extremity could be handled as necessary for care of the soft-tissue wounds. Management of the fracture by skeletal traction would probably have provided adequate reduction, but joint exercises would have been delayed and hospitalization would have been prolonged overseas.


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FIGURE 35. - Staged surgery of bilateral compound battle fractures of shaft of femur, reparative phase. This soldier received 1,500 cc. of whole blood in a forward hospital before and during initial wound surgery, 1,500 cc. in the general hospital before the reparative operation, 500 cc. during the operation, and 500 cc. after operation. In spite of these massive transfusions, the highest hematocrit reading after blood replacement was 41.  A. Anteroposterior views of each femur in the general hospital, with double hip spica used for transportation splinting still in situ.   B. Lateral views.


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FIGURE 35 - Continued.  C. Medial stellate compounding wound of left thigh after suture.  D. Lateral compounding wound of left thigh after suture. Drainage was maintained for several days through the posterolateral fascial plane.


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FIGURE 35 - Continued.  E. Anteroposterior and lateral views of left femur showing inadequate reduction with tibial pin for traction in Army half-ring leg splint.  F. Same as view E, after addition of femoral wire for lift of distal fragment (two-wire traction). The distal fragment is now in excellent apposition and alinement.


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FIGURE 35 - Continued.  G. Two-wire skeletal traction applied to left lower extremity. Note sound healing of compounding wound 3 weeks after reparative surgery. H. Active motion of left knee (65 0 to 70 0 ) 6 months after wounding. At this time, the fracture of the femoral shaft is firmly united. and all compounding wounds are well healed.


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FIGURE 35 - Continued.  I. Rather severe compounding wound of fracture of right femur. Patient is on operating table, ready for reparative surgery. Note loss of muscle tissue and skin. Note also tourniquet about limb, to reduce further blood loss.  J. Exposure of fracture of right femur through incision extending distally from wound. The fracture was easily reduced and firmly fixed internally with multiple screws.  K. Partial wound closure, loose packing of remaining defect with dry fine-mesh gauze. Note establishment of dependent drainage through posterolateral fascial plane. Wound healing by granulation had to be accepted in this instance because of the size of the soft-tissue defect.


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FIGURE 35 - Continued.  L. Postoperative anteroposterior and lateral roentgenograms showing excellent reduction of fracture of right femoral shaft. The internal fixation was protected by balanced-suspension skeletal traction.  M. Appearance of right thigh 8 weeks after reparative operation. All wounds are healed, but the granulating area is not yet scarified. There is no sinus to bone.


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FIGURE 35 - Continued.  N. Range of active motion in right knee 6 months after reparative surgery. The fracture is soundly united, and all wounds are well healed.  O. Anterior view of thighs and upper legs, showing healed wounds, 6 months after reparative surgery. (This patient was managed by Capt. John J. Modlin, MC, 21st General Hospital.)


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designed to obviate the hazards of exposed bone cortex, the salvage of which was probably the most important attainment of reparative surgery of compound fractures (figs. 41, 36, 37, and 40).

In actual practice, some compounding wounds were closed with drains of rubber tissue or dry, fine-mesh gauze, which emerged through the most dependent portion of the wound or through a counterincision (figs. 35, 37, and 38). In others, surgical limitations, such as dead space which could not be obliterated or loss of soft tissue, precluded closure of the wound by suture. In these instances, partial closure, so as to protect denuded bone cortex, was often possible (fig. 42). In still other instances, usually following extensive wound revision for dirty wounds, the entire wound was left unsutured in order to provide the advantages of drainage through an open wound (figs. 30 and 34). In such cases, closure of the wound was usually carried out a few days later, if the wound was clinically clean.

If closure could not be undertaken because of loss of tissue, the wound was loosely packed with dry, fine-mesh gauze in the expectation that healing would occur from the depths by granulation (figs. 42, 31, and 35).

POSTOPERATIVE MANAGEMENT

Immobilization of the compound fracture was instituted immediately after reparative surgery. Special techniques are discussed under the heading of management of regional fractures (p. 115).

Compounding wounds closed by suture were dressed within 2 to 4 days after operation, to make certain that wound healing was progressing as had been anticipated. When the extremity had been put up in plaster, the wound was reached through a window cut into the cast; care had to be taken, when the window was replaced, to avoid so-called window edema, which could be prevented by using the same amount of padding as had been used originally. Ideally, inspections and dressings were carried out under a strict aseptic technique, including the use of masks to cover the nose and mouth, to reduce the chances of droplet infection. Practically, this ideal was seldom achieved.

RESULTS

The delayed primary closure of combat-incurred wounds was carried out infrequently and in only a limited number of cases in World War I (p.58). Under the principles of reparative surgery, the program of staged wound closure was established in World War II as a logical and surgically sound policy in wounds of the soft parts and in compound fractures.

It is true that wounds limited to the soft parts are naturally inclined to heal, but they healed faster and with less scarring under the program of reparative surgery. With this method, multiple dressings of open wounds, which were often extremely painful, were eliminated. The chances of secondary infection of granulating wounds were reduced. Scar formation was minimized.


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FIGURE 36. - Compound fractures of left tibia and fibula managed by internal fixation of tibia by multiple screws.  A. Anteroposterior and lateral views of fractures before and after fixation of tibia, which has been stabilized in reduction by multiple screws through anteromedial wound. Note that the contour of the fracture permits stabilization by this method. In addition, the screws could be placed without significant periosteal stripping, and soft parts were available to cover all exposed bone and metal. The fractures were compounded by anteromedial arid posterolateral wounds.  B. Healed anteromedial wound. Closure without tension was effected by a posteromedial relaxing incision. The supplementary incision might have been split grafted at the same operation, though this was not done. Drainage was established through the smaller posterolateral wound. healing by granulation occurred in this wound and in the relaxing incision.  C. Anteroposterior and lateral views of fractures 6 months after internal fixation of tibia, showing healing of fracture in anatomic alinement. Note that only 2 of the 3 screws have been effective in stabilization.  D. Solidly healed anteromedial wounds 8 months after reparative surgery. Note the shorter, more anterior scar on the leg, resulting from the incision made in a Zone of Interior hospital to remove the screws, because of some tenderness over the head of one of them, before the patient was returned to duty. (This patient was managed by Maj. Joe M. Parker, MC, 21st General Hospital.)


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FIGURE 37. - Severely comminuted compound fracture in middle third of right humerus associated with extensive loss of muscle and skin over anterior surface of arm and clinical signs of radial-nerve paralysis. Staged management. This patient was admitted to a general hospital 6 days after initial surgery, during the formative phase of the reparative-surgery program. The arm was placed in balanced skeletal traction, and the large wound was dressed in anticipation of healing by granulation. Eight days later, the wound was draining profusely, and adequate reduction of the fracture had not been achieved. The wound was then revised under anesthesia, and all residual devitalized muscle tissue was excised. The radial nerve, damage to which had been suspected, was found intact. Several totally separated fragments of bone were removed, and the segmental defect thus created was overcome by approximating major fragments with a wire suture through the cortex of each fragment. Available muscle tissue and fascia were sutured to cover exposed bone, and a shoulder spica cast was applied. Three weeks later, the granulating defect on the arm was successfully covered with a split-thickness graft.  A. Anteroposterior and lateral views showing inadequate reduction of fracture in skeletal traction.  B. Apposition of major fragments achieved by wire-suture fixation after removal of totally loose comminuted fragments.  C. Healed soft-tissue wound after application of split-thickness graft through window in cast. Access could not be obtained to the wound over the anterior chest wall near the axillary fold, and it was still unhealed when the shoulder spica was removed 10 weeks after reparative surgery. Additional surgery was required in the Zone of Interior because of scar-tissue contracture of the anterior axillary fold.  D. Anteroposterior and lateral roentgenograms made in Zone of Interior showing solid healing of compound fracture of humerus.


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The incidence of permanent disability was decreased, and the period of temporary disability was shortened.

The program of reparative surgery also proved a sound surgical method in the management of clinically dirty wounds and wounds in which infection had become established. These wounds had always furnished serious difficulties in military surgery. The problem was largely solved by the application of the principles of reparative surgery. By this routine, dirty wounds and infected wounds were promptly converted into clean wounds, and staged reparative procedures could then be instituted.

The reparative-surgery program proved as applicable to combat-incurred compound fractures as to soft-tissue wounds. When it was applied, wound infection was reduced. If infection did develop, secondary wound revision was instituted. The aggressive policy (1) of excising the pabulum upon which pathogenic bacteria could feed and (2) of instituting drainage was in sharp contrast to the former plan of waiting for the sequestration of devitalized tissue, including devitalized bone, a plan which was always attended by the further necrosis of living tissue.

The World War II experience supplies complete refutation for the former concept that surgery carried out in an infected field is inevitably followed by generalized infection. So far as is known, no deaths, amputations, or serious systemic sequelae could be attributed to the program of reparative surgery.

Reduction of fractures was greatly improved after the introduction of reparative surgery, for the reason that inadequate and unsatisfactory reduction was no longer accepted if it could be corrected by either surgical or nonsurgical measures. Segmental bone defects, in which nonunion is almost the rule if they remain uncorrected, were also seldom accepted. Internal fixation was chosen on definite indications to maintain anatomic position and permit early joint motion and exercise. In many instances, functional results were thus greatly improved.

The complete healing obtained in most cases following suture of the wound converted the compound fracture into a simple or closed fracture. Even if healing was not complete, the fracture site was often rapidly closed off, so that the same effect was achieved. Small skin defects either were left to heal by granulation or were covered by skin grafts. As a rule, when wound healing was not as good as had been hoped for, the unsatisfactory result could be attributed not to any defect in the surgical program but to errors in judgment as to what was surgically feasible or to errors in surgical technique.

In some cases encountered in the Mediterranean theater, the nature of the injury was such that prolonged drainage from the depths of the wound was inevitable, no matter what method of management was used. These injuries were characterized by numerous partially detached bone fragments and a great deal of associated dead space. The clinical course was usually the same. Drainage persisted until the denuded bone had been revitalized or had sequestrated and could be removed surgically. Sinus formation was frequent and persistent when sequestration occurred. When the sinus led to


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FIGURE 38. - Severe compound comminuted fracture of middle third of shaft of right humerus with loss of more than 4 cm. of bone. Management by approximation of major fragments with single wire suture and wound closure.  A and B. Anteroposterior and lateral roentgenograms made on patients admission to evacuation hospital before initial wound surgery. At this operation, the brachial artery and the median arid ulnar nerves were found intact, but the radial nerve was severed.


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FIGURE 38 - Continued.  C. Lateral compounding wound seen in operating room in general hospital 9 days later.  D. Closure of wound by suture, without excessive tension.  E. Large and small medial wounds of same extremity ready for reparative surgery. F. Same wounds at conclusion of reparative surgery. The smaller wound has been sutured; the larger has been covered with a split-thickness skin graft.


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FIGURE 38 - Continued.  G. Anteroposterior and lateral views showing the minimal contact of major fragments obtained by wire suture.  H. Same as view G, 7 months after reparative surgery, showing nonunion of fracture. A tantalum cuff encloses the repaired radial nerve. The soft-tissue wounds in this case healed promptly, and the prompt healing greatly facilitated nerve repair. The fracture was finally united after bone grafting several months later. The failure of the attempt to obtain union by use of a wire suture at reparative surgery does not in any way lessen the correctness of the effort. (This patient was managed by Maj. Charles M. Henry, MC, 36th General Hospital.)


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FIGURE 39. - Staged management of associated humeral-radial fracture and nerve injury. Inspection of the radial nerve at reparative surgery 10 days after wounding showed destruction of 1 ½ inches of nerve tissue. The fractured humerus was shortened by excision of portions of the comminuted fragments; then the major fragments were plated. The nerve ends were united with one suture and wrapped in fibrin film. Prompt healing after closure of wound by suture; definitive nerve suture 16 days later; excellent end result.  A. Steps of reparative operation 10 days after wounding.  B. Steps of definitive nerve repair 16 days later.  C. Anteroposterior and lateral roentgenograms showing united fracture in perfect alignment 6½ months later. At this time, there was evidence of returning function in the radial nerve supply. Orthopedic surgery was performed by Maj. Joe M. Parker, MC, and neurosurgery by Lt. Col. Henry G. Schwartz, MC, 21st General Hospital.


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FIGURE 40. - Reparative management of mildly comminuted fracture of right tibia resulting from penetration of limb by high-explosive shell fragment.  A. Anteroposterior and lateral roentgenograms at general hospital 10 days after wounding. The compounding wound had been left open after debridement in a forward hospital.   B. Closure of compounding wound at reparative surgery. A long posteromedial relaxing incision permitted the use of a sliding flap and thus permitted closure without tension. The defect created by the relaxing incision has been covered with a split-thickness graft.   C. Healed wounds 2 weeks after reparative surgery. Note that the take on the skin graft is about 95 percent. Sound wound healing followed soon afterward. This casualty could be rehabilitated for duty in the theater of operations, which was a rather unusual result in compound fractures of the bones of the leg and one which would have been impossible except under the regimen of reparative surgery. (This patient was managed by Capt. George H. Marcy, MC, 23d General Hospital.)

sequestra that could not be prevented surgically, the outcome had to accepted as the inevitable result of injury. In these cases, failure of wound healing was attributable to the presence of retained dead tissue and bacterial infection per se.


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FIGURE 41. - Management of compound comminuted fracture of shaft of femur by balanced-suspension skeletal traction; sequestration of denuded bone not covered by soft parts. The anterolateral wound compounding the femoral fracture was extensive, and the considerable muscle loss left the femoral fragments exposed for several inches. Reduction of the fracture was carried out in a general hospital shortly after the patient was received, but reparative surgery was omitted.  A. Anteroposterior and lateral roentgenograms showing fracture of femoral shaft in traction just before reduction in a general hospital.  B. Anteroposterior and lateral roentgenograms showing healed fracture with massive sequestrum formation, 68 days after wounding. C. Wound of thigh 78 days after wounding. Note continued drainage and lack of healing.

The sequestra were eventually removed, and dependent drainage was established, under penicillin protection, but skin grafting was necessary before wound healing was eventually achieved. In this case, early reparative surgery, with closure of the wound over the exposed hone, might have prevented sequestration of the femoral fragments. Wound healing and fracture healing were finally achieved, after delayed reparative surgery. (The case was managed at the 21st General Hospital in January 1944, before the program of reparative surgery of compound fractures had become theaterwide.)

The program of reparative surgery proved again that in the management of combat-incurred compound fractures there is no substitute for surgery. Blood and penicillin were essential adjuvants, but the whole program was based upon the concept that the bacterial flora in an open war wound is of minor


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FIGURE 42. - Management of compound fracture of upper third of right tibia by staged surgery and modified closed plaster technique.  A. Anteroposterior and lateral roentgenograms showing defect in upper third of tibia following initial surgery.  B. Large compounding wound of soft tissues, with several stellate extensions, shown in operating room in general hospital just before reparative surgery.  C. Suture of extensions of wound, so as to cover all exposed cortical bone. The remaining defect was left open, and the modified closed plaster regimen was instituted. When the sutures were removed, 12 days after the reparative operation, through a large window in the cast, the stellate incisions were found well healed.

The remaining defect was loosely packed with fine-mesh gauze, and the window was replaced in the cast and secured with several turns of plaster bandage. The next dressing was set for the period at which the cast would be changed, 4 to 6 weeks after the first dressing, probably after the soldier had been transferred to the Zone of Interior. The modified closed plaster method was used in this case because loss of tissue made complete closure of the soft-tissue wound impossible. In addition, closure would have been doomed to failure because of the underlying dead space caused by the defect in the cancellous bone. It was essential, in this injury, that the exposed cortical bone be covered, and this was achieved by partial closure.

importance compared to the pathologic process itself. By the end of World War II, this concept of the management of combat-incurred wounds had been generally accepted, and the spotlight of attention had been focused where it belonged; that is, upon their surgical management.