MEMORANDUM TO: Colonel Mather Cleveland, MC, Senior Consultant in Orthopedic Surgery, European Theater of Operations.

SUBJECT: Treatment of Hand Injuries.

1. The following are the simple principles which I think we should make an effort to see practiced in this Theater in the treatment of hand injuries:

a. Conservative, meticulous, and proper debridement of the primary wound. The wound should not be closed primarily in an evacuation hospital, but displaced skin flaps can be dressed back into place.

b. "Purposeful splinting" always, with maintenance of the palmar arch, and flexion of the metacarpal phalangeal joints.

c. Closure as early as possible, preferably on the third or fourth day. It should be accomplished by secondary closure, split graft, or pedicle graft.

d. Traction only in those cases in which it is urgently indicated, and then for a minimum length of time. The fishhook traction which has been developed at the 22nd General Hospital is probably the best.

e. In some of the severe types of injuries, forget about the restoration of the injured part and concentrate entirely on maintenance of function of what is left. This may mean amputation of an irreparably damaged finger in order to get a healed hand.

f. Active motion should be instituted as early as possible. When the hand is healed, this should be further encouraged by occupational therapy.

g. An effort should be made to avoid the development of a markedly edematous hand with an infected open wound. Proper debridement, proper dressing, proper splinting, and effective elevation of the hand will prevent such a development.

h. So long as there is an open wound in the hand, it should be treated aseptically. This means face masks and instruments or gloves, whether the wound is infected or not.

2. The following points are what I consider to be the requirements of a satisfactory hand service:

a. The availability of both an orthopedic and plastic surgeon.

b. The segregation of patients so that they are all together and can receive their exercises simultaneously and benefit by the development of a competitive spirit.

c. Adequate facilities for physiotherapy, with physiotherapists particularly interested in rehabilitation of hands. In a busy center, this may mean additional physiotherapists. There should be special provisions in the physiotherapy department for hand exercising machines, et cetera. If possible, noncommissioned officers who have had hand injuries themselves should be placed in charge of ward exercises.

Eugene M. Bricker
EUGENE M. BRICKER
Lieutenant Colonel, MC
Senior Consultant in Plastic Surgery