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Appendix B

Contents

APPENDIX B

Proposed Revision of Manual of Therapy1(Orthopedic Section)

CARE OF BATTLE CASUALTIES AND INJURIES
INVOLVING BONES AND JOINTS

Foreword

The Manual of Therapy, European Theatre of Operations, served a useful purpose as a professional guide during the military operations in Europe. Some of the policies of treatment were changed from time to time because of the lessons learned from experience. These changes were published in Circular Letters by the Office of the Chief Surgeon. In an attempt to summarize the principles of orthopaedic treatment which were evolved in the course of the various campaigns in the European Theatre of Operations, those sections of the Manual and the Circular Letters which pertain to bone and joint injuries in battle casualties have been combined. Policies which conflict have been deleted, and a considerable amount of material which appeared to be important prior to the campaigns has been omitted in the interest of brevity.

The material has been divided into three sections:

A. Therapy in Division Installations (Battalion Aid Station, Collecting Company, Clearing Company).

B. Therapy in Army Installations (Field Hospitals, Evacuation Hospitals, Convalescent Hospitals).

C. Therapy in Communication Zone Installations (General Hospitals, Station Hospitals).

SECTION A

Therapy in Division Installations (Battalion Aid Station, Collecting Company, Clearing Company)

I. Strains and Sprains

1. Diagnosis: Great care must be taken to exclude the possibility of fracture. Sharply localized tenderness over bone, rather than ligament,

1As noted in the text (p. 161), the orthopedic section of the Manual of Therapy prepared for use in the European Theater of Operations required considerable modification as the experience increased. A completely revised draft of this section was prepared in June 1945 by the senior consultant in orthopedic surgery, with the assistance of Lt. Col. John G. Manning, MC, and Lt. Col. William J. Stewart, MC, but was not published because of the end of the fighting in the Pacific. It is reproduced in this appendix precisely as it was prepared for publication in June 1945.


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muscle, or tendon, and pain at the site of injury upon manipulation of bones at a distance from the injury are more characteristic of fracture than of sprain. If there is any doubt as to the diagnosis, the patient should be evacuated to an Army hospital where a roentgenographic examination can be made.

2. Treatment: The objects of treatment are:

a. To prevent oedema and hematoma formation;

b. To disseminate, for more rapid absorption, any hematomata which have formed.

This is best accomplished by the application of cold (where possible) to the fresh injury, by compression, and by rest to the injured part. Heat in any form as a primary treatment is illogical and harmful and should not be applied.

All patients with strains and sprains which do not respond rapidly to conservative treatment should be evacuated to the rear. Treatment of moderate and severe sprains of the major joints and of the back should not be attempted in the forward areas.

II. Dislocations

No attempt should be made to manipulate or reduce dislocations prior to a roentgenographic examination or without anaesthesia. Pain should be relieved with morphine. The patient should be placed in a litter and the affected part splinted by use of folded blankets in the position of maximum comfort. The patient should then be transferred as rapidly as possible to an Evacuation Hospital.

III. Simple Fractures

Simple fractures should be splinted. These patients should be transported to the Evacuation Hospital as soon as conditions will permit, but in general these are low priority evacuation cases.

IV. Compound Fractures

The following suggestions are made for the initial handling of patients with compound fractures due to battle injuries:

1. Examination: A rapid but careful examination of the patient should be made to determine the site of the injury or injuries, so that proper splinting can be applied. It is not advisable to remove the clothing from the patient for this examination. Each extremity should be examined separately, and the thorax and the back should be checked carefully.

2. Treatment:

a. Shock should be treated promptly by infusion of plasma or blood.

b. Morphine should be administered in sufficient quantities to relieve pain, but morphinism must be avoided. Subcutaneous injections of morphine are not easily absorbed by patients who are cold or who have low blood pressure and are in shock. If these conditions are present, the morphine should be administered intravenously to assure immediate relief of pain, but overdosage must be avoided. The dosage must be recorded on the Emergency Medical tag.

c. Wound


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(1) Hemorrhage: The first consideration in the local treatment of the wound should be the control of hemorrhage. Unless a large vessel has been severed, this can be done by the application of a pressure dressing. If this fails, a tourniquet must be applied. If a tourniquet is required, every precaution should be taken to guard against the dangers of resulting ischaemia of the extremity.

(a) Place the tourniquet at the lowest possible level.

(b) Attach a red tag to the tourniquet and record the time of application.

(c) Release the tourniquet and reapply it every hour. In the lower extremity it may be left in place for two hours.

(d) Evacuate the patient rapidly to a point where the hemorrhage may be controlled surgically.

(2) Chemotherapy: Do not place sulfonamides in the wound, but start oral administration if the patient does not have an associated belly wound.

(3) Cover wound with an ample sterile dressing.

(4) Immobilize extremity in the appropriate splint.

d. Tetanus Toxoid: Administer 1 cubic centimeter of tetanus toxoid to any member of the United States Forces and record on Emergency Medical tag. Administer 3,000 units of anti-tetanic serum to any other patient, unless otherwise instructed.

V. Amputations

Amputations should not be attempted in the forward treatment stations unless the extremity is almost completely detached. Complete or incomplete traumatic amputations should be treated like other compound fractures. Control pain, shock, hemorrhage and apply sterile dressing and adequate splint.

VI. Immobilization of Fractures

The following splints are recommended as emergency measures for application in the field and for immobilization during initial transportation.

1. Femur, Knee, and Proximal Half of Tibia: Apply the Army half-ring hinged splint and foot traction strap. The shoe must not be removed. A tendency to apply too great a degree of traction must be guarded against. If too much traction is applied, there is great danger of causing severe and disabling pressure sores over the heel cord and dorsum of the foot. If the patient is detained at any station, the ankle strap should be released temporarily.

2. Distal Half of Tibia, Ankle, and Foot: Apply well-padded wire ladder splints in the following manner:

a. The first one should be applied posteriorly from the tip of the toes to well above the knee.

b. The second wire ladder splint should be applied like a sugar tong, extending down the outer side of the leg around the sole of the foot (crossing over the first splint) and back up the inner side of the leg.

c. Bandage the two splints together snugly.


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3. Shoulder, Humerus, and Elbow: Bind the injured extremity to the chest wall with triangular bandages or with a Velpeau dressing made from gauze or muslin bandages. Do not use the Murray-Jones hinged ring splint, as it is painful, difficult to apply, and dangerous.

4. Forearm: Apply a well-padded sugar-tong wire ladder splint, supported with an arm sling.

5. Wrist and Hand: Apply a well-padded wire ladder splint to the volar surface of the forearm and palmar surface of the hand.

6. Lumbar and Dorsal Spine: Place the patient gently on a litter, in the prone position if possible.

7. Cervical Spine: Place a blanket (folded so that it makes a pad three inches thick) beneath the shoulders, thus permitting the head to fall backward slightly. Place folded blankets, articles of clothing, or any other convenient object on either side of the head to reduce lateral motion of the head.

SECTION B

Therapy in Army Installations (Field Hospitals, Evacuation Hospitals, Convalescent Hospitals)

I. Strains and Sprains

1. Acute Strains

Acute strains as a rule respond rapidly to rest. The most common strain is probably that of the lumbar muscles. Absolute rest until all tenderness has subsided is recommended. The patient is allowed to become ambulatory if the pain and spasm do not return; if he continues to improve, he should be transferred to the Army Convalescent Hospital. Those patients with strains which do not respond promptly to conservative therapy should be evacuated to General Hospitals for study and treatment. Patients with chronic disabling strains should be immediately evacuated to General Hospitals for study and disposition.

2. Acute Sprains

a. Wrist Joint: An injured wrist should never be treated as a sprain until fracture of the navicular has been absolutely excluded. Roentgenograms in three planes should be taken. Even if no fracture line is seen in the first roentgenograms, a clear-cut history of a fall on the outstretched hand, with tenderness in the anatomical snuff box, is usually sufficient to justify immobilization in plaster for ten days. At the end of this period, sufficient absorption will have occurred to make the fracture line visible in a re-check x-ray.

b. Ankle and Knee Joint: Some minimal sprains may be treated in Army installations. Patients with moderate and severe sprains should be evacuated immediately, as they cannot be returned to duty within any normal holding period. Any markedly distended joint should be aspirated under aseptic precautions. The involved joint should be immobilized in the appropriate circular plaster-of-Paris splint for evacuation.


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II. Dislocations

Dislocations of major joints should be treated as surgical emergencies. As soon as possible after the diagnosis has been confirmed by roentgenographic examination, a closed reduction under general anaesthesia should be performed. After reduction, the joint should be immobilized in the appropriate circular plaster-of-Paris splint and the patient should be evacuated as soon as possible. If closed reduction cannot be accomplished or if, for any other reason, open reduction is indicated, the patient should be transferred as rapidly as possible to the nearest General Hospital. Open reductions should not be performed in Army installations.

III. Simple Fractures

Only a few of the simple fractures lend themselves to reduction by manipulation in Army installations. In fractures of the long bones, it is futile to attempt reduction by manipulation if it is known that reduction cannot be maintained by the use of a circular plaster-of-Paris splint. Fractures should be immobilized and the patient should be evacuated as soon as possible to a General Hospital where he can have definitive reduction by skeletal traction and where he can remain until the fracture has become stable. No open reductions should be performed in Army installations.

IV. Compound Fractures

1. Because of the high morbidity and permanent disability which result from infection of compound fractures, it is essential that they receive a high priority for surgery. Only by an early, thorough, and adequate débridement can infection be prevented.

2. Shock following compound fractures of the long bones is usually severe due to the great loss of blood; this is especially true of fractures of the femur and fractures of more than one of the long bones. Sufficient replacement of whole blood is essential. Although it may appear that the patient has been adequately resuscitated prior to the time of surgery, he may easily drop back into a state of shock during the time of operation. It is frequently necessary, therefore, to continue the administration of blood during the procedure.

3. Preoperative roentgenographic examination is of value in determining bone damage and providing information as to the number, size, and location of opaque materials, besides giving some information as to the degree of soft-tissue disruption which has occurred. The x-ray films should accompany the patient to the operating pavilion, so that they will be available to provide information to the surgeon both before and during the operation.

4. Débridement: The value of an adequate and thorough débridement cannot be overemphasized. An adequate débridement cannot be performed unless the surgeon is able to see and differentiate what is healthy and what is devitalized tissue. It is essential to avoid further insult to the wound, endangering vital structures which, although fortunate enough to have escaped the enemy shell fragment, may not escape the careless surgeon's instruments.


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The following principles of débridement in connection with compound fractures are therefore emphasized:

a. An adequate débridement cannot be performed under local infiltration anaesthesia.

b. Skin must be conserved. Excise only a very narrow margin. Rarely will it be necessary to excise more than one-eighth of an inch.

c. Incision: Every wound, with few exceptions, will require enlargement by incision, so that underlying damage can be visualized and dealt with properly. Incisions for enlargement of the wound ordinarily are made in the long axis of the extremity, but should be so placed that they will assist the surgeon in the General Hospital in performing the delayed primary wound suture.

d. Subcutaneous Fat: Remove all contaminated and crushed subcutaneous fat.

e. Fascia: Linear incision of the enveloping fascia is not sufficient to afford adequate drainage and prevent accumulation of blood and hematoma formation. It is, therefore, necessary also to incise it transversely. All crushed and devitalized fascia must be excised.

f. Muscle: Excise all devitalized muscle. Non-viable muscle does not contract when stimulated, or bleed when cut. Never cross-cut viable muscle bellies to provide exposure. Adequate exposure can be obtained by muscle-splitting incisions which are made parallel to the muscle fibers.

g. Retraction: The importance of retraction for visualization cannot be overemphasized.

h. Irrigation: This should be utilized to the utmost. It is realized that many times, due to actual water shortage, it will be impossible.

i. Foreign Bodies: All foreign bodies of any size should be removed. If adequate exposure has been provided, their removal will not present any problem. Blind probing and prolonged searches for very small metallic foreign bodies are condemned.

j. Bone: Do not remove bone fragments. Any obviously dirty bone fragments should be cleaned. If detached bone fragments are left in situ they act as a framework for new bone formation.

k. Internal Fixation: No internal fixation is to be performed. Reduction of fractures is not of importance at this time.

l. Wound dressing: Cover the wound with a dry, fine-mesh gauze dressing. In no case should the wound be packed or plugged. Place a large absorbent dressing over the entire wound and fix it in place by use of circular wraps of sheet wadding.

m. Immobilization: Immobilize the extremity in the appropriate circular plaster-of-Paris splint.

V. Amputations

1. Indications for Amputation

a. Complete destruction of the blood supply. This means the loss of the main artery and most of the collateral arteries.


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b. Diffuse clostridial myositis.

2. Level of Amputation: Amputation should be performed at the lowest possible level which the nature and situation of the wound will permit.

3. Type of Amputation: Experience has shown that the open circular amputation is the procedure of choice in the treatment of war wounds. The guillotine amputation has not been found as satisfactory and it should not be used. The skin, muscle, bone and all tissues are divided at exactly the same level in a guillotine amputation, while in a circular amputation each tissue layer beneath the skin is allowed to retract before it is severed, so that, after amputation has been completed and traction has been applied to the skin, the stump has the appearance of a shallow inverted conic or saucer.

4. Technique of Open Circular Amputation

a. Prepare skin of extremity for surgical procedure.

b. Apply tourniquet.

c. Skin incision is made at the lowest possible level in circular manner down to the deep fascia. The incision may be made obliquely where indicated in an effort to conserve skin and length of extremity.

d. Allow skin to retract and next divide deep fascia at the level to which the skin had retracted.

e. Divide muscle in circular sweeps, cutting about three-fourths of an inch deep with each sweep, so that as the muscle retracts the next muscle division takes place at a slightly higher level.

f. Cut the periosteum of the bone circularly at the level to which the last muscle layer has contracted.

g. Saw the bone off cleanly at this level. Do not elevate, strip, or attempt to remove the periosteum at a level higher than the saw cut.

h. Nerves should be severed cleanly at the level of surrounding muscle division. Do not crush or ligate the nerve ends, or inject them with alcohol.

i. Hemostasis of the stump is essential. All large veins and arteries should be doubly ligated, each one separately, and extreme care should be taken not to include large amounts of muscle when ligating small vessels. After all the larger vessels have been ligated, the tourniquet should be removed and all remaining bleeders ligated.

j. Cover stump end with dry fine-mesh gauze. Do not "dust" or "frost" the stump with sulfonamide.

k. Skin traction should be applied immediately and be maintained continuously, while the patient is being evacuated and until healing takes place. There is one exception to this rule. In those cases where amputation is for clostridial myositis, skin traction should not be applied for the first twenty-four to forty-eight hours. No patient, however, should be evacuated from an Army installation until skin traction has been applied. Skin traction for transportation has been found to be most satisfactory if applied in the following manner:

(1) After the stump end has been covered with a sterile fine-mesh


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gauze, apply a circular roll of stockinette to the stump and roll this proximally as far as possible.

(2) Paint the skin with tincture of benzoin and allow it to dry.

(3) Apply an adherent to the skin down to the cut skin edge, then unroll the stockinette down on the stump. Allow it to adhere to the skin. Then place traction on the stockinette and put more dressings inside the stockinette up against the end of the stump.

(4) While an assistant continues to apply traction on the stockinette, apply several layers of sheet wadding loosely over the stockinette which covers the stump. Then apply a circular plaster pylon with an outrigger made of a wire ladder splint. Tie the end of the stockinette to the outrigger with a short piece of elastic traction cord. Plasma tubing may be substituted if elastic traction cord is not available.

(5) The plaster pylons indicated in each instance are as follows:

(a) Below-the-Knee Stump: Below-the-knee-to-groin pylon, with the knee in full extension;

(b) Thigh Stumps: Single hip spica pylon, with the hip in neutral position;

(c) Forearm Stumps: Full-arm pylon with the elbow flexed at 90 degrees;

(d) Arm or Humerus Stump: Shoulder spica pylon with as little abduction as possible. The axilla should be well padded to avoid pressure.

5. Consultation: Decision for amputation should not be made without consultation with the Chief of the Surgical Service, or the Senior Surgeon present. The consultation should be noted in the patient's medical record.

6. Psychotherapy is of utmost importance in the rehabilitation of the amputee, and the surgeon, by a few words, can help in this program. It is important that the operating surgeon himself verbally inform every amputee of the following before the patient is evacuated from the hospital:

a. That the amputation was necessary as a life-saving procedure;
b. That it was decided upon after consultation;
c. That further surgery for revision of the stump will probably be necessary;
d. That he will be sent to a center where he will be given a limb and where there are other facilities for his rehabilitation.

7. Disarticulation: A disarticulation should be performed only when absolutely necessary. The stumps are difficult to handle, discharge profusely, and skin traction is most difficult to maintain. The stumps all need extensive revision and the majority of these revisions have to be performed in two stages. Disarticulation of the knee may be undertaken as an emergency measure, but should not be done routinely.

VI. Immobilization of Fractures for Evacuation

1. General Principles

a. No bandage, dressing, or adhesive tape which encircles an extremity, other than sheet wadding, is to be used under a plaster splint.


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b. Adequately padded plasters are safer in average hands; therefore, padding should be used over all bony prominences, and sufficient sheet wadding should be over the soft parts to allow for some swelling.

c. All layers of plaster and sheet wadding encircling the affected extremity must be cut through down to the skin immediately after the application of the splint, and the splint must be slightly spread. In a large percentage of cases, swelling of the extremity will occur and, unless all layers of the plaster and sheet wadding are cut through, it will be impossible to spread the cast sufficiently to prevent extensive damage. This is a safety measure which must be strictly and universally adhered to.

d. Attention should be paid to the position of the extremity encased in plaster. Ordinarily the foot should be at a right angle to the leg, the knee should be in flexion of 10 degrees to 15 degrees, and the hip in flexion of 20 degrees. The wrist should be supported in slight dorsal flexion, and the elbow ordinarily at a right angle. Plaster applied to the hand should be trimmed back to the proximal palmar crease to permit full flexion of the fingers and metacarpophalangeal joints. A loop of wire or wicket of plaster should be applied to the foot of the plaster splint to protect the toes from pressure exerted by blankets. A plaster splint must never extend beyond the width of the litter.

e. A line diagram in indelible pencil should be inscribed on the circular plaster splint to indicate the approximate location of wounds and fractures. The date of injury, date and type of surgical procedure, and the name of the unit to which the patient belongs should be written on every circular plaster splint.

2. Circular Plaster-of-Paris Splints: Experience has shown that the best form of splint for use in immobilizing fractures for transport from Army installations to the Communication Zone is the circular plaster-of-Paris splint. The following splints are recommended for the fractures indicated:

a. Double Hip Spica: Any fracture involving the hip joint, femur, knee joint, and proximal end of the tibia should be immobilized in a hip spica. The spica should extend to the toes on the affected extremity and to just above the knee on the unaffected extremity. Abduction at the hips must not exceed that which would cause the extremities to spread beyond the width of the litter. A strut should be placed posteriorly to anchor the thigh sections together and to furnish strength. This should be placed as far distally as possible so that a bed pan can be used. The body portion of the spica need not extend higher than the rib margin. A folded bath towel should be placed over the abdomen during application of the splint, and removed when the splint is completed, so that there will be room for some abdominal distention. The posterior portion should be trimmed adequately to allow for bowel movements. A patient with fracture of the pelvis will be most comfortable in a full-length double hip spica. The Army hinged half-ring splint should be used only as an emergency measure and should not be used for transportation of patients from the Army installation to the General Hospital. If it is necessary, because of the tactical situation, to use this splint for evacuation of patients from the Army Zone,


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the traction strap must not be used; adhesive plaster applied to the skin of the leg should be substituted for the traction strap to provide maintenance of traction.

b. Toe-to-Groin Circular Plaster Splint: All fractures of the lower half of the tibia, of the fibula, and of the ankle joint should be immobilized in a toe-to-groin splint. A toe-to-groin cast should extend up to within an inch of the groin. However, this type of splint is not sufficient immobilization for fractures involving the knee joint and the proximal end of the tibia.

c. Toe-to-Knee Circular Plaster Splint: All fractures of the fore part of the foot should be immobilized in a toe-to-knee splint. The plaster should extend up to a point approximately two inches from the knee joint. Mid-calf plaster boots are very uncomfortable and should never be applied.

d. Plaster-of-Paris Velpeau Bandage: Patients with fractures of the scapula, shoulder joint, and the proximal two thirds of the humerus, travel very comfortably in this type of splint. Adequate padding about the elbow and over the bony prominences of the shoulder is essential. Care should be taken not to bind the arm too tightly to the chest. However, the splint is not comfortable if the patient is expected to be ambulatory. It is not an adequate splint for fractures in the distal third of the humerus, and those involving the elbow joint.

e. Shoulder Spica Splint: This is the best immobilization for all fractures of the shoulder joint, humerus, and elbow joint. It should be applied with the arm held forward and internally rotated, so that the forearm rests in front of the body and slightly below the level of the nipple line. The medial epicondyle of the humerus must be adequately and carefully padded. The elbow should be flexed to or slightly beyond 90 degrees.

f. Circular Arm Plaster Splint: All fractures of the radius, ulna, and wrist joint should be immobilized in a circular arm splint. The splint should extend from the proximal palmar crease to within an inch of the axillary folds, with the elbow in flexion of 90 degrees. The forearm should be in slight pronation. A circular arm splint applied for transportation should not be employed as a hanging cast for fractures of the humerus.

g. Anterior Molded Plaster Splints: Fractures of the metacarpals and phalanges are best splinted for transportation by the use of an anterior molded plaster splint, with the hand and fingers in a position of function, - the wrist slightly dorsiflexed, and the fingers flexed approximately 30 degrees to 40 degrees at all joints, the thumb adducted and slightly flexed. Only those fingers involved should be immobilized.

h. Body Jacket: Compression fractures of the vertebrae in which the spinal cord is not involved, or in which there are no accompanying fractures of the laminae or pedicles, should be reduced by hyperextension, and a plaster-of-Paris jacket applied with the patient in this position. For fractures of the lumbar or lower thoracic vertebrae, the jacket should extend from the symphysis pubis to the sternal notch. Cervical and upper thoracic spine fractures will require an extension of the jacket to include the head. If there are fractures of the pedicles or laminae without involvement of the spinal cord, manipu-


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lation or hyperextension must not be performed, and the spine should be immobilized in a plaster jacket in neutral position. Plaster-of-Paris jackets should not be applied in cases of paralysis caused by gunshot wounds of the spine unless the stability of the spine has been destroyed.

3. The following forms of immobilization will not be used:

a. Any form of internal fixation.
b. Any form of skeletal fixation with wires or pins.
c. Murray-Jones hinged ring splints for the upper extremity.
d. Unpadded splints.
e. Unsplit circular plaster splints.
f. "Pulp" or finger-nail traction.

VII. Treatment of Joint Wounds

The following principles will be followed in the treatment of battle wounds involving joints.

1. All joint wounds must be debrided thoroughly.

2. A bloodless field should be obtained by the use of a tourniquet whenever possible.

3. Where adequate exposure cannot be obtained by enlargement of the wound, it should be assured by use of a standard arthrotomy approach.

4. All foreign bodies, loose fragments of bone and cartilage, including damaged intra-articular cartilages, must be removed.

5. All small debris and blood must be removed by thorough irrigation of the joint with normal saline solution.

6. The synovium and joint capsule should be closed with a single layer of interrupted non-absorbable sutures. (Sometimes it will be necessary to close defects in the capsule by swinging a fascial flap from the outermost layer of the capsule.)

7. If the patella has been badly shattered it should be excised, and the quadriceps and patella tendons sutured together with interrupted non-absorbable sutures.

8. After the joint capsule has been closed, aspirate the joint and inject 10,000 units of penicillin in 5 cubic centimeters of distilled sterile water.

9. Do not close the skin wound.

10. Do not place sulfonamides into the joint.

11. Do not leave drains in the joint cavity.

12. Arthrotomies should not be performed for recovery of very small metallic foreign bodies; in the majority of instances they would not be found. In these cases, aspirate the joint and inject 10,000 units of penicillin.

13. Immobilize the joint by use of the appropriate circular plaster-of-Paris splint.

14. Aspiration of the joint and re-injection of penicillin should be carried out at the end of twenty-four to forty-eight hours, or as may be indicated in each individual case.

15. The skin wound may be closed at the end of five days if no evidence of infection is present.


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16. If the tactical situation permits these cases should be held for a minimum of ten days.

VIII. Care of Hand Wounds

The hand is an extremely useful member of the body and great disability results from its loss or its relative loss due to dysfunction. Experience in civilian and military fields has shown that early closure of wounds of the hand is essential to recovery of good function. In selected cases, primary closure may be performed in Army installations. Good surgical judgment and technique must be exercised in this procedure. Therefore, this type of work should not be relegated to the untrained and unqualified surgeon. The following instructions are guides to be followed in early surgical treatment of battle wounds of the hand.

1. Surgical procedure

a. Thorough cleansing of the entire hand with soap and water is essential. This should include the clipping of the fingernails.

b. Débridement must be thorough, but should be done with meticulous care to avoid further damage. It is essential that the surgeon have an assistant. All devitalized tissues and foreign bodies must be carefully removed. Hemostasis must be complete and should be accomplished by ligation of all severed vessels with the finest ligature available (silk, cotton, or chromic catgut). Do not remove bone fragments. Only that portion of the tendon which is macerated should be excised. The suture of tendons at this time is not indicated.

c. Closure should be performed with widely placed interrupted sutures without tension. Drains should not be inserted into the wound. If it is impossible to close the wound without tension, approximate the skin edges as closely as possible with a few well-placed stay sutures. It is important that bone and tendons be covered by soft tissue wherever possible. In a few selected cases, a thin split-skin graft may be taken to cover large denuded areas.

d. Amputation of Fingers: Amputate only those fingers which are irretrievably destroyed. It is possible sometimes to save some skin from a finger which must be amputated; this will aid in the closing of the remainder of the hand. It is important to salvage every possible portion of the thumb.

2. Dressings

a. Dressings will be applied snugly but not tightly and will adequately cover the entire wound.

b. Immobilization: The hand will be supported on a molded anterior plaster splint, with the hand and fingers in the position of function, - that is, wrist in slight dorsiflexion, the fingers flexed approximately 30 to 40 degrees at all joints, and the thumb slightly flexed and in moderate adduction and apposition.

3. Aftercare

a. If primary suture of a hand is done, the patient must be held a minimum of five days for close observation.

b. The hand must be kept elevated continuously during this period to minimize swelling and oedema.


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c. Penicillin is to be administered throughout the entire period.

d. The primary dressing should not be disturbed until the fifth day, unless there is evidence of sepsis. If fever or increase of pain occurs, the wound should be inspected; and, if infection is present, enough sutures should be removed to allow adequate drainage.

e. Change dressing on the fifth day and inspect the wound under aseptic conditions. This is to avoid placing in the chain of evacuation the occasional patient who may have a low-grade infection without clinical manifestations.

f. Instruct the patient to keep the hand in a position of elevation during his evacuation.

IX. Gas Gangrene

1. Types of Wound: Wounds destroying muscle, either directly or by interruption of the blood supply, are articularly susceptible to anaerobic or clostridial infections.

2. Types of Infection: The following types of infection must be recognized, since they require different methods of treatment.

a. Clostridial Gas Gangrene

(1) Diffuse myositis;
(2) Localized myositis;
(3) Cellulitis or "gas abscess".

b. Streptococcal Gas Gangrene (rare): Myositis.

3. Diagnosis

a. Clinical: Differential diagnosis of the various types of clostridial gas gangrene and streptococcal myositis must be made to avoid unnecessary or radical surgical treatment.

(1) Clostridial myositis, diffuse: This may develop within six hours from the time the wound was received and usually develops within three days. The onset is acute, with a severe systemic reaction. Locally there is pain, marked swelling, frequently profuse serous exudate, slight gas formation, variable odor of decay, and pale or blue-gray appearance of the involved muscle. The skin is tense and often white, but may be mottled with a livid appearance if the process is widespread.

(2) Clostridial myositis, localized: Symptoms and signs are the same as for the diffuse type except that the process is restricted to a single muscle or group of muscles.

(3) Clostridial cellulitis: This process is limited to the immediate area of the wound. The onset is gradual, usually three days after injury, with slight systemic reaction. Locally there is abundant gas formation with a foul odor and slight swelling, and little local change of the muscle and overlying skin is present.

(4) Streptococcal myositis: The onset is delayed for three or four days, and severe systemic reactions do not appear until the late stages of infection. Locally, there is marked swelling, with profuse purulent discharge, slight gas formation, and slight odor. The involved muscle is slightly oedematous and the


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overlying skin is tense, often with a coppery tinge. Streptococcal myositis comprises only a few of the cases of gas gangrene.

b. Laboratory Evidence: Recognition of the infections mentioned must be made on the basis of clinical findings because adequate laboratory facilities are not usually immediately available. Confirmatory laboratory evidence is of statistical importance only and should be obtained when possible, but should not influence the treatment.

c. Roentgenographic Evidence: The mere presence of gas shadows in a roentgenogram is not sufficient evidence of gas gangrene infection.

4. Prophylaxis: Early adequate débridement of wounds is the best prophylaxis for anaerobic infections. Débridement in cases where there has been massive destruction of tissue, more particularly in the region of the perineum and the proximal portion of the femora, and in cases where major vessels are injured, must be radical and thorough, and long incisions must be made.

5. Treatment

a. Surgical: This depends upon the extent of the disease and the type of anaerobic infection.

(1) Clostridial myositis, diffuse: Amputation well above the site of involvement must be carried out immediately, using the circular method, and leaving the wound open. Do not apply skin traction for forty-eight hours.

(2) Clostridial myositis, localized: Extirpation of the involved muscle, or group of muscles, is indicated.

(3) Clostridial cellulitis: Incise the localized area and remove the devitalized tissue. Radical surgery is not indicated.

(4) Streptococcal myositis: Extensively incise and drain the involved muscles. Radical extirpation or immediate amputation are not indicated.

b. Serum Therapy

(1) Gas-gangrene antitoxin is only effective in combatting the toxin. Its use is not indicated in those cases in which toxic manifestations are not present. When indicated, it should be administered intravenously and the dosage should be governed by the degree of toxicity manifested. Precaution should be taken to guard against allergic reaction, both early and delayed.

c. Antibiotics and Chemotherapy: None of the sulfonamides nor the various antibiotic agents have any specific action against clostridial infection, but they may be used parenterally or by mouth to help control other bacteria present in these wounds. In the European Theatre in 1944 and 1945, when only penicillin and sulfonamides were available, the following routine was used:

(1) Penicillin: Give an initial dose of 20,000 units intravenously and 20,000 units intramuscularly, followed by 20,000 units intramuscularly every two hours for a period of three days. Period of therapy may be modified as necessary.

(2) Sulfonamides: Give 6 grams of sulfadiazine by mouth initially and 1 gram every four hours thereafter.

d. X-ray irradiation is not indicated.


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e. Supportive treatment: Since there is a rapid destruction of erythrocytes, frequent whole-blood transfusions will be necessary.

f. All instruments used in cases of anaerobic infections should be sterilized by autoclaving, whenever possible. The instruments must not be covered with oil, since bacteria surrounded by oil are protected against moisture and therefore are not killed at the usual temperature.

g. If gas-gangrene antitoxin is used, record the number of ampules used and the name of manufacturer.

X. Vascular Injuries

All patients whose extremities are affected and who have had injuries or ligatures of major arteries should be held in Army hospital installations for treatment and observation until the danger of either circulatory or gas gangrene is past. In most cases, this time interval is approximately ten days. If either gas or circulatory gangrene develops, amputation and other indicated procedures should be carried out before the patient is evacuated.

Patients with a damaged popliteal artery and exhibiting a cold extremity, with hard muscles and loss of sensation distal to the lesion, should have a transcondylar amputation as a primary procedure.

SECTION C

Therapy in Communication Zone Installations (General Hospitals and Station Hospitals)

I. Strains and Sprains

1. Strains: Those strains which do not recover rapidly with conservative treatment should be studied thoroughly for a definite diagnosis or to establish the cause of continued symptoms.

2. Sprains

a. Ankle joint: Severe sprains lead to partial permanent disability if they are not properly diagnosed and treated early. The possibility of diastasis of the inferior tibiofibular joint and rupture of the collateral ligaments must be considered.

b. Knee joint: A differential diagnosis of the pathological findings in the joint must be made. Treatment and disposition will depend upon the evacuation policy. If the patient has a sprain of the knee, he may be returned to duty within six weeks. If the injury is more serious, such as an internal derangement, the period required for recovery and return to full duty will be four to six months. Many will never be able to return to full duty. No purely exploratory arthrotomy of the knee joint will be performed.

II. Dislocations: Ordinarily reductions will be performed by manipulation under general anaesthesia. Open reduction may be resorted to, after adequate consultation, when closed reduction has failed.

III. Simple Fractures: Fractures of the long bones should be treated by skeletal traction. Open reduction is not to be performed routinely, but only after an


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adequate trial of reduction by skeletal traction has failed. After these fractures have become stable, they should be placed in the appropriate circular plaster-of-Paris splint and the patients will be evacuated to the Zone of the Interior. Double pin and plaster fixation is not to be used. Badly displaced fractures of the radius and ulna which cannot be reduced by other means may be treated by open reduction and internal fixation.

Fractures of the metatarsals and phalanges should not be immobilized for long periods of time in plaster casts. "Pulp" traction should not be used.

IV. Compound Fractures

1. Delayed Primary Wound Closure: This is the greatest single advance in the treatment of compound fractures due to battle wounds. Experience has shown that it is desirable to close these wounds as early as possible after the patient arrives in the General Hospital. This should be performed at the time of the first wound dressing, providing the wound is clean and there is no gross evidence of infection. If infection is present, it should be treated; and, as soon as the infection has been controlled, the wound may be closed. Some wounds may require secondary débridement to control or eliminate infection before they are ready for delayed primary closures. If the closure is done within the first ten days, the skin edges are usually still mobile and may be readily approximated with widely spaced and deeply placed non-absorbable sutures without undue tension. Where wounds cannot be closed without tension because of loss of skin, the closure should be completed with skin grafts. If the wound is ten days old or older, it will usually be necessary to excise the new epithelium at the margin of the wound and undercut the skin edges to make them mobile so that they may be approximated. Penicillin or other antibiotics parenterally or by mouth should be administered one day prior to and several days after the operation. Sulfonamides should not be placed in the wound.

2. Reduction and Immobilization

a. Fractures of the Long Bones: Fractures of the femur, tibia and fibula, and of the humerus will be treated by skeletal traction in every instance where it is possible to achieve a beneficial result within a reasonable length of time. Skeletal traction will be maintained until the position of the fragments has become sufficiently stable so that they will not displace or angulate during transportation in a circular plaster-of-Paris splint. The average periods during which patients with these fractures were held in the European Theatre of Operations are as follows:

Femur    9 to 12 weeks
Tibia and fibula    5 to 7 weeks
Humerus     4 to 6 weeks

b. Fractures of the Long Bones with Loss of Bone Substance: Those patients who have had large loss of bone substance should not be placed in skeletal traction. The part affected should be allowed to shorten so that there will be bone contact. This method is far from ideal. Alignment should be maintained


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by plaster immobilization and every effort made to effect an early primary closure of the wound. These patients need not be held until the fracture becomes stable, but should be returned to the Zone of the Interior at an early date in the appropriate circular plaster-of-Paris splints.

c. Fractures of the Long Bones with Severe Nerve Paralysis: In these patients, the nerve injury takes precedence; therefore, they should immediately be transferred to a neurosurgical center where they will be handled in the following manner:

Do not overcome shortening by application of skeletal traction as it may defeat the possibility of accomplishing an end-to-end suture of the nerve. Splint the fracture in good alignment and perform a primary delayed wound closure at the earliest possible date. If closure is successful and there is no evidence of residual infection at the end of three weeks from time of closure, a combined operation should be done, suturing the nerve end to end, performing open reduction of the fracture and using internal fixation when indicated.

d. Internal Fixation in Compound Fractures: Internal fixation of compound fractures is prohibited as a routine procedure. It should be resorted to only after a thorough trial of skeletal traction has failed to secure adequate reduction, and after healing of the compound wound has been accomplished by suture or skin graft.

e. Fractures of Forearm: These may be treated by circular plaster splints or by skeletal traction when feasible. Badly displaced fractures may require open reduction with internal fixation if other methods have failed. This will not be performed until three weeks after a successful delayed primary closure of the compound wound.

f. Fractures of the Hand and Fingers: In no case should they be immobilized for more than two weeks (see Care of Hand Injuries, VIII).

g. Fractures of the Foot: The primary consideration should be the healing of the wounds through treatment by suture or skin grafting, followed by early active motion of toes and tarsal joints.

h. Steinmann Pins and Plaster, Anatomical Splint: The use of double Steinmann pin with plaster-of-Paris fixation and external metallic fixation splints is not to be permitted as a routine procedure. This method of reduction and immobilization has led to gross infection and ulceration about the pin wounds in a high percentage of cases.

V. Amputations: The same principles for amputation as are outlined in Section B will also be followed in General Hospitals. All amputations performed are to be done by the open circular technique. (In cases where traumatic amputations were followed by amputations done in the forward areas, the stumps showed irregular skin edges.) In most instances, skin traction will effect closure if it is adequately applied and maintained. Secondary closure of these stumps will not be performed in this Theatre. If the skin sleeve is inadequate for closure by traction, or if the bone ends are obviously too long, revision of the stump should be performed. The skin edges should be mobilized by undercutting. The protruding muscle and bone should be re-amputated just sufficiently to


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allow closure by continuous skin traction. Split-thickness skin grafts on stumps of the lower extremity will not tolerate a prosthesis. The use of such grafts to cover amputation stumps is prohibited unless there is an unusual indication. Skin traction should be maintained continuously. As soon as possible after an amputation case is admitted to a General Hospital, the temporary pylon splint and skin traction should be removed and replaced. In the General Hospital traction is best applied by use of weights and pulleys attached to the bed. The traction apparatus should be arranged so that in thigh and leg stumps a greater degree of skin traction is exerted on the posterior portion of the stump. Patients with amputations should be in a condition to be evacuated to the Zone of the Interior two or three weeks after admission to a General Hospital. Stumps do not have to be completely healed. However, skin traction is to be maintained during evacuation by the reapplication of the plaster splint pylon with outrigger as described in Section B.

VI.Splinting of Fractures for Transfer to the Zone of the Interior

The same general principles (Section B, VI) will be followed in the application of circular plaster-of-Paris splints for evacuation to the Zone of the Interior, with the exception that these are secondary plaster-of-Paris splints applied weeks after the injury or operation and therefore need not be split. All patients should have new plasters applied just prior to departure.

VII. Joint Wounds: These wounds should be closed at the earliest possible moment by suture or skin graft. If the joint surfaces are not badly damaged, early active motion should be insisted upon. If, however, the joint surfaces are so badly damaged that ankylosis is inevitable, the various joints should be immobilized in the best position for function. The following positions are recommended.

1. Hip Joint: Flexion of 25 degrees and abduction of 5 degrees, and neutral position without medial or lateral rotation.

2. Knee Joint: Flexion of 10 to 15 degrees.

3. Ankle Joint: Foot, 10 degrees less than right angle for males; 20 degrees less than right angle for females.

4. Shoulder Joint. Abduction of humerus of 65 degrees, 45 degrees forward of the transverse body axis, and in midrotation. This position enables the patient to reach his face with his hand.

5. Elbow Joint: Flexion of 90 degrees. In bilateral cases immobilize the more seriously damaged joint at 90 degrees and the other at 130 degrees.

6. Wrist Joint: Dorsiflexion of 40 degrees without radial or ulnar deviation.

VIII. Hand Injuries:

Centers have been established to care for hand injuries, as these present special problems. Those hand wounds which have not had a primary closure in hospitals in the forward areas should be closed by delayed primary closure or with skin grafts as early as possible. The danger of prolonged immobilization of the hand and fingers cannot be overemphasized. A useful hand with imperfect bone alignment is far more desirable than a stiff hand with


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perfectly reduced fractures. In selected cases, skeletal traction may be used, but every effort should be made to maintain active motion of the uninvolved fingers. Such traction should not be employed longer than two or three weeks. In no instance should "pulp" traction be used. Amputations should be performed early if there is no possibility of restoring some useful function. Whenever possible, any portion of the thumb should be saved. Effective active exercises under the supervision of a physical therapist must be instituted early and pursued with diligence.

IX. Gas Gangrene: Same principles of treatment apply as outlined in Section B, IX.

X. Vascular Injuries: These are not considered to be orthopaedic problems except for those cases which require amputation, and those which require treatment of an associated fracture.

XI. Elective Orthopaedic Surgical Procedures: It must be borne in mind that any major procedure of this kind requires a relatively long period of convalescence and that there are few which will result in complete elimination of a partial permanent disability. As a rule patients requiring the following procedures will be transferred to the Zone of the Interior:

1. Arthrodesis of the spine or of any major joint;
2. Bone grafts for non-unions;
3. Any type of operation for recurrent dislocation of the shoulder;
4. Arthroplasties, including bunion and hammer-toe operations;
5. Arthrotomies for correction of internal derangement of the knee joint.

Certain exceptions may be made for the possible salvaging of key personnel. In such cases the concurrence of the local orthopaedic or surgical consultant will be secured before such a procedure is carried out.

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