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Chapter X

Contents

CHAPTER X

The Management of Compound Fractures-
Techniques of Fracture Management

Plaster of Paris

Technique-The following general instructions were issued for the application of plaster casts for transportation in evacuation hospitals:

1. The extremity must be put up in the proper position.

2. Joints proximal and distal to the fracture must be immobilized.

3. Heavy padding must be used freely, with felt or other material applied over bony prominences and major subcutaneous nerves.

4. Anterior and posterior plaster reinforcements must be applied smoothly; then they must be encircled with plaster bandages, which must be applied evenly and snugly and without tension. The turns of the plaster bandages must be rubbed until they form a homogeneous mass.

5. All circular plaster-of-paris casts must be split throughout their length and through all layers, or must be bivalved, as soon as the plaster has set.

6. After the cast has been applied, an outline of the wound and of the fracture must be drawn on it. Data must include the nature of the fracture (simple or compound), the date of injury, the date and hour of debridement, and the unit which treated the patient.

7. The circulatory status and the motion and sensation of the fingers or toes must be checked at frequent intervals after the cast has been applied. If there is any doubt of these facts, the upper half of the cast should be removed, or, if necessary, the entire cast, to be certain that the circulatory status of the limb is not impaired.

8. Symptoms and signs of pressure sores must be looked for. If they appear, a window must be cut in the cast and firm padding applied over the area.

Casts applied after delayed primary suture were usually changed about 10 days later. At this time, the sutures were removed, and new circular plaster splints were applied. No more padding was used than was absolutely necessary. Casts applied at this time, unlike the casts applied after delayed primary suture, did not need to be split, the chief reason being that the patients were in a general hospital and under constant observation. Furthermore, swelling was not apt to occur after reparative surgery.

Commanding officers of hospitals which evacuated patients to the Zone of Interior were instructed to pay particular attention to the condition of plaster casts in which they were to travel. Circular casts over open wounds were always changed just prior to departure. If the wounds had been successfully closed by primary suture, the same procedure was frequently followed but was


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not necessary in all cases, since the splints did not become foul-smelling and stained with blood and discharge as they did in the open method of treatment.

The consultants in orthopedic surgery at first had some difficulty seeing that the rule for splitting plaster casts for transportation was universally applied. There was much less difficulty about insuring that enough padding be used. Both of these were fundamental considerations, about which vigilance could not be relaxed.

Other errors were also fairly frequent. Casts were sometimes unduly heavy. Spicas were too widely abducted. The feet were put in the equinovarus position. The knees were sometimes straight and sometimes hyperextended.

Before D-day, the plan was followed of having the medical officers who had made errors correct them immediately. Theoretically this was an excellent plan but practically it took up a great deal of time, which after the invasion could not be spared from more important duties. Furthermore, the same officers frequently continued to make the same mistakes in spite of the demonstration to them of their errors. Eventually, most orthopedic consultants and chiefs of sections arrived at the conclusion that as long as the basic principles of padding the extremity and splitting or bivalving the cast were adhered to, no permanent harm would come from minor errors which would be corrected in a few days anyway in a general hospital, when definitive surgery was done.

Plaster proved useful and effective for orthopedic purposes in World War II, though it had many obvious disadvantages. The hope is that in the future some plastic dressing may be devised which will permit direct inspection of the wound. If this type of material were available, it might not be necessary to use the enormous quantities of protective sheet wadding which must be used with plaster of paris, and direct inspection of the injury would be possible without removal of the cast. This would permit prompt detection and immediate treatment of incipient gas gangrene and other infections.

Tobruk Splint

Although the splint used by the British in North Africa as a transportation splint for casualties with fractures of the femur was called the Tobruk splint, the name was somewhat misleading. This splint was essentially the Thomas splint, which had been devised in 1870, reenforced with plaster of paris to keep it snugly on the limb while the patient was on his journey.1 The standard method of application was as follows:

1. A wide posterior plaster splint was applied from the level of the upper thigh to a point 2 inches above the malleoli. Two 3- or 4-inch adhesive-plaster strips were applied to the skin of the leg on the medial and lateral aspects from just below the knee to the malleoli. The splint was applied with the knee in 15-degree flexion and was well molded by the use of a muslin bias bandage.

1Surgical meeting, 108th General hospital, Paris, 26 May 1945.


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2. The popliteal space was protected by a 6- by 6-inch piece of felt which was applied before the splint was applied.

3. The splint was anchored to the full-ring Army splint by circular plaster bandages which were applied loosely, so that they could be well crimped to both sidebars of the Army splint.

4. The circular bandages and sheet wadding were split down to the skin.

5. The foot was supported by the device attached to the splint for this purpose.

6. Approximately 5 pounds of active traction was applied by the use of elastic traction cord or plasma tubing attached to the adhesive-plaster strips and tied over a spreader to the end of the Army full-ring splint.

The Tobruk splint, according to its British advocates, was superior to the plaster spica in two respects: It could be applied more quickly, and it required less plaster and less water. In North Africa, where the splint was first used, these were undeniable advantages. British hospitals in forward areas were understaffed, at least by American standards, and supplies of plaster of paris were sometimes inadequate, while water was often difficult to obtain.

In the light of the British experience and recommendations, the Tobruk splint was accepted with enthusiasm by some American surgeons and a training film was produced to teach its correct application. All the orthopedic surgeons who entered the European theater in 1942 and early 1943 were instructed in the technique. Enthusiasm lessened, however, when the splint was observed under battle conditions. Members of the 3d Auxiliary Surgical Group who went to North Africa in January 1943 returned almost unanimously condemning it as inferior to a plaster-of-paris spica.

This did not end the discussion. The relative merits of the Tobruk splint and the plaster-of-paris spica continued to be argued. British consultants, at the meeting held with them by American Army consultants in Paris in October 1944, expressed the opinion that the United States Army Medical Corps was unwise in failing to use the Tobruk splint more extensively. To settle the question on the basis of facts rather than impressions, Lt. Col. John G. Manning, MC, consultant in orthopedic surgery, Ninth United States Army, was requested to conduct a controlled investigation and to report on it as soon as possible.2

Colonel Manning's investigation, which covered the months of November and December 1944, was carried out in five evacuation hospitals.3 During this period, 202 fractures of the femur were treated. One hundred forty-three of these were immobilized for transportation in the Tobruk splint. This technique was not used in the remaining cases for three reasons: (1) The ring of the splint would have caused pressure on a wound of the upper thigh or buttocks; (2) skin traction could not be applied because of wounds of the leg

2Annual Report, Professional Service Division, Orthopedic Surgery, Office of the Chief Surgeon, European Theater of Operations, 1944.
3Semiannual Report, Professional Service Division, Orthopedic Surgery, Office of the Chief Surgeon, European Theater of Operations, 1 January-30 June 1945.


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or fractures of the tibia or fibula; and (3) full-ring leg splints were sometimes not available. The British technique was followed as precisely as possible whenever the Tobruk splint was used.

A questionnaire was placed in the medical records jacket which accompanied each of the 143 patients, and Colonel Manning's report was based on the 63 which had been returned by 15 April 1945. While not all questionnaires were complete on all points, the following summarized data were obtained from them:

The 63 fractures of the femur included in the analysis consisted of 37 fractures of the shaft, 16 fractures of the upper third, and 10 supracondylar fractures.

The time required for application of the splint ranged from 10 to 45 minutes.

Between 6 and 12 rolls of 6-inch plaster bandage were used for each application, the average being 9 rolls.

The splint was kept in place from 1 to 25 days. The average range for the individual hospitals was from 4.4 days (in hospitals in Liége, Belgium) to 18 days (in hospitals in Normandy, France), and the average for the whole group of hospitals was 8.1 days.

The location of the fracture apparently influenced the surgeons' opinion of the value of the splint, though the number of cases is too small to be conclusive in any category. It was stated to be superior to the plaster spica in 1 of 15 fractures of the upper third and to be inferior in 14. In 36 fractures of the shaft, the splint was stated to be superior to the plaster spica in 8 and inferior in 28. In 10 supracondylar fractures, it was stated to be superior in 3 and inferior in 7. For the 61 cases in which this information was available, the splint was thought to be superior to the plaster spica in 12 and inferior in 49. Inconclusive as are these figures, there was no doubt of the preference of American surgeons for the plaster-of-paris spica.

Information as to the patients' opinion of the splint was also secured in 62 cases (table 3). At the meeting of the consultants in May 1945,4 at which the report of this investigation was made, the Theater Chief Surgeon agreed with the criticism voiced by one of the British surgeons present, that it was rather risky to draw statistical conclusions from a patient's evaluation of his

TABLE 3.-Patients' opinions of Tobruk splint in 62 fractures of the femur



Opinion


Location of fracture



Total


Upper third


Shaft

Supracondylar

Comfortable

2

13

5

20

Uncomfortable

10

15

3

38

Painful

3

9

2

14


Total


15


37


10


62

4See footnote 1, p. 110.


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own comfort, and further agreed that a casualty with a fractured femur and compounding wound was unlikely to be very comfortable at the best.

The majority of surgeons who reported on these cases stated that the Tobruk splint could be applied more rapidly and with less effort than the plaster spica. They agreed that patients were comfortable in it as long as they remained in an evacuation hospital. They felt, however, that this splint was not suitable for all fractures of the femur and that it did not supply adequate or comfortable transportation. They therefore regarded it as inferior to the plaster spica for transportation purposes.

A number of complications were recorded in these 63 cases. In 11 instances the ring of the splint had become displaced medially, causing pressure, pain, and discomfort in the perineal area. In 2 instances, superficial pressure sores resulted from pressure on the buttocks.

Two of the 63 patients required amputation, but in neither instance was the splint responsible. In 1 case, the circulation in the leg and foot was unimpaired, but massive loss of soft tissue, bone, and sciatic-nerve tissue made it impossible to save the limb; this patient died after a transfusion reaction. In the other case, the popliteal artery and vein had been ligated when debridement was done. Amputation was required in a general hospital in the United Kingdom 5 days later, presumably for gangrene of circulatory origin.

This report, which was read at a final meeting of British, Canadian, and United States Army consultants in Paris in May 1945,5 produced vigorous discussion but changed few minds. The British and Canadian surgeons remained convinced of the value of the splint. American medical officers continued to favor the plaster spica for transportation splinting in fractures of the femur. The interesting point was made, in the concluding remarks on the subject, that the Tobruk splint was almost the only important matter on which all Allied medical officers were not in substantial agreement concerning the principles and techniques of orthopedic practice.

Skeletal Traction

Skeletal traction proved in World War II to be the safest and simplest method of mass treatment of compound fractures of the long bones. Immediate results achieved overseas and followup reports from observers in hospitals in the Zone of Interior all supported this point of view. One of the great advantages of this technique, furthermore, was that it was readily mastered by the general practitioners, obstetricians, pediatricians, and other medical officers who had had no previous experience with fractures in civilian practice but who often had to be assigned to surgical services in overseas hospitals because of shortages of trained personnel.

During active combat, the holding period on the Continent was never sufficiently long to permit the routine treatment of fractures of long bones by skeletal traction. This technique was, however, widely used in United Kingdom

5See footnote 1, p. 110.


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hospitals. Originally, it was chiefly employed for compound fractures of the femur. After the visit of The Surgeon General to the European theater in July 1944, its use was extended to fractures of the tibia and the humerus, and, in some instances, it was also used for fractures of the forearm.

In the United Kingdom Base, the holding period for compound fractures varied from 5 to 10 weeks, depending upon the type and site of the fracture. If a patient was received within 7 to 14 days of wounding, he could be treated in continuous traction after the wound had been closed by delayed primary suture. The patients were comfortable, and the results from every standpoint were usually good. Reduction was maintained satisfactorily, and wound healing was ordinarily prompt. Every effort was made to encourage exercises which would prevent atrophy of the regional muscles, as well as to secure free motion in the joints above and below the site of the fracture. If these exercises were carried out as directed, functional results were usually good. Practically always the explanation of poor results in cases in which the severity of the original injury did not explain them was either failure to give proper attention and constant supervision to the apparatus in which the patient was put up in continuous traction or failure to carry out exercises as directed.

Patients were held in overseas hospitals until their fractures had frozen sufficiently to assure maintenance of position in a plaster cast during the period of transfer to the Zone of Interior.

As noted elsewhere, it was interesting to observe how conveniently, when the necessity arose, patients in traction could be cared for in tented wards, thought the necessary equipment reduced the number of beds from the usual 30 to 15. In the busiest times, some hospitals had as many as 35 or 40 patients in traction in tents, and many had 200 or more in traction at the same time in wards.

While skeletal traction was, generally speaking, the most universally satisfactory technique for the mass management of compound battle-incurred fractures, each injury required individual analysis with careful consideration of such factors as the location and type of the fracture, the position and size of the wound or wounds, the extent of destroyed or paralyzed muscle, the need for ready accessibility to the wound for secondary operations and dressings, and the necessity for skin grafts and nerve suture.

Only occasionally could traction alone be depended upon to effect satisfactory reduction. Before traction was instituted it was almost always necessary to reduce the fractures by carefully planned, gentle manipulation, which was usually carried out under intravenous Pentothal Sodium (thiopental sodium) anesthesia, supplemented by oxygen and nitrous oxide. Exploration, wound closure, and suspension of the fractures constituted a major surgical procedure, which often occupied several hours. Both before and after operation, blood replacement, maintenance of the fluid balance, and the administration of antibiotics and of dietary supplements were matters of great importance.

The Kirschner wire was almost always used for skeletal traction, with the Steinmann pin reserved for special cases. In many instances, the greater


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surface area of the heavier Steinmann pin might have provided a theoretic advantage, but the Kirschner wire was better tolerated. Experience soon showed that, for optimum results, the wire must be inserted with the limb in its final position in traction. If, for instance, the knee was flexed after a wire had been inserted transversely in the supracondylar area of the femur with the leg in extension, the skin and subcutaneous soft tissues would be folded against or stretched around the wire, and, within a few days, there would be an infected conical cavity extending down to the bone.

It was perfectly practical, however, to use the wire and tautener as a handle for manipulation. When this was intended, the limb was placed in its final position, the wire was inserted, and the necessary manipulations were then carried out.

Whenever possible, the wire was inserted at right angles to the long axis of the bone. The skin was punctured directly by the wire at the point of entrance. On the opposite side, the wire was allowed to create its own aperture for exit. Because of the normal process of bone resorption, even correctly inserted wires became loose 7 to 8 weeks after insertion. Sterile felt, cork, or sponge rubber was inserted between the skin and the tautening bow to prevent the wire from sliding; individual surgeons used for this purpose whatever they happened to have available.

Wires were never inserted into bare bones or through wounds. It was almost always possible to use adjacent areas with normal uninjured bone and skin and to adjust the skeletal traction to compensate. When the proper precautions were taken, infection, loosening, and drifting of pins or wires, and even ring sequestra appeared far less often than might have been expected. Chronic osteomyelitis practically never occurred.

The amount of weight required to maintain reduction was, on the whole, less than was required in similar fractures in civilian life. The explanation was the large volume of destroyed or paralyzed muscle in battle-incurred fractures. When this factor was borne in mind, distraction was readily avoided.

As a rule, patients were put up in permanent traction immediately after delayed primary wound closure, preferably while they were still under anesthesia. In an occasional hospital, this practice was not followed. Instead, the patient was put up in temporary traction and taken to the recovery ward for 24 to 48 hours. This was a bad practice as well as an unnecessary precaution; a properly managed patient almost never went into shock after delayed primary wound closure. On the other hand, when he was placed in traction twice, he sometimes went into shock after the movement and manipulations required by the secondary procedure. From the standpoint of the injury itself, this practice was also undesirable, particularly in fractures of the femur. The continued manipulation of fragments frequently meant loss of position, as well as considerable discomfort to the patient.

In some hospitals, skeletal traction was used so extensively that, as in the 22d General Hospital, a medical corpsman was designated as the traction technician. His only duties were to make continuous rounds to refresh traction


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slings and adjust apparatus. Once daily, he applied 70-percent alcohol to the skin dressings around the pins. The value of the antiseptic application was open to question, but this was a simple and certain way to assure that the technician carried out his major duties on every patient. The morale factor was also important. The maintenance of skeletal traction was a matter of teamwork, and the application of the alcohol, it was found, helped to make the technician feel that he was an important member of the team.

External Fixation

Some of the compound fractures which occurred at Pearl Harbor the opening day of the war were treated by external skeletal fixation. Unfortunately, the reports which described the experience not only concerned too small a series of cases for objective evaluation of this method but were also published prematurely, before the followup was sufficiently long for a fair estimate of results. The enthusiasm of the first reports, however, was contagious, and before it could be shown to be unjustified the Army had invested heavily in various forms of apparatus for external fixation, and inexperienced young Army surgeons had used the method in a fairly large number of cases.

External fixation soon proved itself to be a method totally unsuited to the general management of military casualties. It had an extremely restricted field of usefulness, and, unless the patients were selected with the greatest care, its use in both simple and compound fractures was inevitably associated with a high percentage of both infection and delayed union. In the relatively small number of cases in which the method was used in the European theater, with pins incorporated in circular plaster casts, distraction of the fractures and pinhole osteomyelitis occurred very frequently. The use of the method was therefore forbidden, and the apparatus was removed from the hospitals.6

Internal Fixation

In certain simple fractures, open reduction and internal fixation sometimes seemed to be the only way to secure union with proper alinement. In compound fractures, anatomic replacement of the fractured bones with maintenance of their position by internal fixation was also sometimes indicated. Fractures of the long bones adjacent to joint surfaces often could not be managed in any other way.

In simple fractures, in which internal fixation is seldom indicated, this technique was probably used more often than it should have been. In compound fractures, it proved a useful method in certain carefully selected cases but one that was completely unsuited for general use. Often it was an extremely formidable procedure.

Internal fixation had to be performed with a number of precautions, one of the most important being strict attention to the preoperative blood level.

6Circular Letter No. 131, Office of the Chief Surgeon, Headquarters, European Theater of Operations, 8 November 1944, Care of Battle Casualties, Treatment of Wounds of Bones and Joints. (See appendix A, p. 325.)


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The hematocrit had to be raised to at least 40. Surgeons rapidly learned that in this operation, as in many others, there was no substitute for whole blood in the preoperative preparation of patients.

After penicillin became available, in the spring of 1944, it was administered routinely before all internal-fixation operations. It was given, as a rule, in 25,000-unit doses at 3-hour intervals before surgery and as long thereafter as it was indicated. As time passed, it was found that the postoperative period of administration could be shortened considerably over what had previously been thought necessary.

Minimal traction was used until the wound was healed. No comparative figures are available, but the clinical impression was that this practice, in addition to adding to the patient's comfort after operation, shortened the hospital stay and improved the anatomic and functional results.

One other consideration was extremely important in the use of internal fixation: This method could be used with safety and with relative frequency before D-day, when the general and station hospitals were staffed with qualified surgeons experienced in this technique. As newer hospitals began to arrive staffed with officers who were less adequately trained in bone and joint surgery, its use had to be considerably curtailed, even for noncombat injuries. With the great majority of surgeons who were treating military casualties both undertrained and inexperienced, disaster would have been inevitable if permission had been given for the general employment of this method. For this reason, and for the reasons already stated, internal fixation was forbidden as a primary procedure.

Reports from special hospitals in which internal fixation was correctly used, with discretion and in properly selected cases, show both the possibilities of the method and its extremely limited field. It was used, for instance, in only 71 cases at the 46th General Hospital. These included 30 fractures of the femur, 14 of the tibia, 13 of the humerus, 6 of the ulna, 5 of the radius, 2 of the patella, and 1 of the clavicle. The distribution of cases indicates the relative usefulness of the method in various regional fractures. Examinations of the records showed that without exception these patients did well in the hospital. There was not a single serious postoperative infection. Dependent drainage was often necessary in femoral fractures, and a posterolateral incision was used. Healing usually occurred promptly.

The 23d General Hospital had a similar experience. Internal fixation was used only 55 times in 1,628 bone and joint injuries observed over a 2-month period while the hospital was operational in Italy, and the proportion of operations in the European theater was roughly the same.

On the other hand, it is doubtful that the end results of internal fixation were as good as the immediate results seemed.7 In communications between The Surgeon General's Office and the Theater Chief Surgeon during the winter of 1944-45, it was pointed out that a review of patients treated in the Mediter-

7Circular Letter No. 23, Office of the Chief Surgeon, Headquarters, European Theater of Operations, 17 March 1945, Care of Battle Casualties, Orthopedic Surgery. (See appendix A, p. 330.)


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ranean theater by internal fixation had revealed several disturbing facts. One was that it was necessary to remove the metal in from 25 to 40 percent of all cases in order to end drainage and permit healing. It also seemed that this method had been used in numerous cases in which the indications were doubtful. The Surgeon General therefore proposed that this method be reserved strictly for cases in which there was no doubt of the indications. He also proposed that two series of compound fractures, one treated by the usual method and the other by internal fixation, be studied from the standpoint of wound healing and fracture healing, with particular reference to the position of fragments and the incidence of osteomyelitis. An incidence of infection of 25 to 40 percent was so far in excess of the incidence in patients treated by delayed primary suture and skeletal traction that it seemed essential to know whether the increased accuracy secured in reduction of fractures by internal fixation compensated for the higher rate of infection. The fighting in Europe ended before this study could be made.

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