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Chapter XI

Contents

CHAPTER XI

Regional Injuries

The amount of mechanized equipment used by the United States Army in World War II accounted for the extreme frequency of noncombat injuries both before and after D-day. Traffic injuries were also distressingly frequent. At the 801st Hospital Center, for instance, it was startling to learn that of 150 consecutive compound fractures treated immediately after D-day, 30 were caused by accidents which had nothing at all to do with fighting. Simple fractures were much more frequent in noncombat than in combat injuries, in which compound fractures, often with serious comminution, were the general rule.

It will be observed that in this chapter a distinction is made between the management of noncombat and combat injuries of the bones and joints, as well as between the management of injuries before and after D-day. Before D-day there was time-though perhaps not always justification-for techniques of management which would have been completely unwarranted when hospitals had become crowded with battle casualties whose need for treatment was urgent.

Forearm

Many of the fractures of the forearm treated before D-day were of the type usually encountered in civilian practice and were managed in much the same way as similar fractures would be managed in civilian life. Special types of fractures, especially fractures of the radial head and of the carpal scaphoid, were frequent and will be discussed in detail later in this chapter. A large number of Monteggia's fractures were handled at the 803d Hospital Center, whose staff believed that the best results were accomplished by early surgery on the ulna, through an incision which gave complete exposure of both the fracture and the elbow joint. The procedure consisted of internal fixation of the ulnar fracture, reduction of the head of the radius, and suture of the orbicular ligaments.

Wounds of the forearm of combat origin usually healed well after delayed primary suture. Special methods of reduction were, however, often necessary to establish bony continuity, in order to speed healing and improve functional results. The difficulty in fractures of the radius and ulna was to effect and maintain reduction. They were preferably put up in plaster of paris in moderate pronation. A decided tendency was noted on the part of some surgeons who had had no special orthopedic training to put them up in full supination. Cross union was inevitable in most cases in which this position was maintained for any length of time. If the patient was caught in the chain of evacuation for 3 or 4 weeks, as could readily happen, the initial bad position was likely to become permanent.


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Skeletal traction-When simple reduction of fractures of the bones of the forearm was not sufficient and open reduction was contraindicated because of the seriousness of compounding wounds, infection, extensive bleb formation or other complications, unstable fractures of the shaft of the radius and ulna were sometimes managed by the use of heavy Kirschner wires to maintain reduction. At the 298th General Hospital, the practice was to insert one wire through the bases of the second, third, fourth, and fifth metacarpals and a second wire through the olecranon process, after which spreaders were applied and the fragments were manipulated into good alinement. The wires were then incorporated in a long arm plaster-of-paris cast, the spreaders being removed after the plaster had set firmly. The wires were withdrawn at the end of 6 weeks, but immobilization was continued until firm union had occurred. Careful selection of cases was essential. No serious complications were encountered in the fractures in which this method was used, and it served as a satisfactory alternative to open reduction in some of the cases in which the latter method was contraindicated.

At the 802d Hospital Center skeletal traction was used in 30 fractures of the bones of the forearm, as follows:

Wires through the olecranon process and distal radius were used in 20 fractures of the proximal radius and ulna. The ulna could usually be controlled very well, but satisfactory realinement of the proximal third of the radius was much more difficult to achieve.

Traction through the metacarpals was used in 10 fractures of the distal radius and ulna. A nice adjustment of ulnar or radial deviation was necessary, and particular care was required to insert the wire and preserve the palmar curve of the hand. The wire did not always transect all four metacarpals, and the method was extremely difficult to apply, even when an experienced technician was in charge of the case. This particular technique also had other disadvantages, such as the following:

Patients were reluctant to exercise the fingers because movement was painful and because even the slightest fixation of the carpometacarpal joints interfered with the rotation, gliding, and interaction of the complicated, highly flexible joints of the hand. When the fracture was in the distal or middle third of the radius, traction through the metacarpal of the thumb or the styloid process of the radius, with the hand put up in ulnar deviation, proved a satisfactory method of management. At this hospital center, traction was practically never used in fractures involving only the ulna.

When fractures of the radius were associated with extreme shattering of the fragments, the collapse of the bone was often enough to cause radial shortening. Radial deviation was then the end result, even when the cast had been carefully applied in ulnar deviation. One alternative, the application of traction through the carpus or the first metacarpal, was not viewed with particular favor, since traction had to be maintained at least 8 weeks to obtain solid union. Many surgeons thought that more satisfactory function of the hand and wrist could be obtained by a technique which permitted earlier removal of


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the cast, even though a later resection of the ulna might be necessary to correct radial deviation. The relative end results of the two techniques are not known, since wartime exigencies made followup of most patients entirely impractical.

Internal fixation-Internal fixation was the preferred method of management of compound fractures of the radius and ulna which could not be handled by more conventional methods. In many cases, however, in which comminution of the radius was considerable, it appeared, regardless of the technique employed overseas, that osteotomy and bone grafting would eventually be necessary in Zone of Interior hospitals.

Fractures of the Radial Head

In the early orthopedic literature, fractures of the head of the radius. although they were always recognized as important because of the disability they caused, were regarded as rather uncommon. The increasing use of roentgenograms helped to overturn that impression, though many incomplete vertical fractures, and even some complete fractures, continued to be diagnosed as sprains of the elbow.

This civilian type of injury assumed considerable importance in World War II not only in training areas but also overseas, where it accounted for a considerable loss of days from duty. For that reason, two typical series of cases are presented in some detail.

The 168th Station Hospital, according to a report by Maj. Nathaniel Gould, MC, treated 49 of these injuries in England in 1943 and 1944. The 65th General Hospital, according to a report by Maj. Julian E. Jacobs, MC, and Capt. Harold B. Kernodle, MC, treated 42, also in England, in the course of 10 months. The latter hospital, over the same period, treated 10 simple fractures of the radial neck, 2 Colles' fractures, 2 Smith's fractures of the distal radius, and 100 simple fractures of the scaphoid bone.

Nature of the injury-The history of the injury in fractures of the radial head is sometimes that of a direct, forceful blow upon the elbow, or a fall upon the elbow. Much more often, and much more typically, the story is of a minor accident, a fall from a bicycle or a ladder, or merely a fall, with the attempt, whether the fall is forward or backward, to break its effect against the outstretched hand, with the forearm partly pronated and the elbow slightly flexed. In the fractures under consideration in the two overseas hospitals these stories, which are typical of injuries in civilian life, were frequently heard, but the histories also included falls from the wings of planes, or simple falls during the blackout.

The regional anatomy (fig. 23) serves to explain the result of such accidents. Grossly, the head of the radius is of the same bony composition as the patella, with the columnar type of dense cancellous bone running lengthwise. That is why the plane of the fracture is so often longitudinal. The head, which is rounded on its lateral aspect and somewhat hollowed on its proximal end, to permit articulation with the capitellum of the humerus, is entirely covered by articular cartilage. Unless the articulation is almost anatomically perfect, full


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FIGURE 23.-Lateral view of partly dissected joint of right elbow, showing relationship of radial nerve to annular ligament. Insert shows ligamentum capitulum radii as continuation of quadrate ligament. Note relationship of biceps tubercle to fracture with forearm pronated (from dissected specimen, Cambridge University Medical School).

supination and pronation of the forearm will not be possible. As a result of the fall or other accident which causes the fracture, and the effort to break its force, an abduction force is transmitted through the head of the radius to the capitellum. The degree of leverage and the resulting angle at which the pronated radial head is driven into the capitellum determine both the degree of comminution and the degree of displacement which result. Unless the coronary ligament, by which the radial head is strongly bound to the ulna, should rupture, the general contour of the radial head will be maintained, even if mushrooming occurs.

The radial head is entirely covered by articular cartilage. The posterolateral continuation of the attachment of the quadrate ligament (ligamentum capitulum radii) is covered by a distinct fold of synovial membrane (fig. 23), which is a fact of importance in cases treated surgically.

The abduction force which damages the radial head also traumatizes the medial capsule. This explains why, even late in the followup, some patients may complain of discomfort about the medial aspect of the elbow joint. In the 42 patients treated at the 65th General Hospital, 3 of 28 with mild fractures


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in the form of simple cracks of the bone and 2 with comminuted or displaced fractures complained of this type of pain. The fact that patients with much more severe injuries did not complain of it was explained in those cases by dissipation of the abduction force by collapse of the radial head.

Classification-All 49 fractures of the radial head observed at the 168th Station Hospital were classified as simple. The 42 fractures treated at the 65th General Hospital were divided into three groups:

1. Twenty-eight fractures, two-thirds, were simple cracks, in the form of a single longitudinal cleft across the head, without depression (fig. 24) or with a slight depression (fig. 25). In this type of fracture, there was no actual increase in the circumference of the head. The abduction force had been applied briefly to the anterolateral segment of the head against the capitellum (fig. 26). All fractures in this group could be treated conservatively.

2. Five fractures in which the circumference of the head had been increased moderately by comminution or had been disturbed by marginal displacement of the anterolateral segment (fig. 27). All 5 cases were treated conservatively, though the question of surgical excision was raised in one or two.

3. Nine fractures in which there was marked displacement of one or more bony fragments (figs. 28 and 29). All these cases were treated surgically.

The circumstances of the accident determined the side affected. In these 42 cases, the distribution was almost equal, 22 of the fractures being on the left side and 20 on the right.

FIGURE 24.-Cleft fracture of radial head, group 1, 10 months after patient had sustained a "sprain." Note persistence of fracture. (See also figures 31 and 33.)


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FIGURE 25.-Cleft fracture of radial head, group 1. Note slight depression of anterolateral segment.

FIGURE 26.-Fracture of radial head, group 1, with forearm in pronation (position at time of injury), showing relationship of fractured segment to capitellum.


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FIGURE 27.-Fracture of radial head, group 2, with comminution and some displacement.

FIGURE 28.-Fracture of radial head, group 3, with severe comminution involving entire head.


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FIGURE 29.-Fracture of radial head, group 3, showing severe comminution with displacement.

Diagnosis.-The diagnosis of this injury presented no difficulty in either of these series, partly because the story was always typical and partly because the relative frequency of the fracture made it impossible not to bear it in mind as a possibility. Usually, as already noted, there was a history of a fall upon the extended hand, with the forearm also extended. Less often there was a story of a direct fall or blow on the elbow. As a rule, immediate discomfort was slight, and a full range of motion was possible for some hours. Then the elbow began to feel stiff, there was pain of increasing severity even when the arm was at rest, and there was severe pain on motion. The pain was always most severe on attempted supination. A full range of motion was impossible. The arm could not be extended completely, and full flexion was also impossible. The limitation of motion was chiefly due to hemorrhage into the elbow joint, which is almost invariable in this type of fracture.

An occasional patient with a fracture of the radial head complains of discomfort or pain referred to the wrist. This type of pain was not observed in any of the cases in this series. On the contrary, the absence of clinical or radiologic evidence of trauma to the distal radio-ulnar joint was repeatedly noted. When pain in the wrist is present with a fracture of the radial head, it is best explained as referred pain. The explanation is that the wrist joint is innervated by the terminal branches of the deep branch of the radial nerve, which has conceivably been irritated by trauma to the radial head.


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When the patients in this series were first seen, the position of the injured extremity was usually typical. The forearm was supported, in neutral position, with the elbow flexed 100 to 135 degrees. Attempted supination of the forearm by either the patient or the examiner caused great pain, especially in the region of the radial head. Palpation over the head of the radius elicited a complaint of tenderness. An effusion, which invariably proved hemorrhagic, could be demonstrated in the joint.

Anteroposterior and lateral roentgenograms confirmed the clinical diagnosis.

Management.-It was the practice at some hospitals in the European theater, when fractures of the radial head were encountered, to decide immediately whether the damaged head should be excised or be left in situ, on the ground that delay in excision might end in the development of a degenerative arthritis between the radial head and the capitellum. If surgery was decided upon, it was carried out as promptly as possible, on the ground that to delay excision for a period of months and then perform it for the relief of a painful elbow was simply tempting fate, since arthritis is almost never relieved by delayed surgery. It was the practice at other hospitals to treat fractures of the radial head conservatively unless the articular surface was badly damaged. This policy was followed even if there was a slight angulation at the neck. The two series of cases upon which the foregoing discussion has been based were chiefly treated conservatively.

At the 168th Station Hospital, 43 of the 49 fractures of the radial head were treated conservatively but as immediate emergencies.1 As soon as the clinical diagnosis had been made and had been confirmed by roentgenograms, the patient was taken to the operating room, where the joint was aspirated under strict sterile conditions. The surgeon wore gloves and was masked, and his assistants were also masked. The elbow, after it had been prepared with iodine and alcohol, was draped with sterile towels.

After the affected area had been injected with sterile Novocain solution (2 percent), a No. 20 intravenous needle was introduced into the joint and aspiration was continued until all the blood had been evacuated. The amount removed ranged from 6 to 36 cc. and averaged between 18 and 20 cc.

A well-padded plaster cast was then applied from the midarm to the base of the fingers, with the forearm in neutral position and the elbow at 90 degrees. In the early experience, the cast was kept on the arm for 7 days. As experience increased, it was removed on the fourth day.

As soon as it was removed, the patient was sent to physical therapy. He kept his arm in a sling for the remainder of that day but discarded the support the following day. Exercises in the physical-therapy department consisted of active flexion and extension exercises, at first with a 2-pound weight, pulley, and rope. On the following day, the weight was gradually increased until a maximum of 15 pounds was reached. Massage and whirlpool treatments to

1The 6 other patients, because of associated fractures of other bones, had to be transferred to a general hospital for treatment, since theater policy limited the holding period in station hospitals to 30 days.


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the arm, forearm, and elbow were also used. In the later part of the experience, formal exercises were supplemented by hot water soaks and by exercises on the ward. Since pain was relieved dramatically almost as soon as the joint was aspirated, only the occasional patient had to be persuaded to carry out these instructions. Incidentally, no patient in this series required any sedation.

At the 65th General Hospital, 33 patients (groups 1 and 2) were treated conservatively and the other 9 (group 3) by surgical measures.

The 28 (group 1) patients with simple noncomminuted or nondisplaced fractures used slings for a week or 10 days, but aspiration was employed only if the joint was tense. It was repeated as necessary. It was preferred, when aspiration was indicated, to delay it for 24 hours after injury, by which time active bleeding had usually ceased.

In the 5 cases in group 2, the same type of treatment was used, unless comminution was considerable. Then a plaster splint was applied for 10 to 14 days, with the forearm in neutral position and the elbow at a right angle. When the splint was removed a sling was employed. Aspiration was carried out in 2 of the 5 cases in this group but was not thought to have influenced the end results. Heat and light massage were employed when the splint was removed.

The 9 patients in group 3 were subjected to surgical excision of the entire radial head. It was not always possible to determine, before direct inspection, whether excision could be limited to the small fragment demonstrated roentgenologically or whether so much comminution would be found that resection of the entire head would be necessary. Total resection was necessary in all 9 cases in this group. Trauma to the articular cartilage, which was not revealed by roentgenograms, was also considerably greater in every case than had been suspected.

The technique of operation was as follows:

A sphygmomanometer cuff, inflated to 200 mm. Hg, served as a tourniquet. An incision was made extending from the lateral epicondyle through the conjoined tendon of the extensor digitorum and the extensor carpi ulnaris (fig. 30). It was usually about 2 inches long. It extended down to, but not beyond, the annular ligament. Care had to be taken not to cut or otherwise traumatize the deep branch of the radial nerve by traction on the supinator muscle mass. Adequate exposure of the joint could always be obtained by carrying the incision to, or proximal to, the epicondyle.

When the forearm was fully pronated, the triangular ligament came into view through the incision. The relationship of this ligament to the bicipital tubercle and the fracture (fig. 23 insert) which had been demonstrated at the anatomy table was invariably confirmed.

The ligamentum capitulum radii was stripped with the osteotome down to the point at which it blends with the synovial reflection, to provide a flap that could be sutured across the raw stump. The use of a sharp osteotome, held rigidly at the base of the radial head, proximal to the annular ligament, produced a smooth stump. Frequent light tapping, together with rotation of


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FIGURE 30.-Lateral incision at elbow used in resection of radial head.

the forearm through 150 degrees, left a smooth cut and offset the minute bony fragments that resulted from the use of the Gigli saw. Any shredding of the cartilage over the capitellum was then pared down. Further inspection of the lateral joint compartment and visualization of the humeroulnar joint allowed removal of any interposing fragments.

The ligamentum capitulum radii, which had previously been reflected, was now sutured across the smooth radial neck, completely covering it. The incision was closed in layers, (1) the synovial membrane and capsule, (2) the split conjoined tendon, and (3) the skin.

After the wound had been dressed and the arm covered with sterile sheet wadding, a plaster cast was applied, with the elbow flexed to 90 degrees and the forearm in neutral position.

At the end of 14 days the cast was removed, the skin sutures were removed, and active motion and physical therapy were begun. A sling was worn for the next 14 days.

End results-At the 168th Station Hospital, where treatment was entirely conservative, the hospital-stay days ranged from 12 to 26. In the first cases, when the cast was worn for 7 days, the stay days averaged 22. In the later cases, when the cast was maintained for only 4 days, the average stay days were 15. An additional reason for the reduction in the period of hospitalization was the more intensive physical therapy in the later cases and the


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self-treatment on the ward with hot water soaks and continued flexion and extension exercises. In the cases treated later, a more intensive effort was also made to gain the confidence of the patient and to assure him that the continuous rigorous workout would help his arm and not injure it. One patient, who was on duty in the hospital, was treated as an outpatient, with satisfactory results. There were no readmissions after discharge.

There were three criteria for discharge, (1) freedom from pain, (2) complete pronation and supination, and (3) flexion or extension disability of no more than 8 degrees.

Forty of the forty-three patients treated at the 168th Station Hospital could be followed up for 2 months or more after their discharge. Results were good in all 40 cases. Most patients had no disability at all at the end of the period of observation and all of them were on full duty and had no difficulty in performing their duties. These results were attributed to the brief period of bleeding, as the result of prompt aspiration, with the resulting prevention of adhesions or of a mechanical block due to the presence of an unresolved clot. Prompt resumption of motion also played a part in the good results.

At the 65th General Hospital, where an adequate followup was also possible, only 17 of the 42 patients had entirely satisfactory results, the distribution being 9 of 28 in group 1, 1 of 5 in group 2, and 7 of 9 in group 3, which was the surgical group.

Of the 33 patients treated conservatively in groups 1 and 2, 18 had a 5- to 10-degree limitation of extension and supination, which was painless in 15 cases and painful in 3 (fig. 31). The discomfort was not severe enough to

FIGURE 31.-Fracture of radial head, group 1, 6 months after injury, with limitation of extension. The patient, who had been treated conservatively, complained of discomfort on both extension and supination. (See also figures 24 and 33.)


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FIGURE 32.-Fracture of radial head, group 3, 6 months after resection of head. At this time patient had full range of painless motion. A. Extension. B. Flexion. C. Supination. D. Pronation.

bring any of the patients back for treatment; the complaint in each case was elicited on the routine followup visit. Both the discomfort and the limitation of motion were attributed to the presence of the injured radial head. Surgical excision, however, was not considered, partly because the pain and disability were slight and partly because this operation, whether it is performed early or late, does not always correct limitation of motion.

None of the nine patients who were operated on (group 3) had any complaints on their 6-month followup visit, and their range of motion (fig. 32) was often better than in some of the nonsurgical cases. The only postoperative complication was a temporary palsy of the radial nerve, which disappeared in 7 weeks. It was attributed to unnecessarily tight application of the sphygmomanometer cuff.

In the 2 cases in group 2 in which, as already noted, aspiration of the joint was carried out in addition to the use of a sling or the application of a cast, the results were not considered any better than were accomplished in the cases in which aspiration was omitted.


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FIGURE 33.-Fracture of radial head, group 1, 12 months after injury, showing roughening of capitellum and persistent bony cleft. (See also figures 24 and 31.)

In 1 case in group 1, the fracture was still present in the roentgenograms made at the end of 10 and of 12 months (figs. 24 and 33) and the patient had some limitation of motion (fig. 31) and discomfort on movement. The findings were explained by the presence of an intra-articular fracture. Trauma to the capitellum was evident in this case.

The absence of bony spurs or myositis ossificans (fig. 34) in all the surgical cases was considered due to the surgical technique, which included covering of the stump left after excision of the radial head. Osteochondritis dissecans was not observed in any case in the series.

Specimen Case Histories

The 2 case histories which follow (the first and last in the series of 49 from the 168th Station Hospital) are presented as typical of this kind of injury in respect to the nature of the accident; the clinical picture, including the usual delay of several hours before symptoms became severe enough to require medical consultation; the ease of diagnosis; the roentgenologic confirmation of the clinical diagnosis; the prompt relief of pain and discomfort by aspiration; and the excellent end results, which permitted prompt return to full duty. It is interesting to note that the patient described in case 2 was treated on an ambulatory basis and was returned to full duty in 13 days, while the patient described in case 1 was hospitalized for 18 days.


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FIGURE 34.-Fracture of radial head, group 3, 6 months after resection of head. Note absence of any bony reaction.

Case 1.-A 21-year-old soldier fell from his bicycle on his right elbow 4 October 1943, 4 hours before admission to the hospital. Clinical examination suggested a fracture of the radial head, with hemarthrosis of the joint. X-ray examination revealed a vertical, incomplete fracture of the radial head, without displacement. Aspiration of the joint yielded 16 cc. of blood. Upon his discharge 18 days later, the patient had full function and no pain. One month later, he was entirely symptom free and was performing all his required duties as an airplane mechanic.

Case 2.-A technician, from the hospital's medical detachment, fell from his bicycle on his extended left hand and forearm 30 August 1944, and was seen in the outpatient department 3 hours later. The clinical diagnosis of fracture of the radial head with hemarthrosis was confirmed by roentgenograms, which revealed a transverse impacted fracture of the radial head. Aspiration of the joint yielded 22 cc. of blood. The cast was removed 48 hours later and physical therapy was begun. This patient, who was treated on an ambulatory status, was returned to full duty as a cook 13 days after injury, with no limitation of motion and no pain. He had no difficulty in performing any of his duties during the several months he was under observation.

Fractures of the Carpal Scaphoid

Fractures of the carpal scaphoid, a civilian type of injury, were even more frequent in the Army than in civilian life. Diagnostic errors are more common in fractures of this bone than in fractures of any other bone in the body; this was as true in the Army as it is in civilian life. The situation is strange, since, without exception, all these fractures are produced in the same manner-by


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force transmitted through the proximal palmar surface of the hand-and the history is the key to the diagnosis. When the same type of trauma occurs in the middle-aged person, whose muscles are flabby and whose reaction time is longer, the result is the Colles fracture, which was seldom encountered in soldiers.

The data which follow were collected by Lt. Col. Marcus J. Stewart, MC, at the orthopedic service at the 826th and 827th Convalescent Centers. The 436 injuries which were observed at these centers between September 1942 and September 1945 consisted of 433 fractures of the carpal scaphoid bone and 3 sprains of bipartite scaphoids. The 433 fractures fell into 3 groups:

Eleven incomplete fractures of the distal third of the carpal scaphoid, all of which healed promptly and without definitive treatment.

Three hundred and twenty-three fresh or acute injuries, which were diagnosed within a month of the accident.

Ninety-nine old fractures which had occurred, on the average, 38 weeks before the diagnosis was made.

Fresh fractures-Of the 323 patients with fresh fractures, 320 were treated by immobilization in plaster, and 3, all of whom had good results, by early excision of the proximal fragment.

Immobilization was accomplished in a position of maximum relaxation of the carpus, the so-called grasping pose (fig. 35). The wrist was placed in extension of approximately 30 degrees, with midulnar and radial deviation.

FIGURE 35.-Type of plaster cast used for immobilization in fractures of carpal scaphoid bone. Note so-called grasping pose. Note also possible range of motion of metacarpophalangeal joints.


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The first metacarpal was abducted and the metacarpophalangeal and interphalangeal joints of the thumb were flexed toward the palm. A circular plaster cast, which was skintight except for a single layer of stockinet, was applied from 1 inch below the elbow to the metacarpophalangeal joints and the base of the thumbnail on the dorsal aspect, and to the distal end of the proximal flexion crease on the palmar side. This position usually permitted the hand to pass through the sleeve of the shirt or the coat. The practice of having the patient clench his fist during the period the plaster was setting was avoided, on the ground that in this movement the flexor muscles recede proximally and the circumference of the wrist is correspondingly reduced. If the plaster hardens in this position, the patient has considerable difficulty in extending the fingers and opening the hand.

Movement of the interphalangeal joint of the thumb was permitted during immobilization, provided that the plaster did not weaken and allow movement of the metacarpophalangeal joint. The latter motion, since the middle fibers of the abductor of the thumb are attached to the tubercle of the scaphoid, would permit movement of the fracture. In the position in which the fracture was put up, the thumb was relaxed and the metacarpophalangeal joints of the fingers were completely free. Thus meant that the patients, who were seen at a rehabilitation center, could carry on an active program of work or play. They were encouraged to participate in such activities as rope climbing, tumbling, chinning exercises, and even baseball.

The cast was changed and the fracture studied by roentgenograms at the end of 4 to 6 weeks. When the cast was removed, the patient was instructed not to move the thumb or wrist until he was told expressly that he might. When necessary, immobilization was reinstituted immediately after the roentgenographic examination. Routine roentgenograms included a true anteroposterior view, a lateral view, and 2 oblique views, 1 in pronation of 45 degrees and the other in supination of 45 degrees (fig. 36, A through D).

Of the 320 patients treated by immobilization according to this technique, 258 obtained solid bony union, with restoration of full function in the wrist and hand, an excellent range of painless motion, a normal grip, and normal strength in the wrist. The other 62 patients were transferred to other hospitals or to the Zone of Interior, and the end results are not known. At the time of transfer, 45 were progressing satisfactorily, and union was expected. Three had definite signs of persistent nonunion, and 14 had been treated too recently to permit any conclusions. It may be considered, however, that 303 of the 320 patients, about 95 percent, had good to excellent results.

When these results were analyzed, a number of factors were found to have influenced healing.

1. Location of the fracture. This was a most important consideration, as it always is in this type of fracture. As a matter of fact, fractures in various portions of the carpal scaphoid should be considered as if they were different bones in different parts of the body.


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FIGURE 36.-Routine roentgenographic studies in fractures of carpal scaphoid bone. A. Anteroposterior view. B. Lateral view. C. Oblique view in pronation of 45 degrees. D. Oblique view in supination of 45 degrees.

Of the 258 patients who obtained bony union under conservative treatment, 44 (17 percent) had fractures of the distal third of the scaphoid, which required immobilization in plaster for 5 to 20 weeks and for an average of 8 weeks; 207 (80 percent) had fractures of the waist or middle third, which were immobilized in plaster for 3 to 35 weeks and for an average of 12 weeks; and 7 (3 percent) had fractures of the proximal third of the bone, which were immobilized from 12 to 32 weeks and for an average of 23 weeks.


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FIGURE 37.-Serial roentgenogram showing fracture of carpal scaphoid bone through waist. A. Development of sclerosis in proximal fragment in spite of early and adequate immobilization. B. Excellent end result, after 30 weeks of immobilization in plaster before union and revascularization occurred.

The average period of immobilization for the entire group of 258 patients was 12 weeks. The reconditioning period necessary after removal of the plaster was encouragingly short, the average time required for complete recovery of function being only 3.5 weeks. Activity of the fingers while the plaster was in situ apparently maintained good tissue turgor, stimulated the blood supply, and kept the tendons freely movable.

2. Reduction. The accuracy of reduction proved of paramount importance in the healing process. This is shown by the necessary duration of immobilization. In 9 of the 258 patients, reduction was fair, and an average of 16 weeks in plaster was required. In 129, good reduction was obtained, and an average of 14 weeks in plaster was required. In 120, anatomic reduction was obtained, and an average of 10 weeks in plaster was required.

3. Vascular changes. It is well known that fractures through the proximal third of the carpal scaphoid and those through the waist may result in deprivation of the blood supply to the proximal fragment in a certain proportion of cases, with resulting necrosis. This development was observed in this series:

In 41 patients, mild to marked vacuolation or cystic changes were observed at the site of the fracture. Immobilization in plaster was maintained for an average of 16 weeks. In spite of early diagnosis and adequate immobilization, avascular necrosis developed in 22 (8.5 percent) of the 258 patients who obtained bony union and excellent results.

In 10 cases, increased density or sclerosis was observed at the site of the fracture. Plaster immobilization was maintained from 11 to 35 weeks, the average being 21 weeks.

In 12 cases, avascularity of the proximal fragment occurred. These patients (fig. 37) spent an average of 21 weeks in plaster. Before they left


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the hospital, all of them were able to negotiate an obstacle race and participate in vigorous sports, and all returned to full duty with normal function of the hand and wrist. In such cases, however, there is always the possibility that degenerative arthritis may develop later.

Old fractures-Of the 99 patients in this series with old fractures, 90 were treated only by immobilization. Fifty-one of the 90 were returned to full duty. All had obtained solid bony union, as shown by roentgenograms, and all had an excellent range of motion in the wrist and hand, without tenderness, and with normal grip and strength.

Thirty-nine patients were returned to the United States or discharged to other hospitals before the conclusion of treatment. In 15 cases, healing was progressing satisfactorily at the time of transfer, but in 3 cases nonunion was evident. In the other 21 cases, treatment was too recent to permit any evaluation of results. There was, however, solid bony union or reasonable expectation of union in 66 of the 90 patients (73.3 percent). These results are to be compared with the approximately 95 percent of good results secured in the 320 cases in which treatment was instituted while the fractures were still fresh.

The same factors influenced healing in the old fractures as in the fresh fractures:

1. Location. The 2 fractures which involved the distal third of the carpal scaphoid remained undiagnosed for 16 weeks and 34 weeks, respectively. Immobilization in plaster was maintained for 22 weeks and 8 weeks, respectively, an average of 15 weeks.

The 43 fractures through the waist of the bone remained undiagnosed for from 4 to 82 weeks, an average of 22 weeks. Immobilization in plaster was maintained for 6 to 59 weeks, an average of 19½ weeks. Prolonged immobilization in these cases did no harm, since daily exercise and activity of the fingers was systematically practiced.

The 6 fractures of the proximal third remained undiagnosed for from 10 to 56 weeks, an average of 23 weeks. Immobilization in plaster was maintained for 12 to 60 weeks, an average of 24 weeks.

The period of immobilization required in these 51 old fractures in which return to full duty was possible averaged 20 weeks, as compared with an average period of 12 weeks for fresh fractures. Aside from any other consideration, the delay in diagnosis caused an average of 8 additional weeks in plaster.

2. Reduction. As in fresh fractures, the character of the reduction obtained influenced the duration of immobilization. In 9 cases in which reduction was excellent, immobilization was necessary for an average of 10.9 weeks. In 38 cases in which it was good, immobilization was necessary for an average of 22.9 weeks. In 4 cases in which it was fair to poor, immobilization was necessary for an average of 23.1 weeks.

3. Vascular changes. Mild to marked cystic changes were observed in 42 cases, in which immobilization was necessary for an average of 19.3 weeks. Sclerosis at the fracture site was observed in 9 cases, in which immobilization was necessary for an average of 21.4 weeks. Six of the nine patients showed


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arthritic changes, but none of them complained of pain or weakness, and all had full range of motion.

The presence or development of cystic changes or sclerosis, as these cases show, does not preclude the use of prolonged immobilization in fractures of the carpal scaphoid. The sclerotic area present in many fractures when the cast was applied looked worse after 4 to 6 weeks in plaster, but improvement became evident (figs. 38 and 39) as immobilization was continued. The freedom and activity of the fingers, as already noted, contributed materially to the success of the treatment.

FIGURE 38.-Serial roentgenograms showing fracture of carpal scaphoid bone which was not diagnosed for 10 weeks. A. Cystic changes at fracture site. B. Appearance after immobilization in plaster for 5 weeks. C. Appearance after immobilization for 22 weeks. This was an excellent result, with solid union.


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FIGURE 39.-Serial roentgenograms showing fracture of carpal scaphoid bone which was not diagnosed for 56 weeks. A. Roentgenogram taken when patient was first seen. B. Appearance of bone after immobilization in plaster for 4 weeks. C. Appearance of bone after immobilization for 12 weeks. Fracture union was solid, but mild osteoporosis developed.

Nine patients with old fractures were treated by surgery, as follows:

Five patients were treated by autogenous bone grafts. In 1 of these cases, the graft was resorbed and the fracture failed to unite; the patient was then transferred to the Zone of Interior for further treatment. Another patient had marked stiffness of the wrist, with 50-percent disability after operation; he was returned to limited duty. The 3 other patients were returned to full duty. In the light of present knowledge, and on review of the roentgenograms, there is every reason to believe that at least 3 of these fractures would have healed just as satisfactorily and rapidly if they had been treated by immobilization alone.


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FIGURE 40.-Serial roentgenograms showing fracture of carpal scaphoid bone which was not diagnosed for 6 weeks. A. Roentgenogram taken when patient was first seen. B. Roentgenogram taken after immobilization in plaster for 25 weeks. At this time there was still no evidence of progress toward union. An inlay type of cancellous-bone grafting was done. Postoperative immobilization was maintained for 8 weeks, and 4 weeks' reconditioning was required. C. Roentgenogram taken 3 months after patient had returned to full duty as truck driver.

One of the patients treated by bone graft (fig. 40) had a fracture which was not diagnosed for 6 weeks. No improvement was evident after immobilization for 6 months. Solid union was secured 8 weeks after excision of the fibrocartilage at the fracture site, and an inlay bone graft was performed. The patient was returned to full duty as a truck driver. This case presented the ideal indication for grafting; namely, failure of viable fragments to show progress toward union after 6 months of immobilization.

Two patients were treated by excision of the proximal fragment. One fracture, through the middle third of the scaphoid, was not diagnosed for 24 weeks; mild sclerosis was then present at the fracture site and moderate sclerosis


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in the proximal fragment. The patient returned to limited duty after 10 weeks of postoperative treatment, with pain and weakness in the wrist and an estimated 40-percent disability. The other patient in this group had a fracture of the proximal third of the scaphoid which had remained undiagnosed for 40 weeks (fig. 41). The proximal fragment was greatly displaced. The fragment was excised and the patient, who was a paratrooper, was returned to full duty after 8 weeks of postoperative reconditioning.

FIGURE 41.-Roentgenogram showing fracture of carpal scaphoid bone with marked displacement of small proximal fragment. The fracture was not diagnosed for 40 weeks. After excision of fragment and 8 weeks of postoperative reconditioning, the patient could be returned to full duty.

Two patients were treated by multiple drilling. One obtained union within 6 weeks but required 7 weeks' reconditioning before he could be returned to full field duty. The other had no sign of union 18 weeks after drilling and was returned to the United States.

Comment.-As this analysis shows, excellent results can be obtained, with a minimum period of immobilization, in fractures of the carpal scaphoid bone which are promptly diagnosed and accurately reduced. The proportion of good results obtained in fractures which are not promptly diagnosed is considerably less, and delayed union or nonunion must be expected in a certain proportion of cases. The presence of vacuolation or cystic change in delayed cases does not, however, necessarily presage a poor result; when the fracture has been properly immobilized, healing in the cystic area will include the fracture line. If the proximal fragment is viable, sclerosis at the fracture site is not a contraindication to prolonged immobilization. In most cases of avascular sclerosis, a continuation of nonsurgical therapy is warranted; protection of the wrist is essential until revascularization is complete. Generally speaking, sur-


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gery does not offer any better prospects of union than does nonsurgical therapy. Normal function of the wrist is seldom obtained following an excision operation, though in the occasional fracture with excessive displacement of the proximal third, early excision of the proximal fragment is the best course unless accurate reduction can be obtained by manipulation. Plaster should be applied with two objectives, (1) adequate immobilization and (2) free use of the hand. Immobilization may be prolonged for a year or more if daily exercise and activity of the fingers are systematically practiced. Perhaps the most significant point of this analysis is the very large proportion of soldiers who could be returned to full duty after an injury that, if not properly diagnosed and treated, could have resulted in a serious loss of manpower.

It should be noted that this interesting study of fractures of the carpal scaphoid bone was begun in September 1942, 21 months before the invasion of the Normandy beachhead. During this period, the number of hospital beds in the European theater considerably exceeded the need for bed space. After the invasion, with the beginning of what was to prove a steady flow of battle casualties, the maximum holding time in the European theater was reduced to 120 days, or 17 weeks. Holding times of 20 weeks, the average for fractures of the carpal scaphoid bone seen late, were no longer permissible. In many instances in this series the holding time was considerably in excess of this average. When battle casualties must be treated, there is no reason to consider holding in an overseas theater patients whose treatment may require as long as 60 weeks, as happened in 1 case in this series. Many of these patients who were seen after the D-day invasion should have been, and doubtless were, promptly evacuated to the Zone of Interior.

Attention is also directed to the proper treatment of recent fractures of the carpal scaphoid, as exemplified in this series. When diagnosis is prompt and treatment is correct, soldiers with this type of injury can usually be returned to duty within the prescribed limits of time in an overseas theater.

Clavicle

Fractures of the clavicle encountered before D-day were satisfactorily treated by Blake suspension traction for 12 to 21 days, followed by ambulation in a figure-of-8 plaster bandage for 7 to 14 days. Whether the patient was in bed or ambulatory, hospitalization was necessary. Traction was preferred by some orthopedic surgeons because it caused the least deformity, which is always of importance in fractures in this area.

In battle-incurred fractures of the clavicle, the emphasis was on immobilization and early evacuation. The plaster figure-of-8 dressing and the clavicular cross were used with equal effectiveness. A common error in fractures of the clavicle treated in plaster was failure to instruct the patient in active shoulder exercises. This omission often resulted in significant, and unnecessary, stiffness of the shoulder joint.


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Humerus

Before the invasion of the Continent, simple (closed) fractures of the humerus were chiefly treated by hanging casts, as in ordinary civilian practice. Compound fractures were also treated by the methods employed in civilian practice.

Battle-incurred fractures required a different approach. Standard treatment at some hospitals was the insertion of a Kirschner wire through the olecranon process, combined with traction and vertical or horizontal suspension. Excellent results were also obtained after reduction and fixation by continuous Blake traction, whether skeletal or skin traction was employed.

Severely comminuted fractures with loss of bony continuity and large compounding wounds responded excellently to open reduction, usually by the use of a wire or screws or by a combination of these methods. When there was considerable loss of bony substance, no hesitancy was felt in shortening the bone as much as 2 inches to obtain good bony union and to forestall the necessity for later bone grafting.

The most common complication of a fracture of the humerus was radial nerve injury with resulting paralysis. In such cases, management of the nerve injury took precedence of management of the bone injury. Vascular injuries were sometimes associated with the bone injury, and in at least 1 instance, at the 68th General Hospital, the vascular damage was severe enough to require amputation.

Patients with fractures of the humerus were transported in plaster-of-paris spicas. A hanging cast was not suitable, as was proved in the few cases in which it was employed shortly after fighting began on the Continent.

A shoulder spica or plaster Velpeau was readily applied by the following technique: An issue type of Army arm splint was stretched between two tables, with the ring end higher than the other end. The patient was then placed on the splint, the ring of which formed an excellent head cushion. In this position the plaster was easily applied about the body. When it had dried, the splint was withdrawn. A metal bar 2 or 3 inches wide served the same purpose.

At the 802d Hospital Center, the 1,065 compound fractures of the humerus treated in traction fell into 3 groups:

1. Fractures of the upper third. Traction through the olecranon process was used in all but a few of the fractures in this group. The Kirschner wire was introduced from the medial to the lateral side, particular care being taken to identify the ulnar nerve by palpation and to avoid it. In a few instances, a temporary neuritis developed from irritation caused by the adjacent wire, but in no instance was there permanent nerve damage. The humerus was usually held at right angles to the thorax and in midrotation (fig. 42). Often a posterior wound had to be kept from contact with the bed or underlying apparatus. In some instances, the axis of the immobilization


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FIGURE 42.-Skeletal traction applied for treatment of injury by 88-mm. shell fragment, which caused compound comminuted fractures of the radius and ulna and a simple fracture of the humerus.

apparatus was applied with the humerus at anterior flexion of 90 degrees and with traction directed overhead.

The hanging cast was not suitable for early treatment of extensive compound fractures. After, however, a good callus had developed, at 6 to 8 weeks, a thoracobrachial or hanging-type plaster cast could be substituted for traction.

2. Fractures of the middle third. Traction through the olecranon process was also found most satisfactory for this group of cases. Fractures in this area were seldom manipulated and were often reduced by traction alone; 10 pounds of weight for 12 to 24 hours almost invariably produced satisfactory alinement, after which the weight could usually be reduced to 4 to 6 pounds. The Thomas arm splint was used only when a Pierson attachment was needed for traction on the forearm (fig. 42).


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Approximately 20 percent of the patients with fractures of the upper third of the humerus exhibited radial nerve weakness or paralysis in which recovery followed, sometimes as early as 72 hours after reduction of the fracture and institution of traction. Complete interruption of the nerve and loss of bone substance were frequent complications. They were managed by deliberate shortening of the bone when necessary, though not until after the wounds were clean and covered with healthy skin. In these cases, the presence of infection and the loss of muscle, vascular, and nerve tissue directly over the fracture site were a direct threat to the function of the hand, and correction of these defects was obviously more important than strict immobilization and purely mechanical treatment of fractures of the arm or forearm.

3. Fractures of the lower third and at the elbow. In this group of cases, early motion of the elbow joint and hand was the primary consideration, and anatomic reposition of fragments was not sought at the price of immobilization. Traction was instituted either through the olecranon process or at some point in the dorsal cortex of the proximal third of the ulna. Active motion of the hand in the traction apparatus was begun at the earliest possible moment. In no instance did this practice appear to inhibit the formation of callus. The functional end results obtained by these policies in fractures of the elbow were, in fact, curiously better than might have been expected from the deformity and displacement often evident in the roentgenograms. Results were, however, notoriously poor after prolonged immobilization and after open operations intended solely to obtain anatomic position.

Pelvis

Fractures of the pelvis were at least as often caused by the highly accelerated vehicles and heavy machines of modern war as by missiles, though the latter produced shattering compound wounds which were not present in the vehicular type of injury. In battle-incurred fractures, injuries of every organ within the pelvic basin were seen, and treatment of the bone injury often had to be deferred until urinary and bowel function had been reestablished by urethrostomy, cystostomy, and colostomy as indicated. In many instances, the position of the fractures could not be changed, although manipulations of every description were attempted.

Once reduction had been effected, the elements of traction had to be carefully analyzed and applied with due regard both for immobilization of the fracture and for the nursing care required by the patient. Lateral suspension of the pelvis by traction through the femoral condyles, with the hips flexed at 90 degrees, was both useful and comfortable in properly selected cases. Certain extensive comminuted fractures with a tendency to collapse were maintained by lateral traction through both iliac crests and distal traction through the upper tibia or lower femur. The Rouvillois or lumbofemoral suspension frame (p. 236) obtained from liberated medical depots in France was often a more comfortable and more effective apparatus from the nursing standpoint than the conventional hammock.


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Patients with the conventional fractures of the pelvis usually caused by vehicular accidents, without complications to the intrapelvic soft parts, did very well in bilateral plaster-of-paris hip spicas carried to the knee.

Spine

Fractures of the spine and injuries of the spinal cord are discussed in detail elsewhere in this series of volumes, and only one or two points concerning these injuries need be mentioned here.

Transportation of the patient was the major problem in fractures of the cervical spine. No movement was attempted until conditions were favorable. All manipulations were avoided, and the head was not raised under any circumstances. Good results were usually obtained by moving the patient on an ordinary litter, supported with massive gauze rolls or folded blankets to minimize lateral movement. When possible, a jacket of the Minerva type was used.

In injuries of the thoracic spine, a plaster body jacket was also used to good advantage. The patient was usually transported prone on the litter if laminectomy was likely to be necessary.

It was standard practice to evacuate immediately all patients with neurologic involvement, so that a neurosurgeon might decide whether or not laminectomy was necessary.

Femur

General considerations of management-The fractures of the femur received in the United Kingdom from forward hospitals immediately after D-day were not always well managed. The wounds were often firmly packed with gauze and were sometimes in such condition that delayed primary closure could not be performed within the optimum period. Later, as experience increased, the state of the wounds was improved, and gauze was placed in them lightly, as was desirable.

Delayed primary wound closure sometimes had to be deferred while the patients were prepared for it. Fractures of the femur were often associated with heavy blood loss, and massive transfusions were necessary before operation could be safely performed. An interesting incidental observation was made in this connection at the 802d Hospital Center. In a number of cases in which extensive wounds of the thigh required incision and debridement before suspension in skeletal traction could be carried out, two teams worked in friendly competition with each other to minimize blood loss by accomplishing complete hemostasis by the use of fine ligatures and endothermy. The amount of blood lost at operation was estimated by studies of the supernatant fluid after all dressings, drapes, and gowns had been soaked in a dilute solution of saponin. The smallest amount lost at any operation was 600 cc. The amount of blood lost on the field and during transportation was assumed to be at least equal to this quantity, and probably greater.

Patients with fractures of the femur were transported to the Zone of


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Interior in plaster-of-paris spicas. The fact that some fractures, especially those in the upper portion of the femur, became displaced in the plaster during transportation, after they had been regarded as frozen, made it clear that in some injuries, at least, the designated holding period of 6 to 9 weeks was too short.

Fracture management-Two definite lessons were learned from the more than 1,000 fractures of the femur treated at the 802d Hospital Center: (1) In no other site in the body is the action of muscles more important in producing deformity; and (2) in no other group of fractures is correct application of traction more important for the achievement of satisfactory alinement of the fracture.

The general plan of management was to use the femoral condyles or the tibial tubercle for the site of the Kirschner wire, depending upon the nature of the fracture and the position of the associated wounds (fig. 43). When the wire was inserted through the lower end of the femur it had to be above the attachments of the collateral ligaments and posterior to the medial and lateral aspects of the suprapatellar pouch. If the wire was inserted with the leg fully extended and the knee was later flexed in the splint, the skin and deep soft

FIGURE 43.-Roentgenogram showing method of locating approved sites of election for insertion of Kirschner wires in lower femur and tibial tubercle. The topographic anatomy is shown by means of barium sulfate paste applied to the skin. Iron washers show areas for insertion of wires. This graphic method was useful, as an adjunct to the method of palpation, in teaching skeletal landmarks and orthopedic techniques to physicians without previous orthopedic experience.


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parts would become folded up or stretched around it, and ischemia and infection were apt to follow. When the wire was correctly applied, damage to the knee joint did not occur as a result of traction through the tibia, even though a weight of 30 pounds was sometimes used for brief periods.

Fractures of the femur were managed according to the location of the fracture:

1. The neck and intertrochanteric region. In this group of fractures, a coxa vara deformity was invariably present by the time the patient had been brought in from the battlefield. Reduction was effected by manual traction and maintained by continuous skeletal traction through the lower femur, with suspension in either an inverted Keller-Blake half-ring splint or the French lumbofemoral splint. If the half-ring splint was used in the standard manner, the patients were uncomfortable, dressings of the wound were difficult, and displacement was relatively unimproved.

2. Upper third of the shaft. This group of fractures was one of the few in which displacement followed a standard pattern. The proximal fragment was almost always flexed, abducted, and externally rotated. Reduction by manipulation was usually successful and could be satisfactorily maintained merely by lining up the distal fragment and the leg with the position of the upper fragment.

3. Shaft. Sixty percent of the fractures in this group showed satisfactory position after suspension in skeletal traction and did not require manipulation. In the remaining 40 percent, manipulation was necessary. The minimum acceptable position required 50-percent contact of the fracture ends in 2 planes, without overriding or angulation. Less than 50-percent contact of the fracture faces was generally untenable, and every effort was made to achieve at least 75-percent contact. Displacement occurred insidiously, and roentgenograms made 4 to 6 weeks after the institution of definitive traction sometimes showed unexpected loss of position and the presence of deformity which could lead to malunion or nonunion. Disability was greatly prolonged when massive callus had developed to overcome inadequate apposition or muscle interposition.

The majority of fracture patterns, fortunately, were dentate, spiral, comminuted, or of the so-called blown-straw variety and therefore could be interdigitated well by manipulation. The possibility of muscle interposition was always investigated at the time of delayed closure of the wound, as well as when open reduction was necessary. Only occasionally were the mass and bulk of interposed muscle sufficient to form an obstacle to normal healing. In almost all instances, the muscle was found attached to periosteum or callus at the fracture site and was present in soft, hemorrhagic flaps, which could easily be pushed aside by simple manipulation.

4. Supracondylar fractures. Shattering injuries of the lower third of the femur were the commonest of all battle-incurred fractures of this bone, though the condylar variety of fracture caused by indirect violence is seldom seen in civilian practice. The distal fragment varied from a single condyle to the entire lower third of the femur. The main deformity factor was the pull of the gastroc-


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nemius muscle. Lateral or forward displacement of the distal fragment was infrequent and was easily corrected.

The insertion of Kirschner wires in both the supracondylar region of the femur and the upper third of the tibia, followed by manipulation by manual traction on the tautening bow at right angles, was usually successful. The use of a posterior sling in place of skeletal traction from the distal fragment was found undesirable. It retarded wound healing and interfered with the circulation when it was applied to a swollen, edematous thigh. In a few cases treated at the 802d Hospital Center, simple suspension through the distal fragments, with the hip and knee each flexed at 90 degrees, produced satisfactory results. This position was also often used, of necessity, for the care of extensive soft-tissue wounds of the posterior aspect of the thigh.

The management of the so-called T-fracture of the lower femur which extended into the knee joint was a problem created by the differential pull of the two heads of the gastrocnemius muscle. After aspiration to relieve the severe pain in the knee joint, which was usually greatly distended with blood and bone-marrow fat, it was possible, without much difficulty, to palpate the condyles and manipulate them into a satisfactory position. Compression could be exerted manually, and a padded carpenter's clamp or other mechanical device was seldom necessary.

Fractures of the lower end of the femur, with large open wounds of the knee joint, were always a serious problem. They were managed by a bold policy of arthrotomy and open manipulation, followed by closure of the wound. Infection was surprisingly infrequent. Large doses of penicillin were administered systemically and implanted locally, though, in the light of postwar knowledge, local implantation of the antibiotic seems of doubtful efficacy.

If the compounding wound was so extensive that no site was feasible for the insertion of pins or wires, open reduction was sometimes preferable to a trial of traction. Fractures of the neck, if there were no contraindications, were sometimes treated by the Smith-Petersen nail.

Results in prisoners of war-An analysis of 63 compound fractures of the femur observed at the 19th General Hospital illustrates possible results of delayed primary closure in cases which were none too favorable, since all the patients, including 5 United States soldiers who had been held by the Germans, were prisoners of war.2 Fractures of the femoral condyles associated with wounds of the knee joint are not included. Seventeen of the wounds were infected when the patients were received, the cause of the infection, in every instance, being inadequate or late debridement. In all of these cases, extensive secondary debridement or wound excision was necessary.

Primary healing occurred in 21 of the 39 wounds in which delayed primary suture could be carried out shortly after these soldiers were received in a general hospital. Eight patients were evacuated too soon to permit evaluation of results. Healing was delayed in 10 cases, but wound necrosis and suppuration occurred in only 1 instance.

2Semiannual Report, 19th General Hospital, European Theater of Operations, 1 January-30 June 1945.


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Tibia and Fibula

Fractures of the fibula furnished few problems. Simple fractures of the tibia and fibula were satisfactorily treated by traction. Reduction was obtained by the insertion of a wire through the os calcis or in the supramalleolar region of the tibia. A long leg cast was applied snugly about the fracture site and loosely about the knee and thigh. The wire was included in the cast.

Oblique fractures of the shaft of the tibia and fibula were more difficult to handle. They tended to be unstable and required continuous traction or open reduction with screw fixation to maintain the correct position.

In battle-incurred compound fractures of the tibia and fibula, delayed primary wound closure was less satisfactory than it was in other fractures. Important causes were the lack of soft tissue in this area and the greater tension in the tissues. These difficulties were increased if the wound had caused tissue and skin defects. Closure frequently had to be accomplished by means of relaxing incisions and split skin grafts. The relaxing incisions themselves sometimes required skin grafting.

In cases which could be managed by traction, wires were inserted in the os calcis for shattering wounds of the lower leg and in the lower tibia for wounds in the upper leg. Suspension of the limb in a Thomas splint with Pierson attachment had many disadvantages. One was that the considerable structure of pulleys and ropes necessary in this technique required daily readjustment, and at the best the patient was likely to be uncomfortable.

The Böhler-Braun method was used in many cases but had one important defect which outweighed all its advantages: When the lower leg was in traction on the cradle, although the distal fragment was relatively immobile, the proximal fragment moved with the patient.

The plaster traction splint (fig. 44) employed at the 22d General Hospital, 802d Hospital Center (p. 45) seemed to combine the best aspects of both of these methods of traction. As already pointed out, this technique was used in 65 compound fractures of both bones of the leg, including fractures at the ankle, treated at the 22d General Hospital. It proved highly efficient. Skin grafting was facilitated in the cases in which it was necessary, and it was even possible for some patients to get about in wheelchairs while they were still in continuous traction (p. 50).

Some badly comminuted fractures of the tibia and fibula were reduced by internal fixation. Maintenance of length was more satisfactory than with other techniques, though this method was not suitable when the compounding wound was extremely severe. In properly selected cases, it secured anatomic reduction, excellent fixation, and a high incidence of satisfactory union, with a minimal number of complications.

Ankle

Sprains and complete tears of the external lateral ligament of the ankle required plaster immobilization for 8 weeks. Any other method of management left a weak ankle, with recurrent luxation of the astragalus on slight


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FIGURE 44.-Compound comminuted fractures of the leg with large avulsed wounds of the leg by 88-mm. shell fragments in France, after immobilization in the plaster traction splint.

inversion strain. The diagnosis of a complete tear was made by anteroposterior films, with the heel held in strong inversion while the patient was under Pentothal anesthesia. Comparison with the normal side was necessary. Significant displacement of the astragalus out of the mortise was considered diagnostic of a complete tear of the external lateral ligament.

Management of fractures of the posterior malleolus of the tibia before D-day depended upon the extent of the injury. If less than a fourth of the articular surface was involved, the residual upward displacement caused little concern. If sufficient smooth joint surface remained intact, the small fragment was displaced out of the way, and there was no tendency for the astragalus to displace posteriorly. If, however, the fragment comprised as much as a third of the articular surface, anatomic reduction was necessary. If closed methods failed, open reduction was relatively easy. A posterior approach was employed, with screw, brad, or nail fixation.

In fractures of the external malleolus, if the fracture line took the usual direction (oblique from behind, downward and forward), immobilization was not always necessary. Treatment consisted of elevation until the swelling had subsided, after which the ankle was strapped in neutral position and the patient was permitted to be ambulatory in a shoe.


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In fractures of the neck of the astragalus with displacement, reduction by manipulation was usually successful. If, however, optimum position was not obtained, open reduction could be done, to assure optimum realinement. The fracture line was often intra-articular, at least in part, and this technique offered the best chance for revascularization of the body. If open reduction was necessary, there was frequently a strong indication for subastragalar arthrodesis at the same time, to increase the chances of early revascularization of the body.

Although fracture dislocations were not always regarded as emergencies, they should have been. Unless immediate reduction of the dislocated body is carried out in this type of injury, necrosis of the overlying skin may result, with conversion of the injury to a compound fracture and with consequent chances of serious infection. The displaced body may produce such severe pressure on the posterior tibial vessels that gangrene may result, while the vascular deficiency caused by direct pressure and swelling may also cause Volkmann's ischemia. Furthermore, the longer the dislocation continues, the more difficult reduction becomes. Although these facts should be of common knowledge, they were not always understood, nor was the emergency nature of this kind of injury appreciated. As a result, patients were sometimes not seen until 4 or 5 days after such an injury, with the fracture dislocation still unreduced.

In a properly treated case of this kind, manipulative reduction was performed immediately, sometimes aided by the application of traction to the os calcis by a Kirschner wire. If closed reduction was unsuccessful, open reduction was resorted to promptly. Astragalectomy was a last resort, as it did not produce satisfactory function. The best method of management, therefore, was to reduce the fracture dislocation and hope that avascular necrosis of the body would be minimal. If the results were poor, later arthrodesis could be done.

Diastasis of the inferior tibiofibular joint, which was often overlooked, always left a painful ankle if it was not treated. This possibility should have been investigated in all injuries about the ankle. If it was diagnosed, it was usually easily reduced by manipulation, after which a plaster cast was applied for 10 weeks. It was important that the cast be snug; displacement recurred promptly if it was not.

After the invasion of the Continent, many of these techniques ceased to be practical in an active theater of operations, and patients with serious injuries about the ankle, after initial treatment, were promptly evacuated to the Zone of Interior, since they could not be returned to duty within the holding period permitted within the theater. Even before the invasion, it would probably have been wiser to return many such patients to the United States rather than hold them in the theater.

Foot

Fractures of the os calcis with no significant displacement were treated by elevation and immobilization until the acute reaction had subsided. Then


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physical therapy was begun, and the foot and ankle were actively exercised once an hour. Weight bearing was not permitted for 8 to 12 weeks except in an occasional case in which, for the last 4 to 6 weeks, the patient was treated in a walking cast.

Fractures with significant displacement but without comminution which caused reduction in the salient angle were also treated by elevation and immobilization until the acute reaction had subsided. Then manipulative reduction was carried out under portable roentgenologic control. A Steinmann pin was inserted through the lower third of the tibia and the posterosuperior portion of the os calcis, with a compression clamp to reduce the medial and lateral displacement of the calcaneal fragment. Both pins were incorporated in a short leg plaster cast.

Fractures with significant displacement and severe comminution, in which a subastragalar joint did not seem a possibility, were treated by elevation and immobilization until the acute reaction had subsided. Then manipulative reduction of the gross displacement was carried out, with early triple arthrodesis.

The results of fractures of the tarsal bones were usually disappointing. In addition, the patient with a compression fracture of the os calcis always had a great deal of pain. Some surgeons believed that the Pridie operation, in which the entire os calcis is removed, might be a more generally useful procedure in such cases than subastragaloid arthrodesis.

These practices were all employed before D-day, but even then prompt evacuation to the Zone of Interior would probably often have been wiser than the performance overseas of such definitive surgery as has been described.

Skeletal traction was advisable for a small number of battle-incurred compound fractures of the midtarsal and metatarsal regions. This technique was used only 15 times at the 802d Hospital Center. Traction was applied by means of a vertical wire inserted through the middle of the distal phalanx of the toes. The ends of the wires were turned back to form hooks for elastic bands, which were attached to a metal hoop incorporated in the plaster cast. The combination of plaster cast and traction to hold the fractures in position was effective, but only after the fractures had been reduced by correct manipulation and a molded splint had been applied.

Several errors were common in management of injuries of the foot. Casts were originally left on for too long a time. It was eventually found that fractures of the tarsal bones without displacement required no immobilization in plaster, except for a short time in some cases for relief of pain. It was an error to immobilize the foot and ankle in a position of equinovarus.

In battle-incurred compound fractures of the foot, some observers came to believe that better results would have been secured if amputations had been done more promptly in selected cases. This was particularly true when the entire os calcis was destroyed. A great deal of time was spent in debridement and other care, and in the end the patient was no better off functionally than he would have been if amputation had been performed at once.

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