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Chapter XII

Contents

CHAPTER XII

Amputations

In all wars, amputation of a limb has been an operation of necessity, not a procedure of choice or election. The total destruction of tissue, including bony tissue, was the chief indication for the majority of amputations performed in the European Theater of Operations in World War II. When the limb was irretrievably shattered and mangled or was almost completely avulsed, the attending surgeon had no choice but to amputate it. In effect, a nearly complete traumatic amputation had already been performed, and it was his clear duty to complete it.

Vascular damage, the second most frequent reason for amputation, was in many instances inherent in the destruction of tissue. This was, however, not always true. It also very often occurred in association with compound comminuted fractures, in cases in which tissue damage was not in itself irretrievable and in which, in the absence of vascular damage, the bone injury could have been managed successfully by one technique or another.

In such cases, the decision to amputate was frequently difficult and painful. Demonstrable, complete loss of blood supply to a portion of the limb, because of destruction of the main artery or arteries, was practically always an indication for amputation. Recoveries were occasionally recorded after anastomosis of a major artery, and from the theoretical standpoint, therefore, there was no justification for amputation of a limb in which vascular damage had occurred without an attempt, at least, at anastomosis and a period of postoperative observation. On the other hand, with vascular surgery at the stage at which it was in World War II1 there was only a remote chance of saving such a limb. The operation was time consuming. For this reason, it could lead to the neglect, or at least the delayed treatment, of other seriously wounded men. Finally, the procedure was not justified on the basis of the results obtained. The reports from orthopedic surgeons in the European theater, from whose observations these data are derived, again and again state that the writers had never seen a recovery after anastomosis of the popliteal artery.

The senior consultant in orthopedic surgery knew definitely of only 3 instances in which survival of the leg below the knee occurred after ligation of the popliteal artery. In each of these instances, the indication for ligation was secondary hemorrhage 2 or 3 weeks after wounding, by which time an

1It should be emphasized that these observations concern only World War II. Although there will probably never be more than a limited number of combat-incurred injuries with damage to the blood supply of the limbs in which vascular surgery would be justified, in selected cases this procedure now (1955) would be both practical and warranted. A fairly large number of successes followed conservative management of vascular injuries in the Korean War, and further advances have been made in this field in the interval since those hostilities ceased. (Author's note.)


156

anastomosis of sufficient size to carry the blood to the leg beyond the knee must have been established. At the 68th General Hospital, the chief of the orthopedic section stated that amputation was done in only 1 of 3 cases in which the popliteal artery had been severed but that the other 2 patients would have been better off if they also had been submitted to primary amputation. The surgeons who performed the two conservative operations were misled by the condition of the superficial tissues. Eventually, the muscles of the leg, with the exception of the gastrocnemius muscle, went on to necrosis and had to be dissected out.

In the light of these results, which were typical of results in general, experienced medical officers almost universally took the position that immediate supracondylar or transcondylar amputation of the limb was indicated whenever the popliteal artery had been divided. The chances of recovery, even when surgery was supplemented by sympathetic block and such other adjunct measures as were practical in a frontline hospital, were seldom good enough to warrant the risk to life inherent in a policy of conservatism. If the anastomosis failed, as it usually did, gangrene invariably and inevitably ensued, and a secondary amputation under these circumstances was fraught with far more risk to life than primary amputation would have introduced.

The third important indication for amputation was clostridial myositis. Fortunately, it was not very frequent. The important point was to make the distinction between diffuse, spreading Clostridium welchii infection, in which amputation was mandatory and in which any significant delay put the patient's life in jeopardy, and localized gas bacillus infection, in which conservative therapy was warranted. The experience reported from the 804th Hospital Center is typical. Clinical Clostridium welchii infection was observed in 10 cases. In 5 of the 10, true clostridial myositis was present and amputation was necessary; 1 patient died. In the other 5 cases, the infection was localized and responded to wide incision and drainage, supplemented by penicillin and sulfadiazine. In the localized type of gas bacillus infection there was, of course, no indication whatsoever for amputation.

Similarly, the question of amputation never arose in the type of case in which Cl. welchii organisms were cultured from the wound but in which they gave rise to no clinical manifestations and were obviously nonpathogenic. Any battle wound, if examined with refined bacteriologic techniques, will probably reveal clostridial organisms, which will, however, grow and multiply only if dead muscle tissue is left as a culture medium.

Conservatism was the rule in all cases in which amputation was a possible procedure. As a rule, it was entirely justified, though, as pointed out elsewhere (p. 154), many observers thought that prompt amputation of badly shattered feet would have been wiser than the policy of conservatism employed throughout the war.

A greater degree of conservatism was both indicated and practical in the upper extremity than in the lower. The reason for this policy was the greater functional importance of the upper extremity. Military surgeons, properly,


157

went to almost any length to save even a small portion of a functioning hand. The reason why this policy was practical was that Cl. welchii infection in both military and civilian surgery is much less frequent in the upper than in the lower extremity.

Incidence and Case Fatality Rates

The incidence of amputation in the European Theater of Operations was not high in relation to either the total number of casualties or the devastating character of many wounds of the extremities. The great advances in surgery between World War I and World War II permitted the salvage of many limbs in the Second World War which would necessarily have been sacrificed in the First. Indeed, it is an ironic fact that during the period of World War II, the number of amputations which were performed for medical reasons or which were of traumatic origin in civilian life exceeded by several times the number of amputations performed for combat-incurred injuries. There was an estimated total of 17,000 major amputees as the aftermath of World War II. The number of civilians who lost one or more of their limbs during the same period has been estimated at about 80,000.

The case fatality rate for amputation was also not excessive. The 2d Evacuation Hospital, for instance, which was a 750-bed hospital, served from Normandy to Naumburg, Germany, between 23 June 1944 and 18 April 1945. During this time, it received 37,377 patients, 10,398 of whom had surgical conditions. Orthopedic admissions included 2,243 fractures of the long bones with 30 deaths (1.3 percent) and 388 amputations with 25 deaths (6.4 percent). Forty-five amputations, sixteen of which were fatal, were performed for clostridial myositis, and 327, of which 9 were fatal, were performed for trauma. There were no deaths in the 16 amputations performed on the indication of circulatory damage.

Col. Charles B. Odom, MC, analyzed the amputations performed in the 64,389 battle casualties treated in Third United States Army hospitals from 1 August 1944 to 1 February 19452 (tables 4, 5, and 6). In this total, there were 39,600 injuries of the extremities, and 3,245 wounds of the buttocks, totaling 42,845. This total represented a proportion of 66.5 percent battle casualties, reasonably near the 71 percent which it had been estimated would occur in these areas. The case fatality rate of all battle casualties was 2.9 percent and for wounds of the extremities (including the buttocks) 0.81 percent.

During the 6-month period covered by this survey, 1,365 amputations were performed on 1,290 patients in 12 evacuation and 5 field hospitals. More than 75 percent of these amputations were of the lower extremities, the disproportionate distribution being tacit testimony to the destructive efficiency of the land mines employed in World War II. Traumatic destruction of tissue was the indication for about two-thirds of the amputations, vascular damage for about a fifth, and clostridial myositis for the remainder. The case fatality rate was 9.0 percent.

2Semiannual Report, Office of the Surgeon, Third U. S. Army, 1 January-30 June 1945.


158

TABLE 4.-Indications for 1,365 amputations in 1,290 casualties, Third United States Army, 1 August 1944-1 February 19451

Hospital


Indications

Total

Deaths


Traumatic

Gas gangrene

Vascular injury

Unknown

Evacuation:

 

 

 

 

 

 

    

12th

45

16

14

---

75

4

    

32d

45

4

6

---

55

3

    

34th

53

12

44

---

109

9

    

35th

97

5

38

---

140

13

    

39th

91

20

20

---

131

11

    

101st

54

16

21

---

91

6

    

104th

77

25

14

---

116

8

    

106th

33

21

19

8

81

6

    

107th

72

15

32

10

129

16

    

109th

41

17

7

---

65

8

    

110th

38

6

18

---

62

4

Field:

 

 

 

 

 

 

    

16th

20

6

9

---

35

9

    

30th

27

---

2

2

31

8

    

59th

14

---

1

---

15

4

    

60th

45

2

---

---

47

4

    

65th

11

5

8

---

24

---


Total

763

170

253

20

1,206

113

1The 159 amputations performed at the 103d Evacuation Hospital are omitted from the tabulated data because the breakdown is incomplete. It is known that 21 amputations were performed for vascular injury, but data are incomplete on how many of the remaining 138 operations were performed for the original trauma and how many for subsequent gas gangrene. There were 3 deaths in the 159 cases.

The 1,290 casualties upon whom these 1,365 amputations were performed included 1,012 United States Army personnel, 28 Allied soldiers, 206 German prisoners of war, and 44 civilians.

Evolution of Techniques

From the historical standpoint, the best way to describe the change in the point of view about techniques for amputation is to summarize the instructions given in the Manual of Therapy3 issued just before D-day and the instructions in the revision of the orthopedic section of this manual which were prepared in June 1945 but were not published because of the ending, shortly afterward, of the fighting in the Pacific. A comparison of the two sets of instructions furnishes an illuminating reflection of how combat experience alters the point of view.

Manual of Therapy, 1944-Amputations, it was pointed out in the manual issued before D-day, should not be done unless the limb was almost

3Manual of Therapy, European Theater of Operations, 5 May 1944.


159

TABLE 5.-Site of injury in 274 amputations for vascular damage, Third United States Army, 1 August 1944-1 February 1945

Hospital

Blood vessel

Total

Axillary

Brachial

Iliac

Femoral

Popliteal

Anterior tibial

Posterior tibial

Both tibials

Evacuation:

 

 

 

 

 

 

 

 

 

    

12th

---

---

---

7

2

5

---

---

14

    

32d

---

---

---

2

4

---

---

---

6

    

34th

1

8

1

15

13

---

---

6

44

    

35th

3

3

---

16

12

---

---

4

38

    

39th

1

9

---

1

7

1

1

---

20

    

101st

1

6

---

2

12

---

---

---

21

    

103d

---

2

---

3

10

2

2

2

21

    

104th

1

2

---

6

5

---

---

---

14

    

106th

---

5

---

8

5

---

---

1

19

    

107th

---

2

---

14

9

4

3

---

32

    

109th

---

2

1

4

---

---

---

---

7

    

110th

1

---

---

10

7

---

---

---

18

Field:

 

 

 

 

 

 

 

 

 

    

16th

---

2

---

6

1

---

---

---

9

    

30th

---

1

---

---

1

---

---

---

2

    

59th

---

---

---

---

1

---

---

---

1

    

60th

---

---

---

---

---

---

---

---

---

    

65th

---

1

---

2

3

1

1

---

8


Total

8

43

2

96

92

13

7

13

274


completely detached. Instructions for the immediate management of the battlefield casualty who was a possible candidate for amputation were to treat a complete or incomplete traumatic amputation as any other open wound; to control active arterial bleeding; and to be certain that a tourniquet, ready for instant application, accompany the patient during his evacuation.

Further instructions in the 1944 manual were as follows:

1. Indications for amputation were (1) complete destruction of the blood supply, which meant loss of the main blood supply and most of the collateral blood supply; and (2) fulminating gas bacillus infection.

2. Indications for amputation of the upper extremity should be more rigid than indications for amputation of the lower extremity because gangrene of circulatory origin is more infrequent in the upper extremity, and because conservation of a small remnant of the hand is of far greater functional importance than conservation of a small remnant of the foot.

3. Regardless of any consideration of prostheses in the future, the limb should be amputated as low as the nature and location of the wound would permit.

4. Two types of amputation were permissible in the 1944 manual, (1) the guillotine amputation, in which the skin, soft tissue, and bone are all divided


160

TABLE 6.-Site of 1,365 amputations in 1,290 casualties, Third United States Army, 1 August 1944-1 February 1945

Hospital


Site

Total

Deaths


Upper arm

Forearm

Hand

Thigh

Leg

Foot

Evacuation:

 

 

 

 

 

 

 

 

    

12th

6

1

---

36

31

1

75

4

    

32d

2

10

2

4

23

14

55

3

    

34th

9

14

1

28

57

---

109

9

    

35th

8

4

4

42

76

6

140

13

    

39th

27

21

3

34

33

13

131

11

    

101st

13

9

2

10

50

7

91

6

    

103d

24

20

7

24

52

32

159

3

    

104th

26

10

---

35

44

1

116

8

    

106th

9

2

2

25

35

8

81

6

    

107th

6

21

4

32

48

18

129

16

    

109th

11

13

4

16

17

4

65

8

    

110th

1

4

---

18

39

---

62

4

Field:

 

 

 

 

 

 

 

 

    

16th

6

2

2

12

12

1

35

9

    

30th

---

3

---

8

18

2

31

8

    

59th

---

---

---

---

15

---

15

4

    

60th

5

5

4

6

24

3

47

4

    

65th

2

2

---

8

7

5

24

---


Total

155

141

35

338

581

115

1,365

116


at exactly the same level, and (2) the circular or irregular short flap amputation, in which the skin and soft tissues are left slightly longer than the bone.

5. The guillotine amputation was to be used in cases in which the amputation level was well within the site of election. This technique was always employed with the idea that reamputation would later be necessary. The circular or irregular flap type of amputation was to be used when the point of bone division was at, or close to, the point of election. As much skin as possible was thereby saved to pull over the end of the stump, and later reamputation would not be necessary. The stump was never to be sutured.

6. If the bone had to be divided at the site of election, and if skin beyond this point could not be saved, a guillotine amputation was then indicated. The main artery and nerve were divided at the same level as the bone. The artery should be secured with a ligature, with a transfixion stitch ligature distal to it. The nerve stump was not to be treated by ligation, crushing, alcohol injection, or any other means. It was simply left unsutured.

7. Careful hemostasis of small vessels in the stump was essential, lest later elevation of the blood pressure of a patient previously in shock should cause bleeding in vessels which had not been identified at operation.


161

8. After both types of amputation, the stump should be frosted with sulfanilamide. A small dressing of vaseline gauze should be applied over the open stump, and additional dressings were to be applied after the stump had been placed in the splint.

9. Skin traction should be accomplished with adhesive tape and a Thomas splint, or a plaster spica could be applied for splinting and the incorporation of distal traction.

10. Skin traction should be maintained indefinitely or until healing took place. The 1944 manual permitted certain exceptions to this rule, though the exceptions were limited to irregular flap amputations with clean, granulating wounds, without discharge or edema, or without a systemic febrile reaction. In such cases, later secondary closure was permitted, with a few loose retention sutures.

11. The 1944 manual recommended that, whenever possible, a written statement should be incorporated in the patient's record, prepared by a second medical officer and signifying agreement with the necessity for amputation of the limb.

The instructions for amputation in the 1944 Manual of Therapy were confusing and were definitely written without the benefit of the extensive experience in combat-incurred wounds which was soon to occur. The chief points of difference between these instructions and those in the 1945 revision of the orthopedic section of the manual will be discussed in detail shortly.

Revision of orthopedic section of proposed Manual of Therapy, 1945-The summarized instructions contained in the proposed revision of the Manual of Therapy in June 19454 were as follows:

1. Amputation was justified for only two reasons, (1) complete destruction of the blood supply, which meant the loss of the main artery and most of the collateral arteries, and (2) diffuse clostridial myositis.

2. Amputation should always be performed at the lowest possible level which the nature and location of the wound would permit.

3. Experience showed that the open circular amputation is the procedure of choice in the management of war wounds. The guillotine amputation had proved unsatisfactory and was not to be used. In the guillotine technique the skin, muscle, bone, and all tissues are divided at exactly the same level. In a circular amputation, each tissue layer beneath the skin is allowed to retract before it is severed, so that, after the operation has been completed and traction has been applied to the skin, the stump has the appearance of a shallow, inverted cone or saucer. The precise technique was described step by step (p. 162).

4. Decision to amputate was not to be made without consultation with the chief of the surgical service or, in his absence, with whatever senior surgeon might be available. The details of the consultation were to be noted in the patient's medical record.

4Appendix B.


162

5. Psychotherapy, it was pointed out, was of the utmost importance in the rehabilitation of the amputee, and the surgeon, by a few words of his own, could help in the program. It was important that the operating surgeon, himself, should inform every amputee of certain facts before he was evacuated:

a. That the amputation had been necessary as a life-saving procedure.

b. That it had been decided upon only after consultation.

c. That further surgery for revision of the stump would probably be necessary.

d. That the patient would be sent to an amputation center where he would be fitted with an artificial limb and where other facilities would be available for his rehabilitation.

6. A disarticulation was to be performed only when there was no other possible choice of a more conservative procedure. This is not a desirable operation. The stumps are difficult to handle, and they discharge profusely. Traction is extremely difficult to maintain. The stumps always need extensive revisions, most of which must be performed in two stages. In view of these considerations, disarticulation of the knee was permitted as an emergency measure but was not to be performed routinely.

Technique of circular amputation, 1945-The successive steps of a circular amputation were set forth as follows in the 1945 revision of the orthopedic section of the 1944 manual:

1. The skin of the extremity is prepared as for a surgical procedure.

2. A tourniquet is applied.

3. The incision is made in a circular fashion, down to the deep fascia, at the lowest possible level. An oblique incision is permitted in cases in which it would result in conservation of the skin and of the length of the extremity.

4. The skin is allowed to retract. The deep fascia is then divided at the level to which the skin has retracted.

5. The muscle is divided in circular sweeps, about three-fourths of an inch being included in each sweep, so that, as the muscle retracts, the next muscle division is made at a slightly higher level.

6. The periosteum is cut in a circular manner at the level to which the last muscle layer has retracted.

7. The bone is sawed through cleanly at this level. The periosteum is not elevated or stripped, and no attempt is made to remove it at a higher level than the saw cut.

8. Nerves are severed cleanly at the level of the surrounding muscle division. They are not crushed or ligated, and the ends are not injected with alcohol.

9. Precise hemostasis of the stump is essential. All large veins and arteries are doubly ligated, separately and not en masse. Extreme care is taken not to include large amounts of muscle in the ligation of small vessels. After all the larger vessels have been ligated, the tourniquet is removed, the field is inspected, and any remaining bleeders are ligated.

10. The end of the stump is covered with dry, fine-mesh gauze. Sulfonamides are not used to dust it or frost it.


163

11. Skin traction is applied immediately and is maintained continuously while the patient is being evacuated and until healing occurs. There is but one exception to this rule: When the amputation has been performed for clostridial myositis, skin traction is not applied for the first 24 to 48 hours. At the end of this time it is possible to determine whether the wound is clean or infected. No patient, however, should be evacuated from any Army installation until skin traction has been applied.

Skin traction for transportation has been found to be most satisfactory when it is applied in the following manner:

a. After the stump has been covered with sterile, fine-mesh gauze, a circular roll of stockinet is applied to the stump and is rolled as far as possible proximally.

b. The skin is painted with tincture of benzoin.

c. After the skin has dried, an adherent is applied to it down to the cut edge of the stump. The stockinet is then unrolled down on the stump and is allowed to adhere to the skin. Traction is applied to the stockinet and additional dressings are placed inside it, against the end of the stump.

d. Traction is continued by an assistant while several layers of sheet wadding are applied loosely over the stockinet. A circular plaster pylon is then applied to the stump, with an outrigger made of a wire ladder splint. The end of the stockinet is fastened to the outrigger by means of a short piece of elastic traction cord or, if the cord is not available, by means of plasma tubing.

The following types of plaster pylons are indicated for special injuries:

Below the knee, a below-the-knee-to-the-groin pylon, with the knee in full extension.

Thigh, a single hip spica pylon, with the hip in neutral position.

Forearm, a full-arm pylon, with the elbow flexed at 90 degrees.

Arm or humerus, a shoulder spica pylon, with as little abduction as possible and the axilla well padded to avoid pressure.

Comparison of the 1944 and revised instructions for amputation-The revised draft of the orthopedic section of the Manual of Therapy for the most part simply took cognizance of changes in technique that had been in effect since shortly after D-day. Most of them were incorporated in Circular Letter No. 101, issued 30 July 1944 from the Office of the Chief Surgeon, ETO.5 Other instructions were contained in Circular Letter No. 131, issued 8 November l944.6 In that letter, secondary closure of the stump was forbidden in the European theater, on the ground that it often led to infection and necrosis of the skin. When the skin sleeve was inadequate for closure by traction or when the bone ends were obviously too long and protruded, the stump was to be revised at the lowest possible level. The skin edges were to be mobilized by undercutting and the bone and soft tissues were reamputated just enough to allow closure by traction, which was promptly reapplied and maintained continuously. Split-thickness skin grafts were prohibited in the absence of

5Circular Letter No. 101, Office of the Chief Surgeon, European Theater of Operations, 30 July 1944 (appendix A. p. 322).
6Circular Letter No. 131, Office of the Chief Surgeon, European Theater of Operations, 8 November 1944 (appendix A. p. 325).


164

unusual and sound indications, for the reason that they do not tolerate prostheses.

The differences between the 1944 and later instructions for amputation concerned both substance and emphasis. As has already been pointed out, the original instructions were written without practical experience in combat-incurred wounds and the later instructions after an extensive experience.

The differences in point of view and specific details may be summarized as follows:

1. In the 1944 Manual of Therapy, both the guillotine and the circular techniques of amputation were permitted. In the 1945 draft of the proposed revision, circular amputation was mandatory, a fact which reflects the early, brief, and unsatisfactory experience with the guillotine technique. This ill-named operation is almost impossible to perform without the help of an actual guillotine. When the skin is divided in a circular amputation, it always retracts, and so does each layer of muscle. The surgeon who attempts a so-called guillotine operation usually ends by performing a true circular amputation, which is an inverted cone, with skin left long enough to pull down over the stump to close it. It was not very long before circular amputations were routine in the European theater, and both the name and the technique of the guillotine amputation were abandoned.

The circular amputation, which was performed at the farthest possible distal point of the wounded extremity, was a preliminary step. Usually a reamputation at an elective site was expected to be performed in an amputation center in the Zone of Interior. The amputee was always informed of this plan.

While the circular technique, with nonsuture of the stump, was the safest procedure for combat-incurred wounds, there was some basis for the claim that immediate flap amputation at an elective site would be equally successful if all damaged muscle and retained foreign bodies were removed. The healing power of young soldiers in superb physical condition, as these men were, was remarkable. On the other hand, the majority of the surgeons who were performing these amputations were inexperienced and, at the time, closure of amputation stumps seemed an invitation to surgical disaster. The advantages of immediate elective amputation, which would have prevented duplication of surgery, therefore had to be foregone. There is no doubt that the technique which was made mandatory was by far the safest under the circumstances.

2. In the draft of the proposed 1945 revision of the orthopedic section of the manual, specific techniques were described in detail. In the 1944 manual, instructions were very general. The greater specificity of the revision is, again, a reflection of the necessity for leaving nothing to the imagination of inexperienced military surgeons.

3. In the 1945 revision, provision was specifically made for the use of a tourniquet at operation. A tourniquet was not mentioned for this purpose in the 1944 manual.

4. The use of sulfonamides on the stump was provided for in 1944 and specifically prohibited in 1945. As has already been pointed out, their local


165

application perhaps did no harm, but it was discovered, after several months' experience, that it also did no good, and the practice was discontinued.

5. The use of vaseline gauze was provided for in the 1944 manual, but in the 1945 revision it was specifically directed that dry, fine-mesh gauze be used. The use of vaseline gauze proved actually harmful because it prevented free drainage of secretions (p. 84).

6. In the 1944 manual, the provision of traction by adhesive plaster strips and the Thomas splint was described. In the revision, this technique was omitted, and a technique of skin traction combined with plaster was described, again very specifically. In the revision, the only exception to the immediate institution of traction was a 24- to 48-hour delay after amputations for clostridial myositis.

7. Consultation before amputation was permissive in 1944 and mandatory in 1945. It was specifically directed that the situation, including the need for a second amputation at an elective site, be made clear to the amputee. It was also to be made clear to him that the second operation, for revision of the stump, was part of the ordinary routine.

8. Psychotherapy was also provided for in 1945. Very early in the experience of the European theater, it became evident that, when the necessities of his special case were clearly and sympathetically explained to an amputee, it was the exceptional patient who did not bear with remarkable fortitude the psychologic blow inherent in the loss of a limb.

Special Considerations of Traction

Orthopedic surgeons stationed in the United Kingdom Base usually found amputation stumps of patients received from the Continent in good condition, from the standpoint of the wound. Frequently, however, the surgeons complained that traction was inadequate. For this error there were several explanations: Sometimes the circular plaster type of countertraction had been used; this was not a satisfactory technique. Sometimes the elastic cords and rubber tubes used for purposes of traction had not been tightened en route. Sometimes the transportation casts were not satisfactory. A hip spica, with traction incorporated in it, proved the only way to guarantee really effective traction during transportation after amputation of a lower limb.

Until the end of the war, occasional medical officers continued to prefer the Thomas splint, as had originally been advised in the 1944 Manual of Therapy (p. 161), with fixed countertraction against the ischium. The reason for their preference was that when this splint is used there is no tendency for the skin to pull in the opposite direction.

Long leg casts were not always satisfactory. When patients were transported in them, traction had frequently ceased to be functional by the time a general hospital was reached. This was true whether the amputation had been above or below the knee. The cuff always had a tendency to slip down, because there was nothing to which it could be anchored. Traction hooked up to wire ladder splints was also not entirely satisfactory in amputations of


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the upper extremity, whether the amputation had been above or below the elbow.

In fixed general hospitals, traction was easily maintained by the use of a pulley and weight over the foot of the bed. The essential consideration was that it be continuous. The maintenance of continuous traction required repeated inspections, with correction of the position of the equipment if it had slipped at all.

Amputations Caused by Special Types of Missiles

Blast injuries-Among the large number of wounds of the extremities encountered in the hospitals in the United Kingdom Base soon after D-day were numerous blast injuries caused by mines at sea. These injuries were frequently presented in the form of destruction of the os calcis, fractures of the upper tibia, and fractures at the knee joint, often with dislocation. Profound damage to the popliteal vessels was usually part of the picture, and amputation was often the only possible procedure.

It soon became apparent that in this type of injury it was not safe to undertake operation without a particularly careful evaluation of the patient's status and without unusually careful preoperative preparation. When the casualties were first seen, they were, for the most part, obviously poor risks. Sometimes, however, they would seem to recover from the initial shock of wounding and to be in good condition. They looked well, the pulse was of good quality, and the blood pressure was well above the dangerous level, or, occasionally, abnormally high. Appearances were deceptive. If the timing of operation was not correct, these patients were likely to go into profound secondary shock, which was difficult, and sometimes impossible, to overcome. It was ultimately found that the best plan in all of these cases was to delay operation several hours longer than on the surface seemed absolutely necessary, to be certain that the appearance of well-being was genuine and not specious and misleading.

Land mines-Patients with wounds of the lower extremities received in land-mine explosions often presented, in addition to multiple comminuted compound fractures, damage to the popliteal circulation, which was frequently total. Multiple foreign bodies had often penetrated the regional vessels. Because of the vascular damage, amputation was practically always necessary in such injuries, though, as in the blast injuries just described, it was best performed as a delayed procedure, to be certain that the patients were completely out of shock.

Guided missiles-Much the same observations as those just described for blast injuries and injuries from explosions of land mines were made on patients who had suffered injuries of the extremities from guided missiles. Their appearance was often misleading, and, unless this fact was recognized and surgery was delayed, fatalities from unrecognized shock were not infrequent.

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