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Chapter XIV

Contents

CHAPTER XIV

Postoperative Complications

Wound Infections

Three types of wound infections were observed in bone and joint injuries treated in United Kingdom Base hospitals after debridement in hospitals on the Continent:

1. In some wounds the infection was superficial; there was no local reaction other than a moderate discharge of debris, and there was no systemic reaction. Closure was usually possible after 3 to 5 days of treatment by compresses of physiologic salt solution and pressure dressings. At operation in these cases, particular care was taken to place the sutures loosely, and drainage was always provided for 48 hours. Penicillin by the intramuscular route was given for at least 72 hours after operation.

2. The type of wound infection just described was sometimes complicated by a low-grade osteitis. These patients were also treated with compresses of physiologic salt solution and pressure dressings for 3 to 5 days, after which secondary debridement was done, with the removal of all obviously infected bone. Compresses were continued for another 3 days, after which the wound could usually be closed loosely. Penicillin by the intramuscular route was given during this entire period and for 5 days following wound closure.

3. Wounds which were grossly infected usually yielded streptococcus and many other bacteria. Retained foreign bodies were frequent. Complete redebridement was done in these cases, under penicillin protection, and sometimes had to be repeated one or more additional times. Foreign bodies were removed, and the wound was counterdrained. Intramuscular penicillin was continued after operation and local penicillin drips were sometimes used also.

Draining sinuses-Draining sinuses were a frequent complication of inadequate debridement. They were also the most frequent complication of unwise closure of infected wounds. The best method of treatment was to cut down on the sinus, remove the underlying dead bone, and reclose the wound. Clostridial infection seldom occurred when this technique was employed.

Clostridial infections-There were two chief causes of clostridial myositis, (1) inadequate debridement and (2) destruction of the regional blood supply. Even if debridement had been adequate, packing the wound tightly with vaseline or other gauze or enclosing it in a tight plaster cast could so completely seal it that anaerobes could flourish in the tissues. Under these circumstances, no amount of sulfonamides or penicillin could control the local growth of the organisms, because there was no local blood supply to carry these agents to them. Similarly, anti-gas-gangrene serum was ineffective.


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The only 2 deaths from clostridial myositis in the 7,500 surgical admissions at the 803d Hospital Center are typical. Both followed compound comminuted fractures of the femur. In both, debridement had been inadequate. In both, the infection was established in the psoas muscle when the patients were received. Death occurred promptly in each case, from toxemia; 1 patient died 2 hours after admission and the other within 16 hours.

Clostridial myositis was more frequent during the Normandy campaign than at any other time during the war; it was especially frequent during the fighting around Saint Lô, France. At this time, debridement was inclined to be somewhat conservative. It was necessary, however, to guard against the other extreme of radicalism, which solved the problem by amputating the extremity with too much haste. Acceptable standards of therapy were eventually worked out as a result of bitter experience.

Local abscesses from which gas bacillus could be cultured were frequent. They were treated by wide debridement, and penicillin therapy was given intramuscularly and was sometimes supplemented by sulfadiazine. The results, due to the debridement, were usually good.

Osteomyelitis

Low-grade osteomyelitis was treated by curettage of the infected bone until normal, bleeding bone was reached. The patient was given penicillin, and a pressure dressing was kept in place for 7 days. In some cases, compresses of physiologic salt solution were substituted for the pressure dressing. If at the end of a week the wound appeared clean, a muscle transplant was placed in the bone defect and the wound was closed with a split-thickness skin graft. Healing usually followed promptly. The patient was then evacuated to the Zone of Interior where, later, the muscle transplant and skin graft were excised and the wound defect was filled with cancellous bone chips. Wound closure was effected at this operation with a full-thickness graft.

Secondary Hemorrhage

The ever-present possibility of secondary hemorrhage furnished an important argument for complete exploration and debridement of every battle-incurred wound. Any wound, no matter what its size, could conceal severe vascular damage, and this damage, in the absence of adequate examination, could remain undiscovered until serious hemorrhage ensued.

Other causes of secondary hemorrhage included the retention of foreign bodies; the pressure of drains and packs placed too near major vessels; and infection which could cause erosion or damage to a vessel wall, or lysis of a thrombosis which had effectively closed the lumen of a lacerated vessel. Oozing through the wall of a gradually enlarging aneurysm was still another cause of secondary hemorrhage. Whenever splinting was careless, two risks were introduced: (1) Movement of the fractured bone during transportation, and


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(2) the impingement of mobile bone fragments on vessel walls, with resulting trauma to the tissue. Hemorrhage could follow in either of these circumstances.

A patient in whom bleeding was considered a possibility was never evacuated until the risk was definitely ended. Whenever the history of previous bleeding or the location of the wound made secondary hemorrhage a possibility, the ward personnel was warned to be on guard and was given instructions in what to do until help could arrive. It was sometimes thought best to warn the patient also of the possibility, so that he would call for help promptly if symptoms appeared. Splints were always so adjusted as to allow for emergency control of hemorrhage until definitive control could be effected. This was accomplished by providing windows in the cast over pressure points proximal to the wound, or by placing a tourniquet beneath the plaster so that it could be tightened, if necessary, for emergency control of bleeding.

It was the general experience that most major secondary hemorrhages were preceded by oozing or by minor hemorrhage. These signs should always have served as warnings, but they often did not because they could be controlled by packs and pressure dressings, sometimes with deceptive ease. It was also the general experience that resort to these temporizing measures simply postponed the severe and perhaps fatal hemorrhage likely to follow the first minor bleeding. Failure to appreciate the gravity of the warning oozing, no matter how slight it might seem, was an outstanding error of management in many hospitals. The correct policy was to explore the wound at once, under general anesthesia and under aseptic conditions, in order to find and ligate the bleeding point. This plan sometimes resulted in unnecessary explorations, but it also prevented many severe hemorrhages which could easily have been fatal, particularly if the patient had been evacuated without first identifying or excluding the source of the first bleeding.

The source and management of secondary hemorrhage are discussed in detail in the volume on vascular surgery in this series. The subject is simply mentioned here because hemorrhage is one of the possible complications of combat-incurred injuries of the bones and joints.

Decubitus Ulcers

Decubitus ulcers were best managed by taking precautions to prevent their occurrence. If they developed, as they not infrequently did in spite of these efforts, local applications of Azochloramid (chloroazodin) with debridement as necessary, was standard treatment. The practice of placing Kirschner wires through the iliac crests and suspending the patient from a Balkan frame, so that the buttocks did not come into contact with the bed, hastened healing and greatly simplified nursing care. A high-protein diet was an essential part of the treatment.

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