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Chapter IV

Contents

CHAPTER IV

Hospital Facilities and Orthopedic Equipment

Hospital Facilities

Bed capacity.-Orthopedic sections of general and station hospitals occupied, on the average, about a third of the total bed space. This was in line with realities. Bone and joint injuries constituted from 35 to 40 percent of all battle-incurred injuries and also constituted the major number of nonbattle injuries.

Allotments varied from hospital to hospital, as well as from time to time within the same hospital. The 217th General Hospital, for instance, when it served as a 1,000-bed transit hospital, set aside 4 ward buildings, each containing 40 beds, for casualties with bone and joint injuries. When it moved to the Continent, it occupied the Hôpital de la Pitié in Paris, a large city hospital with a capacity of about 1,500 beds. A surgical pavilion contained 6 large operating rooms and other facilities. The orthopedic section was assigned the second floors of each of 2 buildings, each floor consisting of 8 wards. The total bed assignment was 403, and this number could be expanded to 550 during periods of stress, by placing the cots in corridors and elsewhere.

At Commercy, France, the 50th General Hospital occupied an old 3-story barracks, in which it could house as many as 460 orthopedic patients at one time.

Tented hospitals sometimes had to serve as fixed hospitals on the Continent, and during the spring, summer, and early fall, these arrangements were generally satisfactory. During the incredible mud of late fall and early winter, buildings with solid floors and modern heating were distinctly better for men with bone and joint injuries, even though it required a longer haul to get them there.

Tented hospitals, while satisfactory for this purpose, did not lend themselves as well as conventional buildings to the definitive treatment of fractures of the long bones, which require Balkan frames for satisfactory skeletal traction. As far as possible, their use was limited to prisoners of war.

The bed capacity of a tent was about half that of an ordinary ward, and there were several other disadvantages. One was the difficulty of moving the portable X-ray machine. Another was the darkness of the tent, which required artificial light around the clock. This made for a monotonous existence and had a depressing effect on the soldiers' morale. Nonetheless, when it was necessary, a Balkan frame could be shortened at the head of the bed to meet the sloping tent roof, and concrete floors could be provided to give stability for both the fracture setup and the making of roentgenograms.


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Location of space-The location of the space assigned to orthopedic surgery was not always convenient, especially in hospitals in which it was the practice to locate septic wards immediately adjacent to the operating rooms. The orthopedic wards were often at a considerable distance from the operating facilities and from the X-ray facilities.

Sometimes these inconveniences were unavoidable. At other times they could be attributed to failure to grasp the realities of military surgery. Some commanding officers and some chiefs of surgical sections were slow to appreciate the magnitude of the trauma sustained by the extremities and spine by men in training, to say nothing of the greatly increased volume of bone and joint injuries which could be expected when combat began. As time passed and lessons were learned by experience, most of these difficulties were smoothed out, though until the end of the war some chiefs of surgical services did not realize the importance of segregating fractures from general surgical cases and placing them in the charge of special personnel.

It was always a great convenience to have the plaster room located near the operating room, though this advantage was canceled out when its supervision was put into the hands of operating-room personnel rather than those of trained orthopedic personnel.

When orthopedic facilities were set up in buildings which had not been constructed primarily for hospital purposes or in which space had not been adapted and fitted for orthopedic use, plaster facilities were frequently inadequate. The experience of the 217th General Hospital is an illustration. When it served as a transit hospital after D-day, the plaster room, which measured 10 by 20 feet, was off the main operating room and had been set up for minor surgical procedures. It therefore had no plaster sink, and the water supply and drainage were both entirely inadequate. Storage space was also insufficient, and it was impossible to provide a backlog of plaster bandages and other supplies.

Equipment and Supplies

United Kingdom hospitals-Most hospitals and hospital centers in the United Kingdom were furnished with a combination of British and American orthopedic supplies. The 68th General Hospital, for instance, was located close to a British orthopedic hospital and secured from it many items not obtainable in United States Army issue. At the 217th General Hospital, when it served as a 1,000-bed transit hospital, all orthopedic wards were equipped with British fracture beds with segmented mattresses and with single bar overhead frames. On the other hand, some centers, such as the 802d Center in the Blandford area, England, had full United States Army table-of-equipment supplies, including orthopedic beds, Balkan frames, fracture tables, full supplies of surgical instruments, and many nonstandardized items. Work in such a center was naturally facilitated, but it was still possible to do excellent orthopedic work with less complete equipment.


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Numerous desirable orthopedic items were missing from the standard equipment of general hospitals, such as curved osteotomes, stainless-steel brads, bone nails, bone punches, stainless-steel rules, and suture wire for tendon repair. The drill points supplied did not contain a sufficient variety of small points. Metal hammers of suitable weight were not available, and the wooden hammers provided did not stand up under repeated sterilization. Smith-Petersen nails were available but only in sizes smaller than those generally used. Nails measuring 4, 4¼, 4½, 4¾, and 5 inches should also have been provided.

These deficiencies, as in the case of larger items of equipment, did not prevent the performance of high-quality orthopedic work. The items listed were needed only in general hospitals in the United Kingdom Base, where definitive orthopedic surgery was done. Medical supply did an extremely good job throughout the war in furnishing promptly all reasonable and necessary supplies. It would be unreasonable to expect many of the special items listed to be carried as standard supply items in an overseas theater.

There were occasional instances of insufficient supplies and procrastination before D-day. In one hospital in the United Kingdom, for instance, it took constant prodding of the medical-supply officer to obtain anything like the proper amount of orthopedic supplies. Eventually, 1,500 rolls of sheet wadding and 1,000 rolls of plaster bandage were obtained, but ambulatory patients had to be used to help the personnel of the plaster room get the supplies ready in time. Enough orthopedic instruments were finally obtained after a hunt through medical supplies, but the Scanlon Morris fracture table was not obtained until the day after D-day. This was, however, an isolated instance. For the most part, supplies were ample for the work which had to be done. Col. (later Maj. Gen.) S. B. Hays, MC, after his assignment as Chief, Supply Division, Office of the Theater Chief Surgeon, did a splendid job of procuring and distributing needed orthopedic supplies throughout the war in Europe.

Supply difficulties sometimes arose when hospitals were shifted from their assigned function, as was sometimes necessary just after D-day. The 68th General Hospital, for instance, did the work of an evacuation hospital for a number of weeks. A general hospital is equipped to handle only a certain number of surgical patients and is not equipped for unlimited emergency surgery. When the population in this hospital suddenly became 90-percent surgical and most of the operations were urgent, there were not sufficient sterile supplies and not enough laundry facilities to take care of the large turnover in the operating room. As a result, some debridements had to be delayed longer than was desirable, though the results indicated that very little real harm had been done by the prolonged timelag.

Hospitals on the Continent-The equipment of fixed hospitals on the Continent, while usually adequate, was seldom equal to that of hospitals in the United Kingdom. Hospitals in the British Isles almost invariably had modern American fracture tables. Those which crossed the channel had only the Army type of portable fracture table, which left much to be desired.


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Every hospital on the Continent required a multiple supply of fracture tables, and all of them were frequently in use at the same time for the application of plaster. It was uncommon, in an evacuation hospital, for at least one fracture table not to be in continuous use around the clock.

Plaster

The most universally useful roll of plaster was 6 inches wide and 4½ yards long. Plaster reinforcements were made of 5 individual layers of plaster-impregnated crinoline, 6 inches wide and 2 feet long. These were folded in squares and stored in paper wrappings. The most satisfactory mesh was American No. 11 gage crinoline, which corresponded to the British No. 14 gage muslin.

As far as possible, all plaster supplies were kept in dry storage, with the rolls wrapped in paper. Lukewarm water was used for soaking the plaster before it was applied.

Braces and Arch Supports

As a rule, the 1,000-bed general hospitals sent to the European theater had few or no facilities for making braces, arch supports, and minor adjustments to shoes. With few exceptions, patients who required braces had to be returned to the Zone of Interior.

At first, the provisions for arch supports and for making minor adjustments to shoes were extremely haphazard. Before D-day, there was no provision at all in Army general hospitals for arch supports, Army issue, which a few noncombatant soldiers required.

These supports were chiefly for the use of the troops in the London area. Combat troops seldom required them; a soldier who needed one, in fact, did not belong in a combat unit. A considerable number of these supports, which were satisfactory and well made, were obtained by purchase from British civilian sources. Each transaction was an individual one and was usually conducted through one of the United States dispensaries in London. This did not wholly solve the problem, for shortages of leather and labor made it impossible to rely entirely upon the British for these and other orthopedic supplies. An occasional hospital solved the problem as did the 68th General Hospital, which took part of the wards originally assigned to venereal disease and converted the space into four excellent plaster rooms, with an adjoining shoe and brace shop. This hospital could thus care for orthopedic shoe prescriptions and for arch corrections on the post without delay.

The disciplinary center at Shepton Mallett, England, had among its officers a young man who in civil life had run a successful chain of shoe-repair shops in Florida. It was possible to work out with this officer a plan for utilizing labor of imprisoned United States soldiers to repair shoes and make prescribed adjustments. As far as shoe repairs were concerned, this arrangement was fairly satisfactory. On the other hand, the arch supports provided on pre-


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scription left much to be desired. An incidental result of this plan was the good effect on the morale of the prisoners, through their feeling that, in spite of their incarceration, they were still contributing to the war effort.

While hospitals were static in the United Kingdom and the number of patients was relatively small, these improvised arrangements worked out satisfactorily. Later, as the number of troops increased and soldiers were moved to the Continent and widely dispersed, other and more elaborate plans had to be worked out. Prefabricated leather and sponge-rubber arch supports began to arrive in the theater and became available through Army medical supply channels early in January 1945. At first, only the 10th General Dispensary in London and the 9th General Dispensary in Paris were authorized to stock these items. As supplies increased, distribution was widened, and eventually certain authorized hospitals and general dispensaries stocked specified levels which could be replaced on requisition. When it was practical, patients were sent to these hospitals for fitting. When it was not, supports were requisitioned. Final arrangements for orthopedic corrective devices were not made until the spring of 1945, and it is not known how effective they were, in view of the constant deployment and shifting of units after V-E Day. If there had been any degree of stability, the new arrangements should have been satisfactory.

Whenever possible, quartermaster shoe-repair units and local shoemakers were used to make minor shoe adjustments. A special graphic, bilingual order form for French shoemakers was devised by the Chief Quartermaster, European Theater of Operations, and the senior consultant in orthopedic surgery and proved very satisfactory.

Improvised Equipment

At a number of the hospitals in the European Theater of Operations, a good deal of ingenuity was shown in the construction of special devices, frequently out of salvaged material, for the care of casualties with bone and joint injuries. Several devices of this kind were made and employed at the 22d General Hospital in the 802d Hospital Center by Lt. Col. Thomas B. Quigley, MC, Maj. Marshall R. Urist, MC, and Capt. Lincoln Ries, MC.

Plaster traction splint-The plaster traction splint for compound comminuted fractures of the tibia and fibula was devised at the 22d General Hospital in Blandford, England, and tested there and at the 97th General Hospital in England and on the Continent, between May 1944 and December 1945. It was constructed and employed as follows (figs. 2 through 6):

A plaster cylinder, padded with felt in the upper thigh and the popliteal and malleolar regions, was applied from the groin to the ankle while the knee and hip were flexed 45 degrees. U-shaped wire hoops, fashioned from No. 12 iron wire or any other available metal, were incorporated in the plaster at the midthigh and the malleolus in such a manner that the closed portion encircled the lateral and posterior aspects of the leg (figs. 2 and 3). Two similar wire hoops, or a single heavier metal hoop, were incorporated in the same manner in the


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FIGURE 2.-Materials required for construction of plaster traction splint for compound fractures of tibia and fibula with interior view, from above, of assembled splint.

They include:

Four pieces of heavy wire, 1/8-inch gage, each 20 inches long, bent into the shape of a U, to fit about the posterior aspect of the cast at, respectively, the middle third of the thigh, the tibial tubercle, and the leg, 1 inch above the ankle joint. One or two wires were used at the knee, to provide a strong fitting for the Pierson attachment. The ends of the wires were turned into loops, so that they could serve as hangers for suspending the completed splint in a Balkan frame.

Three felt pads, suitably cut to encircle the upper third of the thigh under the plaster cuff, to fit the popliteal space and cover the tibial tuberosities, and to fit the posterior aspect of the lower third of the leg.

A standard Army Pierson attachment.

Six rolls of 4-inch plaster-of-paris bandage.

Four rolls of 6-inch plaster-of-paris bandage.

Three rolls of 3-inch sheet wadding.

A Cramer wire ladder splint (fig. 4) used as a frame for the foot support.

plaster at the knee. A Pierson attachment, with a pulley fastened to the crossbar, was placed over the leg in the sagittal plane and clamped in place to the hoops at the knee (figs. 2 and 3). The ends of the wire at the malleolar level were wound about the Pierson attachment. The anterior portion of the cast was cut away between the open ends of the hoops from the superior pole of the patella to the ankle. If access to soft-tissue wounds was necessary, windows were also cut on the posterior and lateral aspects of the cast.

A suitable weight was attached and traction was applied, with the leg suspended in a Balkan frame (figs. 4 and 5). The foot was supported by a stockinet or moleskin sling fastened to a Cramer wire which was attached to the


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long bars of the Pierson attachment. When minor corrections in alinement were necessary, the distal fragment could be moved up to 10 degrees in the sagittal or coronal planes by shifting the pulley from side to side and elevating or lowering the end of the Pierson attachment.

Overhead suspension was continued during the first 2 weeks of healing or as long as nursing care, including the bath and the use of the bedpan, were painful. It was then discontinued, and the patient was allowed more freedom in bed. At the end of 3 to 5 weeks, when movement had ceased to be painful, he could be up in a wheelchair (fig. 6). At the end of 6 weeks, when callus formation was usually adequate and the fracture site had become sufficiently stable, traction was discontinued, and a long leg cast was substituted for the original cast. Ambulation on crutches was then instituted as rapidly as possible.

The efficiency of this plaster traction splint was tested, as already noted, under military circumstances in the 22d United States General Hospital in England and the 97th General Hospital in England and on the Continent between May 1944 and December 1945, on 65 battle-incurred fractures of the tibia and fibula in 63 patients, and in 11 simple and compound comminuted fractures of the same bones which were sustained accidentally.1 During the early months of this period an approximately equal number of similar fractures, which served, in effect, as a control series, were treated in the Böhler-Braun splint or in the Thomas splint with Pierson attachment. The com-

FIGURE 3.-Mechanism of action with splint in traction obtained through Pierson attachment incorporated in long leg plaster cast. The countertraction is mainly from a hoop to which the Pierson attachment is clamped at right angles, and also, but slightly, from the ventral aspect of the cast around the thigh.

1Urist, M. R.; Ries, L.; and Quigley, T. B.: A Plaster Traction Splint for Compound Comminuted Fractures of the Tibia and Fibula. Surgery 23: 801-805, 1948


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FIGURE 4.-Diagrammatic showing of method of suspension of splint and use of trapeze by which patient can lift himself off bed and aid in his own nursing care. Details of construction of the knee-joint section are shown in lower left insert. Method of mobilizing splint and adding foot support is shown in lower right insert.


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FIGURE 5.-Ward at 22d General Hospital showing battle casualties recently evacuated from Germany put up in plaster traction splints to maintain reduction of compound comminuted fractures of both bones of leg.

bination splint was at first used only tentatively, but as its advantages became apparent it was used more frequently.

The combination splint was found to compare very favorably with the classical traction splint from the standpoint of providing skeletal traction and securing immobilization of the fractures in plaster. It was also found to possess several additional advantages:

1. It furnished better protection for the reduced fractures.

2. It made movement less painful during the early days of healing.

3. It eliminated the uncomfortable counterpressure of the ischial ring of the Thomas splint.

4. It also eliminated the painful play at the fracture site permitted by the Böhler-Braun frame.

5. It did not require the time-consuming, continuous, expert attention necessary when the Thomas splint with Pierson attachment was used. This was a particular advantage when heavy casualties had been received and experienced personnel were in short supply.

6. The combination splint proved of great usefulness in patients received more than 8 to 12 hours after injury, when internal fixation was contraindicated by the risk of infection or when extensively comminuted fractures of the shaft of the tibia would have required undesirable dissection of the whole leg for the safe application of plates and screws.


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FIGURE 6.-Patients in traction splints after overhead suspension has been discontinued.

Traction cradle.-At the 22d General Hospital in England, the use of an improved Böhler-Braun type of traction cradle, for the management of battle-incurred undisplaced or incomplete fractures, was found to have several advantages. This cradle permitted easy access to the compounding wound. Alinement of the bone fragments was maintained. The patient could be transported from the ward to the operating room with ease and safety. Most important, the atrophy which was often extreme in limbs treated in plaster was minimized by this type of open immobilization, which permitted exercise of muscles of the uninjured segments of the extremity.

The cradle was fashioned (figs. 7 and 8) of a packing box, into the top of which a trough had been built. The felt padding which covered the top of the box was covered with surgical oiled silk. An adjustable thigh support was attached to the top of the box at one end by means of hinges and a wire stanchion. The angle between the end of the box and the thigh support was adjusted to the plane which provided maximum comfort for the knee; the angle varied with the stature of the patient. The box was supported in bed by a transverse base extension made of basswood splint. A slot in the side of the box allowed for the insertion of an X-ray cassette for portable roentgenograms to be taken.

This cradle proved simple to construct and provided maximum comfort for the patient. It was suitable for use with skeletal or skin traction and also was useful simply as a support for the bony and soft parts of the leg. When it was used with traction, adjustments of the position of the pulley and weight, and the use of a crossbar of the Balkan frame, permitted alinement of minor anteroposterior and mediolateral angulation.

Revolving orthopedic frames-Compound fractures of the hip joint and pelvis were always, in themselves, serious orthopedic problems. They


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FIGURE 7.-Details of construction of Böhler-Braun type of traction cradle made from ordinary packing box.

FIGURE 8.-Management of compound fractures of both bones of leg in improvised traction cradle.


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were considerably more serious when, as often happened, they were associated with injuries of the genitourinary and gastrointestinal tracts. These injuries required suprapubic cystostomy or colostomy or, occasionally, both, and nursing care was extremely complicated, since the orthopedic injuries required complete immobilization for several months in a plaster-of-paris spica. The most careful precautions often did not prevent the development of decubitus ulcers over the sacrum. The situation was also a difficult one for the physiotherapist.

One solution of these problems at the 22d General Hospital was the construction of a wooden frame (fig. 9), which reenforced the plaster spica or plaster bed and compensated for the weakening caused by the large windows that had to be cut into it, to allow care of the bladder and intestinal wounds. This frame supported the patient on an inclined plane, with his hips above the level of his thorax, a position which eliminated pressure on wounds of the buttocks and sacrum. When he was turned from the recumbent to the lateral or prone position, as was usually done in such cases at hourly intervals, 2 attendants could easily lift and rotate both frame and patient 90 or 180 degrees as was desired (fig. 10).

Other frames devised at the 22d General Hospital not only reenforced fenestrated plaster-of-paris casts but also turned the patient. They could be constructed from the salvage material available at any Army Ordnance depot.2 The principles of both the Bradford and the Stryker frame were employed in their construction.

FIGURE 9.-Improvised frame used to suspend and reenforce plaster cast with multiple windows.

2M. Sgt. Robert Ferguson, Army Ordnance Department, assisted in the construction of these frames.


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FIGURE 10.-Cast in frame. Patient has been turned to relieve pressure on hip wound and on colostomy.

In one type of revolving Bradford frame, the boiler-plate rims rolled in tracks on ball bearings (fig. 11). One nurse or other attendant could turn the patient 90 or 180 degrees simply by removing the wing nut and turning the hinge-locking device, so that the rims could revolve. When a revolving twin Bradford frame was indicated, an apparatus could be constructed (fig. 12) in which, by means of a worm gear, a turn of 360 degrees could be accomplished. In the frame shown, the self-locking worm gear was made from the elevating mechanism of a salvaged 75-mm. gun which has a 40:1 gear ratio, making a 360-degree turn possible. The rod for the base consisted of ½-inch by 1½-inch cold mild steel with a ¾-inch rod for the base. The basswood splint was provided for additional fixation.

Devices such as these greatly facilitated the care of the patient and saved time and effort for nurses and corpsmen, who were almost always overworked. The usefulness of these frames was not limited to compound fractures of the hip joint and pelvis. They were also useful in injuries of the spine, in paraplegia, and in any other condition in which it was necessary to change the position on a regular schedule. The patient was simply sandwiched between two full-length sheets of canvas which were laced to the frames. It was also possible, when plaster of paris was not required, to attach a self-retained extension apparatus to the head rim and equip it with a pulley. When traction was required, this was a convenient method of caring for a patient with a fracture of the cervical spine who was being treated by Crutchfield tongs. One patient was evacuated to the Zone of Interior in a revolving Bradford frame which was bolted to a litter.


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FIGURE 11.-Improvised revolving Bradford frame.

FIGURE 12.-Improvised revolving Bradford twin frame with patient in fenestrated bilateral hip spica.

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