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Chapter IX

Contents

CHAPTER IX

The Management of Compound Fractures-
Initial and Reparative Wound Surgery

Wounds of the extremities often made up as much as 70 percent of the caseload of an evacuation hospital. Half or more of these wounds were associated with compound fractures, which means that from 35 to 40 percent of all casualties presented this type of injury.

Col. Charles B. Odom, MC, consultant in surgery, Office of the Surgeon, Headquarters, Third United States Army, analyzed 64,389 battle casualties treated in Third Army hospitals from 1 August 1944 to 1 February 1945.1 Of these injuries, 43,345 were found to involve the extremities or the buttocks. This was 67.3 percent of the total number; it had been estimated that the proportion would be 71 percent. The case fatality rate for wounds of the extremities was 0.82 percent, compared with a rate of 2.9 percent for all battle casualties in this series.

Compound fractures thus constituted a major part of the surgical load in all Army hospitals. They also presented major problems, for four reasons over and above their frequency:

1. They were often of a devastating character not observed in civilian practice.

2. The compounding wound was often so large and extensive that it constituted another problem in itself.

3. There was frequently an accompanying nerve lesion, and less often there was an accompanying vascular lesion.

4. The same soldier frequently presented a multitude of injuries, any one of which constituted a major problem in itself. Thus it was not uncommon to admit a casualty with a perforating wound of the thorax with hemothorax, a perforating wound of the abdomen for which a colostomy had been necessary, and compound fractures of two major bones, frequently associated with division of a major peripheral nerve. The first objective in every such case was naturally to save life, and it was extremely dangerous to overtreat the patient, who might readily go into shock or go back into shock as the result of too vigorous treatment. As a result of the circumstances, the bone injury was usually the last to be treated, and the delay was sometimes considerable.

Development of Policies

The evolution of the method of delayed primary wound closure in the North African (Mediterranean) theater is recounted in detail elsewhere in this

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


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history. The technique was developed and generally accepted by an evolutionary process. It was not put into practice as the result of directives from the Theater Chief Surgeon's Office. On the contrary, the directives finally issued concerning it took cognizance of what had then become an established practice.

Many months were to pass, and many poor results were to be obtained by other techniques, before delayed primary wound closure was routinely adopted in the Mediterranean theater in the management of injuries of the soft parts. It was not until the late spring of 1944, only a few weeks before D-day in the European theater, that delayed primary wound closure was also adopted in the Mediterranean theater as a technique of management of compound fractures, and lack of time, as well as lack of liaison, prevented the general dissemination of the information in the European theater.

In the European theater a similar, though considerably briefer, period of evolution occurred. The Manual of Therapy2 prepared before D-day emphasized, in the directions for initial wound surgery, the importance of "early secondary closure" (delayed primary closure) or early skin grafting. Later directives were specific that wounds were to be closed by delayed primary closure, preferably within 4 to 5 days after debridement if there was no clinical evidence of infection. Closure within 10 days or less from the date of injury was still to be undertaken under the same circumstances.

In the rush of casualties that followed D-day there was a certain inevitable confusion, and the method was unevenly and improperly applied in some cases. Some wounds were closed with strict regard to the regulation about the time of closure but with too little attention to the requirement that they be clinically free from infection. This happened chiefly because many newly arrived hospitals became swamped with casualties, and their medical officers, who were inexperienced and who had not been in the theater long enough to have any thorough training, closed some wounds regardless of their appearance. When cases began to be properly selected and the method was properly applied results were excellent.

It was only in occasional cases that the principles of delayed primary closure of clean wounds 4 or 5 days after debridement was not accepted for soft-tissue wounds. There was reluctance, however, to accept the same principles of management for compound fractures. When this method is successful, as it is in a large proportion of the cases in which it is properly employed, it converts a compound fracture into a simple fracture, but it took some time to convince many medical officers of the possibilities of the technique. Indeed, it was with reluctance and trepidation that many orthopedic surgeons in the European theater finally proceeded with delayed primary closure of compound fractures. They clung to the routine of removing the plaster, redressing the wound, and putting on a fresh cast, with, in selected cases, closure of the wound at a later date. In most cases in which this method was used, healing was permitted to occur by granulation. It was not a satisfactory technique. Infection was frequent overseas, and while it was not possible to determine the

2Manual of Therapy, European Theater of Operations, 5 May 44.


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end results, because the patients were evacuated to the Zone of Interior, the impression was general that function was often not as good as it might have been.

When it was demonstrated in the cases in which the technique was employed that delayed primary closure of compound fractures was a safe and satisfactory method, the situation changed. After persuasion and perhaps some browbeating by the consultants, orthopedic surgeons began to use this technique. In late June of 1944, it began to be employed in a trickle of cases, out of many later shown to be entirely appropriate for its use. By mid-July, the number had become a torrent. By September 1944, the situation in respect to wound closure was well stabilized, and delayed primary closure was being used routinely in all compound fractures in which it was justified. By the end of the war, almost the only wounds left to heal without delayed primary closure were very small wounds which had already begun to close by granulation when the casualties were received in the general and station hospitals to the rear. At this time it was exceptional to find surgeons who were not carrying out the prescribed techniques and who had not greatly improved their original technique.

The full story of the success or failure of delayed primary suture of compound fractures could not, of course, be ascertained in the European theater. Most patients with these injuries were returned to the Zone of Interior in plaster, and final results were evaluated there. There was no question, however, in the minds of orthopedic surgeons in the theater as to the value of this method. The practice of delayed primary wound closure had the same advantages in the European Theater of Operations as had already been demonstrated in the Mediterranean Theater of Operations. Prolonged drainage incidental to healing of the wound by scar tissue from the depths to the surface was obviated. The percentage of infection was minimal as compared to the high percentage of infection which had accompanied the closed plaster method. Underlying exposed bone was conserved and bone healing was expedited along with soft-tissue healing. Convalescence was shorter and far more satisfactory.

Finally, repair of divided peripheral nerves, open reduction of such fractures as required this procedure, the application of bone grafts, and similar surgery could all be performed much earlier, with relative ease and with generally good results, whenever delayed primary wound closure had been practiced.

Debridement

The principles of debridement as it was practiced ideally in the European theater did not differ from the principles by which it was practiced in other theaters. The cardinal consideration in all initial wound surgery was thoroughness. If the debridement was adequate, the patient was almost always received at the general hospital in the communications zone with the wound healthy and ready for primary closure or for skin grafting as necessary. If debridement was not adequate, frank infection or a dirty wound prevented closure at the optimum time. Frequently, in these cases, secondary debride-


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ment or even a drainage operation was necessary. Paradoxically, therefore, the surgeon who was most radical in the debridement of war wounds was really practicing conservatism.

A correct debridement was carried out according to the following principles:

1. The incision was preferably longitudinal and was always generous enough to permit complete exposure of the wound to its depths. It was made through the original wound when possible. If for any reason this was not practical, a new incision was employed.

2. Damaged and devitalized tissue was excised until cleanly bleeding surfaces were reached. Fascial planes were widely opened to relieve tension. The tissue removed consisted, for the most part, of muscle whose fibers had been destroyed by the enormous expansile force of modern high-velocity projectiles.

3. All accessible foreign bodies, particularly bits of clothing, were removed.

4. As much skin as possible was conserved. Intact skin is essential for proper healing of underlying tissues.

5. It was also the rule to conserve bone fragments, especially if they were large. Even bone chips could serve, in effect, as bone grafts and thus provide additional support for the injured extremity.

6. Severed nerves were loosely approximated by a single wire suture. If this could not be accomplished, an identifying suture, which was demonstrable by X-ray, was put in each end. Primary nerve suture was never attempted.

7. Hemostasis was complete and precise.

8. The wound was always left open for drainage at the initial operation. Drainage or counterdrainage was sometimes instituted through another incision also. Provision for drainage was particularly important in wounds in the thigh and buttocks, and failure to institute it accounted for a number of fatalities in patients with bone and joint injuries, as well as for a number of serious infections.

9. The wound was well irrigated at the conclusion of the operation. It was then held open with fine-mesh gauze which was placed loosely in the wound, no more being used than was necessary to accomplish this purpose. Tightly packed gauze prevented drainage, and the damming back of secretions by this means could give rise to serious infections. Vaseline-impregnated gauze was frequently used early in the European theater experience, but as time passed it was found to be open to many of the same objections as tightly packed gauze, and fine-mesh dry gauze was used routinely thereafter.

10. Finally, pressure dressings were applied and the wounded extremity was encased in a plaster-of-paris splint which was well padded and which had been selected with a view to the necessities of the particular case. This splint was merely for transportation purposes. Forward hospitals were not concerned with the anatomic reduction of fractures. The splint was split or bivalved through both plaster and padding before the patient was taken off the operating table. The assumption was that it would be removed within 3 to 7 days for delayed wound closure.


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11. If penicillin had not already been administered, it was begun at the conclusion of the initial operation. In any event, it was continued until 3 days or more after delayed wound closure.

The policy of early, complete debridement, with the establishment of adequate drainage, preferably through the open wound, was the policy set up in the European Theater of Operations for every wound of the extremities, regardless of its type and size. On the whole, as already noted, it was carried out fairly consistently, even in the early days of the theater.

Common errors in initial wound surgery-The availability of the sulfonamides and, more particularly, of penicillin induced an occasional inexperienced surgeon to eliminate debridement, especially in small, perforating wounds. This was not a safe or a wise policy, chiefly because it was impossible to determine by external inspection of an injury what the state of the deeper tissues might be. The burden of responsibility was always placed squarely upon the surgeons who failed to adhere to theater policy in this regard. The senior consultant in orthopedic surgery and the junior consultants lost no opportunity, on their visits to the various hospitals, to stress the point that adequate debridement was the only acceptable policy in a battle wound, and that every surgeon must adhere to this policy, regardless of the size of the wound. In addition to inadequate debridement, the chief errors made in the initial surgery of combat-incurred compound fractures may be stated as follows:

1. Circumcision rather than excision of wounds. Debridement through a linear incision provided the only satisfactory exposure of the deeper tissues. Operation by a circular, coning-out technique was completely ineffective, one reason being that satisfactory closure of the wound was impossible when a circular incision had been made at initial surgery. This type of incision was particularly undesirable in compound fractures, regardless of their location.

2. Failure to expose and examine adequately wounds which also involved vessels and nerves. Nerve injuries were sometimes overlooked in both the upper and lower extremities, though this error, for obvious reasons, was seldom made in vascular injuries.

3. Too free removal of bone chips in comminuted compound fractures.

4. Failure to split all transportation casts and underlying wadding down to the skin.

5. Holding patients too long in forward hospitals and thus delaying primary closure unduly.

6. Using penicillin too frequently and in too large amounts, merely because it happened to be available.

Strict adherence to directives would have prevented all of these errors. The fact that they continued to be made throughout the war is an indication of the extreme difficulty which civilian surgeons experienced in changing over from civilian to military practice. It is also an indication of inability to recognize the difference in the function and responsibility of surgeons in a forward and in a fixed hospital. If all orthopedic surgeons could have had


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some instruction and orientation before they were sent to evacuation hospitals, many of these errors would probably not have occurred.

A report to the surgical consultant of the Third United States Army from Maj. Dudley W. Smith, MC, of the 4th Auxiliary Surgical Group, on detached service at the 94th General Hospital, is an interesting, instructive, and practical commentary on the errors which had to be combated at forward hospitals. His observations were based on 500 cases collected from the First, Third, and Ninth United States Armies. The mission of this hospital was chiefly the delayed primary closure of compounding wounds after debridement and the establishment of skeletal traction. The most important of Major Smith's observations were as follows:

1. Valuable time could be saved and the patient could be spared considerable discomfort if it were prominently marked on both the plaster splint and the field record that the patient had a nerve lesion, and if the extent of the skin loss were also noted. Some patients did bear these notations on their splints and their records, but they were in the minority. A patient with a diagnosed or suspected nerve lesion which was thus identified could be transferred to a neurosurgical center without the necessity for removal of the cast and examination of the wound.

2. Far too many wounds could not be closed for two reasons: (1) Many contained dead muscle and damaged fascia which were actually sloughing when the cast was removed and the wound was inspected. This was because a sufficiently long longitudinal incision had not been made at debridement, which was inadequate because exposure was inadequate; (2) many wounds were actually blocked by heavy vaseline-gauze wicks or Penrose drains which had been inserted deep into them. When these were removed, a well-circumscribed tract was left, which was sloughing and contained more or less exudate. The wounds in perfect condition for closure were those in which a sufficiently long incision had been made for complete excision of damaged tissue and which contained only two flat strips of vaseline gauze on each side, with the flat edges extending into the depths of the wound. These wounds were clean and healthy looking and almost invariably healed well after delayed primary suture.

3. Enough attention was not paid to extremities in which vascular injuries were associated with bone and joint injuries. In 1 such case the popliteal vein had been ligated 4 days before. The leg was enormously enlarged, the foot was cold, and the limb was not supported in any way. The patient was in great pain, and the process was obviously not going to subside. This result might have been prevented if the leg had been put up in a long leg split cast with large lettering on it to warn all concerned to keep the extremity elevated. Surgeons at forward hospitals should have been warned that patients with vascular injuries, whether or not the bone was involved, would not be comfortable without some kind of adequate support to the leg. These surgeons should also have been warned that limbs might be lost by failure to observe this precaution.


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4. In a number of instances, casts had been incompletely split, while in some instances the sheet wadding had not been split at all.

5. In the occasional case, foreign bodies in joints had not been completely removed. As a general rule, however, the results of removal of shell fragments from the joint, followed by the instillation of penicillin and closure of the synovial membrane, had been excellent.

6. Some patients who had been subjected to amputation were grossly anemic and needed massive transfusions, though they had stood the trip well. The care of amputations and stumps was generally excellent.

All these observations attested the paramount importance of adequate initial surgery in the combat zone. If surgery there was inadequate, the mission of the general hospital in the communications zone was complicated and the end results of treatment were jeopardized. It was always valuable when, as in this case, a surgeon from the army area was able to make observations in the communications zone and report to his colleagues the results of failure to carry out precisely the policies of management laid down by the Theater Chief Surgeon.

Anesthesia.-Almost without exception, debridement was carried out under general anesthesia. Only a brief experience was necessary to prove that it could not be satisfactorily performed under local analgesia. For one thing, this technique would have introduced further contamination into an already contaminated and possibly infected field. Furthermore, battle wounds were seldom in the category of inconsequential injuries. Even the smallest wounds, as just pointed out, were likely to be associated with severe damage to the underlying tissues, as well as gross contamination by foreign material. In this kind of injury, an adequate debridement could not possibly be performed except under general anesthesia.

Wounds debrided under local anesthesia in forward hospitals were often frankly infected when patients were received at the general hospitals. Primary closure was not possible in these cases until secondary debridement had been performed. This necessity delayed closure of the wound beyond the optimum period, and healing was never quite as satisfactory as in the cases in which closure could be accomplished more promptly. Even when frank infection did not occur, wound healing was likely to be delayed, and the delay could often be attributed to the original error of not using a general anesthetic for debridement.

Delayed Wound Closure

The management of compound fractures in general hospitals began with an examination of the wound as soon as possible after the patient was admitted. If the cast was merely split and was not bivalved, it was bivalved at this time and the upper portion was lifted off. It was thus possible to inspect the area without contaminating the wound. The operating list was made up after all the casualties had been inspected, priority being given to patients whose


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wounds were of longest duration and to those who had fractures which would require traction.

Plaster and dressings were removed completely in the preparation room or the operating room, and the surgical field was prepared with soap, water, and ether or tincture of Metaphen (nitromersol).

The wound was carefully inspected to be certain it was clinically clean throughout, but the depths were disturbed only if secondary debridement seemed necessary. If the wound was clean, closure was proceeded with at once. If secondary debridement was necessary, the surgeon had to use his judgment to determine whether he might safely proceed with closure at this time or whether it would be better to defer the procedure until a later date.

If closure was undertaken within a maximum of 10 days after wounding, the skin edges were mobile and it was necessary to free them only slightly. The wound was then approximated with vertical mattress sutures of silk or cotton, preferably rather widely spaced. Buried sutures were avoided. If closure without tension was not possible, undermining incisions were employed or split-thickness skin grafts were used on part of the wound or, if necessary, on the whole wound. The directives issued before D-day required the sprinkling of sulfonamide crystals into the wound before closure, but this practice was forbidden by directive several months later.

Rubber-tissue drains were used for 48 to 72 hours in all deep wounds. Small stab wounds were occasionally used for counterdrainage if dead spaces had not been entirely obliterated.

When, for any reason, 10 days or more had elapsed from the time of wounding to wound closure, mobilization of the skin edges, which by this time had become fixed and rigid, was practically always necessary at the reparative operation. Secondary debridement was sometimes necessary also. The criterion of wound closure at this time was the same as the criterion for earlier closure, that is, a clinically clean wound. The preferable technique was the use of interrupted sutures, widely spaced and loosely tied. A drain was placed in the wound for 48 hours, and pressure dressings were kept in place for 10 to 14 days. At the end of this time, the sutures were removed.

Split-thickness skin grafts-When there had been an extensive loss of tissue, particularly of the skin, it was frequently impossible to close wounds completely by suture, and sometimes they could not be closed at all. In such cases, split-thickness skin grafts were employed to complete the partial closure or to accomplish total closure. By this means the objective of converting a compound fracture into a simple fracture was attained, tension on the wound edges was avoided, and scar-tissue formation was prevented. Any surgeon, even with no great amount of training, readily learned the technique of split-thickness skin grafting and the results were practically always satisfactory. If it was found, later, that additional plastic surgery was necessary, the split-thickness graft could be excised and a full-thickness graft applied with little risk of infection.


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The cases in which complete wound closure would be impossible without skin grafting could usually be determined before operation, and the donor site, which was on the thigh whenever possible, was prepared on the ward. Many hospitals eventually adopted the practice of preparing a donor site before operation in any case in which there was a severe compound fracture of the lower extremity. The operating room was always set up with equipment for skin grafting, and, even if the procedure had not been planned previously, there was no delay if it was decided upon during the course of the operation.

Massive pressure dressings were always used after skin grafting.

The results of split-thickness grafts applied to fresh, clean wounds were usually good (figs. 17 and 18). Many surgeons obtained takes of 100 percent. Results were less good in old, previously infected, granulating wounds, but if the granulations were shaved down to the base, takes of 40 to 50 percent were readily obtained. The least successful results were obtained in prisoners of war with neglected wounds, in which successes usually did not exceed 35 percent.

If split-thickness grafts were not successful, the use of a pedicle graft often gave excellent results (fig. 19). In certain selected cases, in which closure by other means was impossible, pedicle grafts were used at reparative surgery, without any trial of other techniques (figs. 20 and 21) or were applied later (fig. 22).

Infected wounds-In the first days of fighting on the Continent, when debridement was frequently inadequate, a distressing number of patients were received in the United Kingdom with infected wounds. Later, it was found that treatment by wet compresses for a few days, sometimes supplemented by secondary debridement, made wound closure possible in many of these cases. In others, closure was not attempted; instead, the wounds were dressed with vaseline gauze, which was then being used by directive. Many wounds treated in this manner were frankly infected when the patients were evacuated to the Zone of Interior.

Management of Fractures

Skeletal traction or, better, balanced suspension with skeletal traction (p. 113) was the method of choice in the management of most fractures of the long bones. It was the policy to reduce the fracture with the use of skeletal traction on the operating table, then check the position and alinement by X-ray. It was thus possible to determine the amount of weight to be used for traction and to determine the cases in which a sling or other supplementary equipment was needed to prevent angulation. The original time spent in careful reduction saved many hours in manipulation and many roentgenologic examinations later, and also avoided distraction.

Open reduction (p. 116) was performed with a high degree of success provided that care was taken to select cases in which there had never been any gross evidence of infection and in which the wounds had been healed for 17 to 21


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FIGURE 17.-Compound fractures of humerus and radius, lacerated wound of arm and forearm, sustained 25 June 1944. Initial surgery was done at a Royal Air Force Hospital, and the patient was received at the 91st General Hospital 29 June. He was returned to the Zone of Interior 7 August. A. Appearance of wound when reparative surgery was undertaken. B. Roentgenogram showing compound fractures of radius and humerus. C, D. Wound closure by suture and split-thickness skin graft after secondary, more extensive debridement.


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FIGURE 17.-Continued. E. Stage of wound healing 18 July, 2 weeks after reparative surgery.

days. Penicillin was used intramuscularly for a minimum of 5 days after operation.

Results of Delayed Primary Wound Closure in Compound Fractures

Overseas Theaters

Results of the policy of delayed wound closure were generally good in the European Theater of Operations. A report by Maj. (later Lt. Col.) John A. Grove, MC, on the work at the 15th Hospital Center is typical of both the material handled and the results of the policy. At this center, the policy of closing all soft-tissue wounds over compound fractures was immediately established and was continued throughout the war. At first, patients were received promptly, and delayed primary wound closure was possible within 2 to 6 days after wounding. In the later stages of the fighting in Europe, when patients had to be evacuated after deep penetration of their units into Germany, wounds were closed on an average of 14 days after wounding. It was the impression of the hospital staff that the results then were somewhat less good than they had been when closure was accomplished on the third or fourth day after wounding, as had frequently been possible in the first weeks of the early European fighting.

During the whole period from D-day to V-E Day, 60.3 percent of all compound fractures managed in this hospital center were treated by delayed wound closure. In another 25 percent, suture was omitted because the wounds were small and of the puncture type; in practically all of these cases, the wounds were well healed or were well on the way to healing when the patients were ready for evacuation. In the remaining cases, the wounds were severely infected and two policies of management were followed, (1) partial closure, and (2) evacuation of the patients to the Zone of Interior with open wounds.


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FIGURE 18.-Compound fracture of right femur, lacerated wounds of posterior thigh and buttock, sustained 16 June 1944. Debridement was done 14 hours after injury, and the patient was admitted to the 91st General Hospital 20 June. Here a secondary debridement was done and skeletal traction was applied. The wound was closed 16 July and by 22 August was well healed. The fracture was also satisfactorily alined. A. Appearance of wounds when patient was first seen in the 91st General Hospital. B. Roentgenogram showing compound fracture of femur. C. Appearance of wound when reparative surgery was undertaken approximately 3 weeks after wounding.


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FIGURE 18.-Continued. D. Wound closure by suture and split-thickness skin graft. E. Roentgenogram showing femoral fracture in satisfactory alinement 2 months after wounding. F. Appearance of healed wound 5 weeks after reparative surgery.


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FIGURE 19.-Compound fractures of tibia and fibula sustained 5 August 1944. Debridement was done at the 104th Evacuation Hospital the same day. Closure of the soft-tissue wound was attempted at the 82d General Hospital 14 August but was not successful. On 6 October, a split-thickness skin graft was applied but did not take. On 21 October a direct cross-leg pedicle graft was applied at the 129th General Hospital. It was divided 15 November and the patient was returned to the Zone of Interior shortly afterward. A. Roentgenogram showing compound fractures of tibia and fibula. B. Appearance of wound 21 October just before delayed primary wound closure by pedicle graft. C. Appearance of cross-leg pedicle graft 15 November just before division.


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FIGURE 19.-Continued. D. Appearance of wound after separation of pedicle graft.

Two somewhat more detailed statistical surveys of wound closure at the 15th Hospital Center were also made by Major Grove. The first included the period from D-day to 6 November 1944. The second covered the period from 1 December 1944 to 1 March 1945.

First series.-During the 5-month period ending 6 November 1944, the 15th Hospital Center received and treated 5,042 compound fractures, excluding fractures of the bones of the face and the skull, and fractures of the spine with associated spinal-cord injuries. With few exceptions, all of these fractures were battle incurred. Bones of the lower extremities were involved in 2,614 instances and those of the upper extremities in 1,895 instances. The remaining 533 fractures consisted, in the order stated, of fractures of the pelvis, scapula, patella, clavicle, and vertebrae. The bones most frequently fractured were the tibia (757), humerus (702), and femur (684).

Preparation for the reparative operation consisted of the standard routine, including transfusions of whole blood whenever the patient showed any evidence at all of anemia. Massive whole-blood replacement was frequently necessary. Whenever operation was delayed for any reason, the extremity was suspended in balanced suspension with skeletal traction, which reduced edema and facilitated later closure.

Delayed primary wound closure was attempted in 2,393 of the 5,042 cases, the average timelag between wounding and closure being 14 days. Closure was accomplished by suture in 2,087 cases, by skin graft in 236, and by a combination of suture and skin graft in 70 cases. In many large, frankly infected wounds, partial closure of the wound was performed with free drainage at the site of maximum infection; counterincisions were sometimes used for dependent drainage. This technique prevented the large losses of serum, with resulting protein deficits, which occurred from large draining surfaces. It was practically always accompanied by marked improvement in the patient's general condition.


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FIGURE 20.-Huge defect with massive loss of skin and other soft tissues on palmar surface of left forearm. Management by pedicle graft. A. Appearance of defect 8 days after initial wound surgery. Note exposed tendons. B. Outline of large pedicle graft from abdomen designed to fit defect on forearm. C. Application of pedicle graft to wound of forearm. Care was taken to avoid excessive tension. D. Healed defect 4 weeks after reparative surgery. It is reasonable to assume that the function of this patient's hand was salvaged chiefly because of the prompt application of a pedicle graft. Early healing could not have been obtained by any other method, and the several tendons exposed in the wound would certainly have sloughed if they had not been promptly protected by skin coverage.
This patient was treated by Lt. Col. Eugene M. Bricker, MC, senior consultant in plastic surgery, European Theater of Operations.

Healing by primary intention occurred in 1,592 of the 2,393 cases (66.5 percent) in which delayed primary wound closure was attempted. In an additional 640 cases (26.74 percent of the total number), closure was partly successful. Wounds in this category were characterized by small sinuses, stitch abscesses, or partial loss of skin grafts. With few exceptions, these wounds healed after secondary suture or secondary skin grafting or, in some instances, spontaneously. This meant, then, that a total of 93 percent of the 2,393


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wounds in which delayed primary closure had been undertaken were completely healed when the patients left the hospital.

In the remaining 161 cases, 6.73 percent of the total, the attempt at wound closure was a complete failure. The entire wound broke down, or an osteomyelitis developed and required wide surgical opening of the wound. These failures chiefly occurred in wounds involving the upper third of the femur or the pelvis, with complicating wounds of the bladder or bowel. Wounds involving the lower third of the leg and foot were also represented in the group of failures. Cultures from the wounds which failed to heal revealed mixed types of infection, with staphylococci and bacilli of the colon group predominating.

FIGURE 21.-Fracture of ulna, with large compounding wound in upper half of right forearm. Management by pedicle graft. A. Wound at reparative surgery 9 days after wounding. Note comminuted fragment of ulna held by tissue forceps. B. Pedicle graft from abdomen immediately after application to wound of forearm. C. Completely healed wound 5 weeks after reparative surgery.
This patient was treated by Lt. Col. Eugene M. Bricker, MC, senior consultant in plastic surgery, European Theater of Operations.


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FIGURE 22.-Compound fracture of right humerus, with paralysis of median, radial, and ulnar nerves, laceration of right brachial artery, and gangrene of tips of fingers of right hand. Wounds were sustained 22 September 1944. Skeletal traction was applied 1 October and a pedicle graft from the chest was applied 28 October; at the same operation, the humeral fracture was fixed with two screws. The pedicle was divided 21 November, and the patient was returned in a plaster spica to the Zone of Interior the following month. A. Roentgenogram showing compound fracture of right humerus with application of skeletal traction. B. Wound of posterior humeral region just before application of pedicle skin graft. C. Roentgenogram showing fixation of fracture of humerus by two screws. This procedure was carried out when the pedicle skin graft was applied.


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FIGURE 22.-Continued. D. Coverage of wound by pedicle from infra-axillary region. E. Healed wound and coverage of donor site by split-thickness skin graft.

It is a matter of interest that 2,152 of the wounds which were not closed surgically, approximately 42.6 percent of the total number, showed spontaneous healing during the period the patients were hospitalized overseas. The maximum holding period in this theater was 10 to 12 weeks at this time, depending upon the site of the fracture. The majority of the wounds which healed spontaneously were small penetrating or perforating wounds. This means that failure of healing occurred in only 658 wounds, 161 in which the attempt at closure did not succeed and 497 in which no attempt at surgical closure was made. In other words, within the holding period permitted, 87 percent of the compound fractures were converted to simple fractures by healing of the compounding wounds. Frank osteomyelitis occurred in 272 cases, 5.4 percent.

Second series-Between 1 December 1944 and 1 March 1945, 3,053 compound fractures were received and treated at the 15th Hospital Center, the


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same center from which the preceding study was made. Delayed primary wound closure was undertaken in 2,241, approximately 75 percent of the total. Eighty-seven percent of these wounds healed satisfactorily. The percentage of absolute failure was only 7.6 percent, since healing occurred spontaneously or later secondary closure was successful in another 5.4 percent of the cases, after failure of the first attempt at suture. The incidence of osteomyelitis was 7.6 percent.

It should be noted that during the period covered by the second of these two series, delayed primary wound closure was attempted in almost three-quarters (73.4 percent) of the cases, against less than half (45.4 percent) of the first series. The incidence of complete success on the first attempt at suture rose from 67.6 percent to 87 percent. The incidence of osteomyelitis rose from 5.4 percent to 7.6 percent, and the small increase may fairly be taken as an indication of how greatly the surgeons on the staff, in spite of the much bolder attack on the problem of wound closure, had increased in surgical wisdom and judgment. If they had not, the proportion of bone infection would undoubtedly have been much higher. In all probability, the success or failure of closure was always determined by the adequacy and boldness of the original wound excision and debridement. The results were better in the second series than in the first, because this lesson had been almost universally learned.

The good results in these cases can also be attributed to two other factors, the youth and generally good condition of the casualties and the generous use of whole-blood transfusions whenever they were indicated. A much higher percentage of good results was secured in the cases in which transfusions were used to correct anemia of any degree. There was no proof, however, that the incidence of serious wound infections in this series was materially reduced by the use of either the sulfonamides or penicillin.

Zone of Interior Hospitals

The results of delayed wound closure in compound fractures of the long bones could not, as already noted, be determined overseas. In December 1944, therefore, an attempt was made by the Office of The Surgeon General to investigate the results of this technique at 23 named general hospitals in the Zone of Interior. The outcome of the investigation was not particularly happy. It was probably undertaken too soon. When the bulk of the questionnaires which were answered were returned, less than 6 months had elapsed since D-day, and there had been insufficient time for the union of many major fractures. The wording of the questionnaires, or so the replies suggested, does not seem to have been as clear as it should have been. A number of different observers prepared the replies, and they naturally determined the results in accordance with their individual standards, so that the personal equation made it almost impossible to tabulate results, let alone correlate them. Finally, the reports on union of fractures (delayed union versus nonunion) were particularly colored by individual interpretations.


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Nineteen of the twenty-three general hospitals queried returned questionnaires covering 3,469 compound fractures. Of these, 1,180 were fractures of the femur, 1,540 were fractures of the tibia and fibula, and 741 were fractures of the humerus. Delayed primary wound closure had been attempted in 1,951 cases and had succeeded in 1,403. Of the 3,190 cases in which the information was supplied, bony union had been accomplished in 2,189 cases, but 417 patients presented malunion and 584 still had no union. The tabulated results confirmed the general impression that closure can be more readily accomplished over femoral and humeral fractures than over fractures of the tibia and fibula. Osteomyelitis was reported in 864 cases, but the figure is misleading since the incidence was figured on both closed and unclosed wounds.

Data from studies of compound fractures in which delayed primary closure had been attempted are more illuminating than the data just cited.

At Battey General Hospital, Rome, Ga., for instance, almost 90 percent of the compounding wounds were successfully closed in fractures of the femur and humerus, the incidence of union was high, and the incidence of osteomyelitis was low. In compound fractures of the tibia and fibula, on the other hand, the incidence of bony union remained high, and the incidence of osteomyelitis low but closure was successful in only about 60 percent of the cases.

In the other hospitals reporting, the number of cases in which closure had been attempted was frequently surprisingly small. Some of the results were also frankly surprising. Thus it is difficult to reconcile the 9 out of 10 failures in fractures of the humerus at Kennedy General Hospital, Memphis, Tenn., with the percentage of successes reported from certain other hospitals, particularly Battey General Hospital, where there were only 4 unsuccessful results in 38 attempted closures.

Unfavorable Cases

Nineteenth General Hospital.-An analysis of a sample of material from the 19th General Hospital is typical of the results obtained in delayed primary wound closure when the circumstances were frankly unfavorable. At this hospital, between 16 February and 31 May 1945, 881 wounds were closed by this technique in 379 patients.3 About 90 percent of these wounds were battle incurred. Almost all of them were severely comminuted compound fractures, chiefly of the long bones of the extremities. In many instances, extensive soft-tissue wounds were associated with the bone injuries.

Seventy-seven of the 379 patients were United States Army personnel; 298 were prisoners of war whose injuries were, almost without exception, the most severe and extensive in the reported series.4

When the patients in this series were first admitted to the 19th General Hospital, their wounds were inspected merely by lifting off the upper layer of the bivalved cast and the top layer of dressings. If the gauze was adherent to the wound, as it frequently was, it was not removed. If a through-and-

3Semiannual Report, 19th General Hospital, European Theater of Operations, 1 January-30 June 1945.
4There were four additional patients of other nations (see footnote 3.).


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through drain had been used, as it had been in a few instances, it was removed at once. If the wound was too tightly packed, the plug of gauze was also removed. The policy at this time was a minimum of wound inspection and manipulation.

If the preliminary inspection just described could be carried out on the ward it saved time. If, however, it was clear from the history that the wound was extensive or if the gauze could not be readily removed, then the first complete inspection was carried out under anesthesia in the operating room.

On the whole, the wounds were in reasonably good condition, and debridement had been adequate. Most of the wounds had been kept open by dry, fine-meshed gauze, lightly packed; only occasionally had the packing been inserted so tightly that it was actually plugging the wound. In some cases there had been too liberal a removal of comminuted bone fragments, and the large bony defects which were left could obviously be corrected only by bone grafting.

All patients with wounds of any severity had immediate blood studies and were given transfusions of whole blood before operation if the hemoglobin level was below 12 gm. percent and the hematocrit level below 35.

The technique of delayed primary wound closure was that ordinarily employed (p. 87).

The results in these 881 wounds in 379 patients were analyzed from several different standpoints. Complete data were not always available in each category.

In the 305 cases in which data are available on this point, wound closure was carried out on the 2d day in 2 cases and on the 75th day in 1 case. The (cumulative) figures show that 200 patients underwent reparative surgery between the 2d and 7th days after wounding; of these, 184 were operated on between the 4th and 7th days. Two hundred and twenty-five patients were operated on between the 2d and 8th days and 251 between the 2d and 10th days. The other 54 were operated on between the 11th and 75th days.

While these patients were under observation in the 19th General Hospital, 59 frank wound infections occurred among them. Seven were in United States Army personnel, and 52 in prisoners of war. Fifty-six of these 59 infections occurred in men wounded in battle, 50 of whom were prisoners of war.

Primary healing occurred after delayed primary wound closure in 195 patients, 68 of whom were United States Army personnel.

It was observed that the highest percentage of good results in these 379 patients was obtained (1) when the hemoglobin at operation was 80 to 90 percent and the red blood cells 4,000,000 to 5,000,000 per cu. mm.; (2) when the wounds were in the shoulder, arm, forearm, and hand rather than in the leg, ankle, and foot (almost 100 percent versus 67 percent); and (3) when the discharge from the wound was serous but not seropurulent.

Composite studies-In his annual report for 1944 to the Theater Chief Surgeon, the senior consultant in orthopedic surgery commented on two other reports dealing with delayed primary suture in prisoners of war.


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The first of these reports concerned 97 prisoners of war who had been caught between lines of fire.5 As a result, the timelag between wounding and initial wound surgery was unusually prolonged in most of these cases. Only 16 of the 97 had received penicillin or sulfonamide therapy before debridement. It is significant that only 33 of the 97 wounds (approximately a third) were considered clean enough to close at once by delayed primary suture.

The second of these reports concerned 51 prisoners of war, in most of whom the timelag was also unusually prolonged. Delayed primary wound closure was carried out in all cases but was entirely successful in only 32 instances. Partial healing occurred in 15 cases. In the other 4 instances, the attempt at closure was a complete failure.6

Three of the 32 patients whose wounds healed satisfactorily after delayed primary suture had finally been performed had undergone debridement on the day of wounding. The average timelag in the other 29 cases in this group was 32 hours. Of the 19 patients in whom delayed primary suture was only partly successful or was completely unsuccessful, 6 underwent debridement on the day of wounding, but in the other 13 cases the average timelag was 72 hours.

Only 7 of the 51 patients in this series had received penicillin before debridement was done; they had had an average of 50,000 units each. Thirty-one others received approximately 120,000 units each after debridement. Two of the four patients whose wounds had failed to heal had received penicillin and two did not.

The figures in this series are far too few to permit conclusions, but they corroborate the generally accepted fact that the longer the delay between wounding and initial wound surgery, the higher is the incidence of infection and the less satisfactory is the healing process. These cases also demonstrate again that basic surgical principles cannot be violated with impunity and that adequate debridement is the keynote of success.

That the use or nonuse of supplemental antibiotic therapy was not the most important consideration in the determination of the end results of wound closure in this series is clearly shown in another series, which consisted of 107 compounding wounds in 73 soldiers. Sixty-three of the 73 patients had received penicillin, sulfadiazine, or both after admission to a general hospital. The largest number of complete or partial failures of wound closure occurred in these 63 patients, although in every instance in the series the wounds had been closed within 13 days, or less, after wounding, which is a fairly early timelag.

The figures, of course, must be interpreted with discretion. These wounds were unfavorable for a variety of reasons. When the cases are carefully analyzed, other factors, such as inadequate blood replacement, the location of the wound, and the size of the wound obviously require consideration. Nonethe-

5Annual Report, Professional Service Division, Orthopedic Surgery, Office of the Chief Surgeon, European Theater of Operations, 1944.
6Ibid.


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less, in every failure or partial failure, the underlying reason was inadequate debridement; the use of chemotherapeutic or antibiotic agents was no guaranty of success when surgical principles were violated.

Combined Nerve-Bone Injuries

The exact frequency of peripheral nerve injuries in battle casualties is not yet known. If the experience of the 45th Evacuation Hospital between 24 June 1944 and 26 April 1945 is taken as typical, it is just over 1 percent.7 During this period, this hospital treated 14,891 surgical patients, all but 409 of the number with combat injuries. These patients presented a total of 20,740 separate wounds, 248 of which included damage to a major peripheral nerve.

About 75 percent of the compound fractures complicated by nerve lesions occurred in the upper extremity, with compound fractures of the humerus and injuries to the radial nerve comprising the great majority of these. Compound fractures of the femur, with division or other injury of the sciatic nerve, did not form more than 10 percent of the combined nerve-bone injuries. The distribution was fortunate. The humerus is not only easier to approach surgically than the femur but it also lends itself better to the shortening sometimes necessary in serious associated nerve injuries. A completely divided sciatic nerve which cannot be repaired leaves an almost useless lower extremity, even if the fracture of the femur heals in good position. In such cases, amputation occasionally proved the solution of the problem.

Routine of management-Several months after D-day, after a joint visit to several specialized treatment hospitals for neurosurgery by the senior consultant in orthopedic surgery and the senior consultant in neurosurgery, the following plan of procedure in combined bone-nerve injuries was proposed to the Theater Chief Surgeon and after his approval became official policy:

1. All casualties with fractures associated with division of a major peripheral nerve were transferred immediately to one of the seven specialized hospitals for neurosurgery in the United Kingdom Base. The same policy was followed when it was suspected that the nerve was contused but not divided. There was, in fact, no sure method of ascertaining, within the first weeks after wounding, precisely how much nerve damage had been sustained.

2. Wounds of the soft tissues were closed as soon as possible, by suture, by skin graft, or by both methods.

3. Fractures of the long bones were treated with skeletal traction and balanced suspension. No effort was made at this time to obtain anatomic length of the bone, because the attempt was likely to defeat the objective of bringing the nerve ends together.

4. Physical therapy was employed as extensively as possible to encourage active motion of the unparalyzed muscles and to maintain mobilization of the joints of the extremities. It included both diagnostic and therapeutic electric stimulation of the injured part.

7 Semiannual Report, 45th Evacuation Hospital, European Theater of Operations, 1 January-30 June 1945.


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5. Definitive neurosurgical and orthopedic surgical procedures were performed approximately 3 weeks after complete healing of the wound, which was usually 5 to 6 weeks after wounding.

6. After operation, if a circular plaster-of-paris splint was applied, windows were cut out over the muscle bellies, to allow postoperative electric stimulation of the paralyzed muscles. Some cases, as indicated later, were managed by skeletal traction with balanced suspension, without plaster.

7. A booster dose of tetanus toxoid was administered before each operation.

8. Penicillin was administered for 48 hours before each operation and for 10 days afterward.

9. Evacuation to the Zone of Interior was effected as promptly as possible, with a plaster splint in place.

Technical considerations-The first step in the management of combined nerve-bone injuries was to secure closure of the wound. If simple suture was not sufficient, a skin graft was used. If the plan for the second operation was to approach the nerve injury through the original wound, full thickness of skin was required, and a full-thickness graft was used. Otherwise, a split graft was used.

After the wound had been completely healed for about 21 days, a second operation was done to explore the nerve injury and repair it as necessary. About 50 percent of the nerve injuries explored in the European Theater of Operations proved to be instances of contusion and not of division. The nerves were found intact and only neurolysis was required, though, as already emphasized, exploration was frequently required to establish this fact.

Whenever possible, the bone injury was cared for at the time that the nerve injury was repaired. This was frequently practical, especially when the neurosurgical center was part of a hospital center and competent orthopedic surgeons were immediately available. When the nerve and bone injuries could be repaired at the same time, it was estimated that the soldier was saved at least 6 months of hospitalization. If the combined operation was not possible, the nerve injury always took precedence over the bone injury.

The neurosurgeon first exposed the nerve and performed the necessary nerve surgery. If possible, nerve suture was performed. If it was impossible to bring the nerve ends together, no hesitancy was felt in shortening the bone, it being regarded as more desirable to have a shorter functional extremity than to have a paralyzed limb of normal length. Motion of the elbow joint was not impeded if the humerus was shortened on an average of 5 cm.

After the nerve repair had been accomplished, exposure of the bone offered no difficulty. Various methods of management of the fracture were employed. Fragments of the humerus were often held in position by one or two screws. Screws could also be used on the femur, or it could be plated. Bone fragments were often used as autogenous grafts, but care had to be taken to place them in such position that they would not impinge upon the nerve.

Balanced suspension with skeletal traction was preferably used after operation. This method had two advantages: Elevation of the limb prevented


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edema, which was particularly undesirable after nerve surgery; and electric stimulation was easily carried out because the motor parts were exposed.

The percentage of shortening operations varied from hospital to hospital but was, on the whole, larger than might have been expected in view of the numerous injuries in which only neurolysis was necessary. Thus, in one 3-month period at the 117th General Hospital in the United Kingdom, 19 percent of the patients with combined injuries of the humerus and radial nerve required shortening operations.

The results in 10 cases treated by this technique at this hospital are fairly typical of the results achieved in shortening operations. The amount of shortening varied from 2.5 to 7 cm. and averaged 5 cm. Within an average of less than 11 months of hospitalization, 4 of the 10 patients received certificates of disability for discharge and had returned to civilian life, while 4 others were on furlough, in expectation of discharge under the same circumstances. No details are known of the ninth case except that the patient was discharged. The 10th patient had such a severe nerve injury that a tendon transplant was regarded as a better procedure than the 9 cm. of shortening which would have been required to approximate the nerve ends. Eight of these 10 patients had well-healed fractures when they were last seen. The only one whose fracture failed to heal satisfactorily was later treated by bone graft. In 8 cases, radial nerve function had ranged from 50 to 80 percent of normal when the patients were discharged from service.

Full details of the management of nerve injuries are set forth in the volume of this series dealing with neurosurgery.

Combined Vascular-Bone Injuries

Most often the vascular injuries associated with bone and joint injuries were caused by the direct effect of missiles, though occasional damage to the popliteal artery resulted from penetration of the vessel by bone fragments in supracondylar fractures of the femur. Vascular injuries associated with bone or joint injuries naturally took precedence over them and required immediate surgery. Full details are given in the volume of this series devoted to vascular surgery.

Almost without exception, loss of the leg above the knee resulted in all cases in which immediate ligation of the popliteal vessels was necessary. If ligation could be deferred for as long as 3 to 5 days, it was sometimes possible to perform the amputation below the knee, resecting the anterior lateral group of muscles, which was most frequently involved, and leaving the patient with a more useful stump. Ligation of the femoral artery below the level of the profundus was attended with little risk to the limb.

After ligation, the limb was protected from trauma and was kept cool. In the absence of edema, the dependent position was preferred. If edema was present, the limb was kept level with the body. Sympathetic blocks with Novocain were repeated as often as necessary, and in some hospitals the patients


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were given small amounts of whisky by mouth to encourage dilatation of peripheral vessels.

Sympathetic block was of great value in the management of vascular spasm, which was often associated with compound fractures of the long bones of the extremities. It was also of value in persistent edema and in causalgia, which were other complications of bone and joint injuries. Sympathectomy was performed in some cases after the value of repeated sympathetic blocks had been established.

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