Contents

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SECTION II

ORTHOPEDIC SURGERY

CHAPTER III

FRACTURES CAUSED BY PROJECTILES

In Chapter III of the volume on general surgery, statistical data concerning fractures may be found. Only brief references to the relative incidence of such injuries are made here.

As a measure of the importance of fractures in military surgery, it may be stated that among the 153,527 battle injuries (excluding trauma by deleterious gases) in the American Expeditionary Forces, there were 25,272 patients (16 percent) with fractures, the major portion complicating gunshot wounds, when consideration is taken of the varied character of such fractures, their almost invariable infection, and the attendant difficulties to which they gave rise in transportation, it may readily be seen that they presented ever-varying problems to the military surgeon.

PRIMARY MANAGEMENT

The primary management of fractures accompanying gunshot wounds, as has been told in Chapter 1, was a function of the Medical Department of a tactical division of troops. To effect this the equipment was set up in places as favorable as possible to the successful operation of a plan of evacuation, and in as close contact with the troops actually engaged in fighting as the military situation allowed. The precepts of such management, as outlined in the Manual of Splints and Appliances, ² are: (1) The application of first-aid, splints, and dressing, to the wounded soldier where he falls. (2) The transportation of the wounded soldiers to an aid post-usually by litter carry.(3) The treatment of shock and hemorrhage and proper splint and dressing application at an aid post. (4) The transportation of the wounded soldier to a hospital where proper facilities make it possible to carry out surgical treatment by motor or animal-drawn ambulance. The following supplies in splints and splinting material were to be carried by the various medical units and detachments in quantity sufficient to meet the casualties of 24 hours' severe combat:

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CHART

FIG. 42.-- Destruction if or humerus, outer portion of the clavicle, head of the scapula, and comminuted fraction of the humerous by rifle missile. Fragments of the shattered missile shown in the soft tissue.

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As carried out in the American Expeditionary Forces the primary management of all fracture cases with reference to splinting was very similar in the front lines and may be outlined in a general way. The object in each case was to get the wounded man back to the evacuation, or mobile surgical hospital in condition for whatever operation was necessary, and, in order that he might arrive thereat in condition for operation, it was necessary, to minimize shock, to protect him as much as possible from cold, pain, and hemorrhage. This was accomplished by the following routine: After a man with a fracture had been removed to the first available shelter, a splint was applied, the wound

FIG. 43.-  X-ray picture, showing fractured clavicle and lodged missile in the outer end of the clavicle

was exposed, and the dressing applied to the wound after the control of hemorrhage: antitetanic serum and morphine were administered, whereupon he was ready for transportation back to the advanced ambulance dressing station. As soon as possible after arriving at the ambulance station, the dressings were inspected as to hemorrhage, the limb as to swelling; the splint was adjusted if necessary, and the man's general condition observed. He was given a hot drink and, if cold, was warmed either by extra blankets or by placing the litter over a Primus stove. He was kept at the ambulance station long enough to get thoroughly warmed before being placed in the ambulance for the triage or operating station.

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FIG. 44.-  Fissure fracture of the greater tuberosity of the humerus by shell fragment, which is shown lodged

FIG. 45.-  Comminuted fracture of the upper portion of the diaphysis of humerus, with moderate dispersion of bone fragments

FIG. 46.- Fracture of upper end of diaphysis of humerus by rifle missile, with much loss of bone. Fragments of the missile are shown dispersed in the tissue about the head of the humerus

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    The medical personnel of the combat troops was informed as to the importance of getting a gunshot fracture case back to the operating station as soon as possible so that the infection might be better controlled by early débridement, and that an important factor in keeping him comfortable on the way back was proper splinting of the fracture. Therefore, little attempt was made in the

FIG. 47.- Wound of the upper portion of the shaft of the humerus. The fragments of bone are large and but little separated, through there is considerable displacement

FIG. 48.- Fracture of middle of shaft of humerus by shell fragment; moderate separation of bone fragments. Shell fragment, relatively large, lodged

forward area to cleanse the wound; it was impossible to do so properly, and by merely applying the dressing, more attention could be given to the application of the splint and control of hemorrhage.

SHOULDER

Gunshot wounds of the shoulder, either with or without fracture of the scapula, clavicle, or upper portion of the humerus, often were associated with

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chest injuries, and frequently it was not possible to splint these cases. The large triangular bandage was applied and the arm pinned securely to the side.

UPPER EXTREMITY

HUMERUS AND FOREARM

It soon proved that the hinged traction arm splint was best adapted for arm and forearm fractures in the forward area, the reason being that with the

FIG. 49.- Wound of diaphysis of humerus by rifle misille, with wide separation of bone fragments

FIG. 50.-  Compound, comminuted fracture, lower end of humerus, result of deformed rifle missile

hinged arm splint, the arm could be carried at the side-an advantage for litter cases. Another important factor was that, because they were more compact, these splints could be carried forward much more conveniently than could the full ring splints. Some difficulty was experienced at first in securing traction in the arm splints, or rather too much traction was attempted. Since

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a hitch or tic of any kind around the wrist often produced excessive swelling of the hand and pressure sores, it proved necessary to forbid its use, and instead it was suggested that adhesive plaster be applied to the forearm and wrist for extension. Experience proved, however, that it was not necessary to have any great amount of traction, and that the splint could be held in place by a bandage through the ring passed over the opposite shoulder. The slings, in which the arms were to rest, were made of ordinary muslin or flannel bandage, and were placed rather far apart. The wire-ladder splint or flexible board was used for support, and the arm was firmly bandaged to the side bars of the splint. In many instances, however, the Jones humerus traction splint was used in the forward areas; it was better adapted for walking cases than for litter cases. When the humerus was fractured traction was made by bandaging the forearm firmly to the splint, countertraction being secured by a bandage over the opposite shoulder, thus holding the ring well up in the axilla, wire-ladder or board splints being applied over the dressing and the arm bandaged to the splint. As the use of adhesive plaster required the removal of too much of the clothing, resulting in undue exposure, it was not practical for arm traction.

In fractures of the upper portion of the forearm traction was obtained by a hitch placed on over the clothing of the lower third of the forearm and tied to the end

FIG. 51.- Rifle missile injury of shafts of ulna and radius, and indirect fracture of shaft of humerus

of the splint, countertraction being secured by bandaging the arm to the upright side bars and securing the splint by a bandage through the ring across the opposite shoulder. (No bad effect was noted from the hitch in flexed arm splints.) Support by means of wire splinting was used and the arm bandaged.

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WRIST AND HAND

For fractures of the wrist and hand, wire-ladder splinting, plain boards, or the Jones "cock-up" splints were used. In all these cases, rather firm bandaging was practical over a large dressing which controlled hemorrhage. obviating the necessity of a tourniquet in cases of bleeding at the wrist or in the hand, and better immobilizing the fractures.

FIG. 52.- Fracture of upper ends of ulna and radius by rifle missile. There is coinsiderable displacement of the fractured shaft of the radius. The lodged missile shows the common form of deformation peculiar to the "spitz” or pointed bullet. This bullet frequently tends to lodge when it strikes cancellous and compact bone tissue

LOWER EXTREMITY

FIRST-AID SPLINTING

For first-aid splinting of the lower extremity the Thomas half-ring leg splint was applied for all fractures from the pelvis to the ankle. After its adjustment and the injured soldier was placed on the litter, this splint was suspended from the litter bar, otherwise it tended to be displaced and traction

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was lessened. The Thomas half-ring splint had advantages over the full-ring splint in the divisional areas; it is lighter, more readily transportable in numbers because it requires less space, and is not so apt to be broken during shipment as the full-ring splint.

FIG. 53.- Fracture or shaft of femur, juncture of middle and lower thirds, by rifle missile, showing explosive effect of missile striking compact bone. Comminution is extensive, the bone fragments are widely separated. Missile fragments are dispersed In the soft tissues

In applying the splint to secure the needed traction, three important points must be borne in mind: (1) The proper pressure upon the tuberosity

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of the ischium. Of course, in getting traction, one must have traction of the foot and countertraction at the head, and the countertraction is obtained by the pressure of the ring of the splint on the tuberosity of the ischium. One of the

FIG. 54.- Same as Figure 53, taken three months after the receipt of injury, showing progress of repair, such as callus formation and sequestration. There is marked angulation of upper and lower fragments

greatest faults was to allow the ring to slip up over the tuberosity, thus losing all traction. (2) The traction anklet. The men had a great tendency to remove the shoe. This took time, it hurt the man, and there was no excuse

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for it. The canvas anklet, which was developed and carried on every splint, was made to fit over the field shoe, and if the shoe was not left on one had to use the foot. Removing the shoe was one of the common mistakes made in

FIG.55.- Fracture of shaft of femur by shell fragment, shown lodged. There is some displacement but little or no comminution

the application of this splint. The shoe would be removed, no cotton padding would be used, consequently the anklet did not fit; it caused undue pressure on the foot and shut off the circulation. (3) The method of supporting the limb. The simplest and quickest way to apply the Thomas half-ring splint under field

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conditions is with three triangular bandages. These are folded as one would fold a cravat, about 4 inches wide, and one of them is applied behind the middle of the thigh. It is passed through under the thigh and over the two side bars and then down around the back of the-thigh again, crossed and tied in front, thus providing support from behind and in front. In the same manner one is applied at the middle of the leg and at the knee. This is all the support needed; already the dressings have been applied, there remains then but the necessity for a circular bandage around the splint and the leg. Needless to say, it is necessary to support the leg on the litter bar.

FIG. 56.-  Rifle bullet wound, lower extremity, femur. Because the missile was nearly spent there has been no marked destruction of bone.

FIG. 57.- Same as Figure 56, viewed from front

The method of first-aid application of the Thomas splint, practiced in drilling the men to familiarize them with the use of the splint, was the same as that taught in the school of instruction for the medical services of the British First Army. The full text is as follows:

DRILL FOR FRONT-LINE APPLICATION OF THOMAS SPLINT

The Thomas outfit consists of: Stretcher on trestles. Blankets, three. Primus stove. Thomas splint (largest size). Reversible stirrup (Sinclairs). Suspension bar. Flannel bandages (6 yards), three. Triangular bandages, four. Dressings. Safety pins. Gooch' splinting (10 by 6 inches and 8 by 6 inches).
             
Personnel required: Operator. No. 1 assistant. No. 2 assistant (if available). When not in use the splint is kept hung tip. The five slings of flannel bandages are rolled around the inner bar of the splint, the leather is kept soft by saddle soap, and the iron bars are kept smeared with vaseline.

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INDICATIONS OF FRONT-LINE API LICATION
             
1. For all fractures of the thigh bone, except where there is an extensive wound in the upper part of thigh or buttock, which would interfere with the fitting of the ring.
2. In severe fractures about the knee-joint or upper part of the tibia.
3. In certain cases of extensive wounds of fleshy part of thigh.

FIG. 58.- Compound, comminuted fracture, lower extremity of femur, with marked dispersion of fragments, resulting in a destruction of both condyles, due to a laterally perforating rifle missile

DETAIL OF THOMAS’ SPLINT DRILL
             
I. Warming (Réchauffement). On the word " One."-The stretcher placed on trestles, with a Primus stove beneath, is prepared as follows: The first blanket is folded lengthwise into three, two folds lie on the stretcher, one hangs over the side. The second blanket is arranged in the same way, one fold hanging over the other side of the stretcher.
             
The patient is now placed on the prepared stretcher and lies on four folds of blanket; the two folds hanging down form a hot-air chamber. The third blanket is placed across the patient's chest, while the splint is being applied.

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FIG.59.- Pistol ball wound, head of tibia, showing effect of low-velocity missile on spongy bone. Note tract of missile
  
FIG. 60.-  Same as Figure 59, viewed from inner side

FIG. 61.- Penetration of upper extremity of tibia by rifle missile, with slight detachment of fragment of shaft.

FIG. 62.- Same as Figure 61, viewed from front

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II. Extension. On the word "Two."- No. 1 assistant stands at the foot of the stretcher facing the patient and opposite the injured limb. Grasping the heel of the boot with his right hand and the toe with his left, keeping the arms straight, he exerts a steady pull, thereby

FIG. 63.- Perforating wound of upper portion of shaft of tibiae by rifle missile. Much loss of bone shows, but there is little displacement of the bone fragments

producing the necessary extension. No. 2 assistant supports the injured part above and below the fracture.

III. Clove hitch. On the word "Three. "- To form the clove hitch the operator takes a length of 9 feet of flannel bandage. Holding it in the left hand by its mid-point, he grasps the center of the left half with his right hand, palm to the right, and makes a loop which is

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carried up and passed behind the left hand, thus forming a clove hitch with a diameter of 10 inches.

This is applied over the boot with the short end on the outer side; the long end is carried under the instep, up and through the loop around the ankle. The two extension bands thus produced are ready to be attached to the splint later on.

FIG. 64.- Same as Figure. 63, viewed from the back

IV. Splint. On the word "Four."- The operator threads on the splint. No. 1 assistant removing and reapplying upper and lower bands alternately to allow the ring to be passed over the foot. The splint should be pushed up under the buttock as far as possible, care being taken to keep the notched transverse bar horizontal. No. 2 assistant as before, steadies the thigh.

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V. Fixation of leg. On the word "Five."- 1. The extension bands of the clove hitch are tied around the notched bar at the end of the splint as follows: The outer band is passed over and under the bar, round the notch, drawn taut, and held over to the opposite side. The inner band is passed under and over the bar, then also round the notch where it crosses the first band and prevents its slipping. The two are finally tied off by a half bow.
2. The middle flannel sling is tied behind the knee which is held partly bent by No. 2 assistant.

FIG. 65.- Compound. comminuted fracture of shaft of tibia, showing typical " butterfly " arrangement of fragments

FIG. 66.- Fracture of middle of diaphysis of tibia, caused by shell fragment. Indirect fracture of fihula. Shell fragment shown lodged

3 and 4. The slings behind the ankle and calf are tied 89 that the leg rests in a shallow trough, with its center on a level with the long bars of the splint.
5. To prevent the leg rising off the splint, a narrow fold bandage is placed across the leg just below the knee; the ends are carried down between the leg and splint and brought up outside the bars and tied off in front of leg. The lower limb is now firmly fixed in a position of extension and it may be moved freely without causing pain to the patient or damage to the injured part.

VI. Dressing wound of thigh. On the word "Six."- The wound is exposed by cutting away the overlying portion of trousers on the front or back of the thigh, and the dressings are then applied.

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VII. Gooch splints and bandages. On the word "Seven."- The Gooch splints are now applied. The short piece is placed behind and secured by tying the remaining two slings The long piece is placed on the front of the thigh, care being taken to avoid pressure on the knee cap. The whole is now retained in position by two narrow-fold bandages carried round the thigh outside the bars of the splint.

VIII. Stirrup and figure of eight. On the word "Eight."- The stirrup is "sprung"on to the splint above the ankle, its foot toward the stretcher. A bandage is then applied

FIG. 67.- Extensive destruction of shaft or tibia caused by shell fragment. Metallic dust is shown in the surrounding soft parts. X-ray taken subsequent to débridement

FIG. 68.- Perforating wound of lower end of diaphysis of tibia. Though there is comminution of the bone fragments are not widely separated. Foreign body lodged between tibula and fibula

to form an additional sling, and by a figure-of-eight turn prevents lateral movement of the foot.

IX. Spanish windlass. On the word " Nine. "- The extension bands are tightened, and a small piece of wood or a nail is introduced to increase the tension by twisting up as required.

X. Pad in ring. On the word " Ten."- A pad is placed inside the ring on the outer side of the thigh to act as a wedge and prevent undue movement.

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XI. Suspension bar. On the word `'Eleven." - The suspension bar is fitted to the stretcher with the "grip" away from the rackets. The splint is slung up three fingers' breadth from the horizontal part of the suspension bar. To damp down the side movements, lateral tapes are tied to the uprights. For the journey in the motor ambulance car an additional band may be passed from the splint round one handle of the stretcher.

XII. Hot-water bottles and blankets. On the word "Twelve."- Hot-water bottles are applied. The third blanket is folded into two lengthwise and laid over the patient. The hanging folds of the first and second blankets are brought up over this so that the patient is evacuated with four folds of blanket on top as well as underneath.

It was surprising how efficient the men became in the application of this splint, even if they had had but little training. As a matter of fact, the above technique could not be so methodically carried out in a shell hole, but the splint could be put on under almost any condition so that the wounded man could be moved back fairly comfortably to where proper adjustment could

FIG. 69.- Cloth goiter, applied over shoe for extension

be made. The comfort of the patient was in direct ratio to the efficiency of the application of the splint, and the task of the litter bearers was much easier if their patient was uncomplaining.

Where there was an extensive wound of the thigh and hip the long Liston splint was applied in some cases and, while it was far from satisfactory. it was of value. For the knee-joint injuries and the upper leg fractures the Thomas splint was used almost exclusively, as it was found to be more comfortable than the Cabot splint. The latter, however, was used to some extent in this group when there occurred a shortage of Thomas splints.

As a rule, men with fractures of the lower extremity were in greater shock on arrival at the ambulance dressing station and required more care than did those with fractures of the upper extremity.

The Cabot posterior wire splint was applied to fractures of the lower extremity occurring so far down the leg as, to prevent applying traction to the foot without danger. The important points to be remembered in its use were

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the necessity for pressure pads behind the ankle and behind the knee and the additional use of lateral wire-ladder or board splints to more securely fix the limb.

OPERATIVE TREATMENT IN HOSPITALS AT THE FRONT

As a rule every gunshot fracture was operated upon, with the exception of the through-and-through machine-gun bullet wounds in which there was little comminution of the bone. The operation (débridement) necessarily included attention to the soft parts as well as to the hone. Since débridement of the soft parts has been given full consideration in Chapter XI of the volume on general surgery no further mention of it will be made here.

When cases of gunshot fracture reached those advance hospitals in which it was possible to do aseptic surgery, they were inspected as to their general condition and as to the condition of their wounds. Patients in bad general condition were sent to resuscitation wards until their condition permitted proper surgical treatment. An almost invariable prelude to any operative intervention was an X-ray examination.

The extent of operative treatment of the fractured bone was contingent upon the presence or absence of infection. Penetration of the diaphysis was usually considered as giving rise to infection of the medullary canal. thus necessitating laying open and exploring it. Detached bony fragments were invariably removed; such fragments are foreign bodies, and if left, necrose in the presence of infection, thus leading to troublesome subsequent bone fistula. In the event it was expedient to remove fragments that were still attached to the periosteum. to effect the necessary exploration and cleansing of the medullary canal, these fragments were so removed as to leave the periosteum intact to insure future osteogenesis.

It was the almost invariable rule not to close, by primary suture, any compound fracture wounds in the hospitals at the front, in view of the fact that patients so injured necessarily had to be evacuated at the earliest possible time and therefore could not remain under the observation of the surgeons originally treating them. Usually, Dakin tubes were inserted and dressings applied, whereupon the patients were turned over to splint teams whose duty it was to make proper alignment of the fractures and to apply permanently the necessary splints.

Since sepsis was met more commonly in compound fracture cases in the base hospitals, the treatment of this complication is given subsequent consideration in connection with the later treatment of compound fractures.

FIXATION TREATMENT IN MOBILE AND EVACUATION HOSPITALS

The splints for the treatment of fractures in mobile and evacuation hospitals, while necessarily embodying principles which would effect fixation and traction, according to the necessity of the case, nevertheless, because of the transitory stay of patients in these hospitals, inevitably had to conform to the restrictions imposed by the necessity of transporting the patients farther to the rear; that is to say, the splints must be few in number; they must be speedily and rapidly applicable so as to make immediate transportation possible. To this end

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the following instructions were issued to surgeons of mobile and evacuation hospitals.^l

Familiarize yourself with the exact number of each splint and splint accessory now in the hospital necessary to carry on the work. Check up with the following list and have the commanding officer requisition the splints not on hand.

LIST OF SPLINTS, SPLINT ACCESSORIES AND DRESSINGS FOR AN EVACUATION HOSPITAL

CHART

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2. Keep this supply always on hand, by requisition on advance Medical supply depot or on emergency depot of your area.
3. Establish special splint depot for your hospital either in tent or room, as seems best, where splints are always under your control and ready for use.
4. Keep operating room adequately supplied with splints and splint accessories, so that they may always be ready for immediate use.  
5. As soon as operation has been finished and dressings applied have your splint team immediately apply proper splint. You will be held responsible for the proper splint of each case.   
6. Supervise the splinting of each case ill the wards and see that the apparatus is in proper order at all times during the patients' stay in the hospital.
7. At time of evacuation see that all apparatus is properly adjusted so that it will effectually stand transportation.    
8. Establish all exchange bureau at receiving ward where ambulance driver may receive a splint for the one left on patient. All ambulance drivers are required to obtain splints, stretchers, and blankets to replace those they have left with the wounded.

Satisfactory fixation can not be obtained unless the splinting material used extends well above and well below the lesion. The fixation splints used in these hospitals were the snowshoe litter, the long Liston splint, Cabot posterior wire, and such fixation material as board splints, wrist and hand splint, and wire-ladder splinting. In certain exceptional instances plaster-of-Paris casts and shells.

Wherever possible traction splints were to be used. For example, in fractures of all long bones and in war injuries to the knee and elbow joint.

The traction splints recommended for use in these hospitals were: The hinged traction arm splint; Thomas traction thigh and leg splint; hinged half- ring thigh and leg splint. Traction was obtained by means of adhesive material fastened to the skin. Zinc oxide adhesive was provided for this purpose and was used preferably in fractures of the upper extremity. The adhesive bands were so applied as to avoid constriction of the limb. The strips were tied to the end of the splint and further traction made by the use of a small piece of wood or nail in the manner of a Spanish windlass.

Many surgeons preferred to use a glue applied to the leg with a brush, the last stroke of the brush being upwards in the direction opposite to the growth of the hail. Extension strips of unbleached muslin were used for this purpose.

Two types of glue were provided-Sinclair's, and resin and turpentine, permitting traction to be made within five minutes after the application. Sinclair's glue consists of best cabinetmaker's glue, 50 parts; water, 50 parts: glycerine, 2 parts; calcium chloride. 2 parts: thymol, 1 part. This glue should be heated in a water bath at a temperature of about 100^° F. before using. The addition of sufficient bicarbonate of soda will slightly alkalinize the reaction. The resin and turpentine glue consists of resin, 50 parts; alcohol, 50 parts; benzine (pure) 50 parts: Venice turpentine, 5 parts.

Powder the resin, then add half the alcohol, then the Venice turpentine and benzine, washing the measure into the bottle with the remaining alcohol. This glue may be removed with alcohol or ether. The bottle containing the glue should be kept tightly stoppered else the proportions of the constituents may change, and the glue, become irritating to the skin. This glue does not require heating before use, and should not be applied too thickly.

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TREATMENT IN BASE HOSPITALS

Because it frequently was necessary to move patients from base hospitals farther to the rear, or even to the United States, their transient status had to be kept constantly in mind, in so far as fracture treatment was concerned. Therefore, the principles used in the treatment of fractures for transportation always had to he borne in mind and the necessary apparatus maintained to carry them out.

FIG. 70.- Fracture ward, Base Hospital No. 41, St. Denis, Paris

In addition, however, more permanent apparatus was provided for fracture cases which remained in the hospital for the greater part of their treatment and convalescence. This apparatus included the following articles:¹

LIST OF SPLINTS, SPLINT ACCESSORIES, AND DRESSINGS FOR A BASE, HOSPITAL. OF 1,000 BEDS

CHART

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CHART CONTINUED

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FIG. 71.-Treatment of fractured humerus

UPPER EXTREMITY

To successfully transport a patient with fractured humerus back to a base hospital, the hinged traction arm splint was generally preferred because it allowed the arm to come down to the side of the body, thus facilitating the transfer; however, many patients reached the base hospitals in straight arm splints and in Jones traction arm splints. Efforts were made to maintain the length of the humerus even though a section of the bone had been removed, as it was found that new bone often formed to bridge such a gap, especially when any periosteum remained.

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FIG. 72.- Compound, comminuted fracture involving shoulder joint. Arm abducted, hand semisupinate

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FIG. 73.– Compound, comminuted fracture involving shoulder joint. Cast in position of abduction; hand semisupinated. Note windows cut for dressing and pelvic support.

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When a man with a fractured humerus arrived at the base hospital, the apposition of the fragments was considered. Up to this time, most of the attention had been centered on the control of sepsis, extension and fixation had been used to approximate the fragments as nearly as possible and to make the transportation of the patient as comfortable as could be. The case was X-rayed as soon as possible; better drainage was instituted if necessary, and attention was given to approximation of the fragments. In fractures of the upper third the arm was abducted, and if the patient had come back in a hinged Thomas splint, this usually was removed and a Thomas humerus traction splint applied. It was noted that often the arm was left extended at the elbow for too long a time, resulting in difficulty in getting flexion at the joint after the fracture had healed. It was also noted that too much abduction was maintained in some cases, but this produced no disability. In cases where the head of the humerus and the shoulder joint were involved abduction of about 45°, with traction, was maintained with the forearm in supination, as this is the best position in ankylosis. When the arm was fractured in the middle third, it was extended with traction and the forearm placed in about two-thirds supination. In the lower third, flexion of the elbow to a right angle with the forearm in complete supination, with traction on the forearm, was the most favorable position in which to maintain apposition. The Jones humerus traction splint was most adaptable for this type. The arm was suspended by means of the Balkan frame in practically all of the cases. This suspension added to the patients' comfort and facilitated irrigating and dressing the wounds. Continuous irrigation by the Carrel-Dakin method was used in most of the badly infected cases. Time results were entirely satisfactory where it was possible to maintain the proper technique.

The management of the sepsis often required additional drainage and the removal of sequestra. In other words, the osteomyelitis had to be treated. In some cases, too much operating was done with the result that the infection was spread into new areas and septicemia developed. It was found that the better policy was to allow the condition to become subacute and to wait until the sequestra had become loose before attempting their removal.

After union had occurred in the cases of fracture of the upper third of the humerus, it was the custom to get the patients up and out of bed. This necessitated putting the fracture up in some form of ambulatory abduction splint. Inasmnuch as very few airplane splints were available, it was necessary for orthopedic surgeons to devise and manufacture their splints, thus resulting in the use of about every kind and type that provided flexion at the elbow and extension of the abducted upper arm.

Most of the hospital centers in the American Expeditionary Forces developed some kind of an orthopedic shop for making the needed accessories in the splint line. Many cases required special splints that were not available on requisition and these also were made in the special shops.

FOREARM, WRIST, AND HAND

Compound fractures of the forearm presented great difficulty in their treatment. In fracture of both bones, on account of the usual comminution and projection of bone splinters into the soft tissues, cross union or callus

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interference frequently occurred; moreover, adequate drainage was difficult to maintain, owing to the numerous muscles and tendons. Extensive sloughing of tendons caused lamentable loss of function in several cases. It was important to maintain traction in fractures of the radius and ulna even when only one bone was broken, especially was this true in fractures of the lower portion of the radius as mesial deviation of the hand with marked loss of function occurred if the radius shortened. Usually the Jones humerus traction splint was applied in these cases, the traction being maintained by tying the adhesive strips to the end of the splint. These cases were evacuated early and after they reached the base hospital further extension was made by applying traction to the splint by means of a weight and pulley after the splint was suspended.

FIG. 74.- Method of treatment of fracture of both bones of forearm

They were treated as bed cases until after the, infection had been controlled. In many instances, the hinged arm splint or the Thomas traction arm splint, when bent to a right angle at the elbow was well adapted to these cases. The hand was completely supinated in a large percentage of the cases treated. When partial union had taken place it was usually not necessary to change the type of splint in order to allow the patients to become ambulatory.

The chief difficulty encountered was maintaining traction; if the wound extended to the lower third of the forearm there was very little room to apply adhesive tape; owing to circulatory conditions it was not possible to apply a bandage tightly to the wrist. To secure needed traction, Sinclair's method of gluing a cotton glove to the hand was very satisfactory when used; also it was possible to secure considerable extension by applying strips of adhesive

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FIG.75.- Compound comminuted fracture carpal and metacarpal bones, showing banjo splint with traction of fingers and molded palm. Plaster splint fitted to palm of hand with moderate dorsal flexion of wrist

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tape to the fingers and tying the ends to the splint, due care being taken, just as with the glove, to equalize the pull on the fingers. Marked swelling of the soft parts was frequent, but very few cases of ischemic paralysis resulted, probably due to the fact that the wounds prevented destructive pressure on the muscle tissue. Frequent drainage operations were necessary but fewer operations for sequestra were required, as compared with other bones.

Fractures involving the bones of the wrist and hand frequently were kept for too long a time in straight splints and often when the Jones "cock-up" splint was used, the fingers became stiff in extension. The reason for this is obvious. These injuries were not serious as to life and the surgeon's attention was centered on the important cases. This condition, however, required munch effort in the readjustment, such as dorsi-flexing the wrist and mobilizing the wrist and fingers.

FIG. 76.- Application of finger splint, showing extension applied

LOWER EXTREMITY

Gunshot wounds of the femur were among the most fatal injuries that were dealt with in the war. A simple fracture of the femur occurring in civil practice is even more serious than it is usually considered, and often is difficult to bring to a successful result. If one stops to consider the problem of the management. in all its many phases, of a compound fracture of the femur as presented by modern warfare, it is remarkable that the mortality, while exceedingly high, was not higher. The most practical lesson taught by the World War in the management of fractures is to be gained by a study of the management of compound fracture of femurs. The British have estimated that the mortality from femur fractures including complicated cases was between 40 and 50 percent in 1914-15 and in 1918 between 20 and 30 percent, including all cases, and that in the uncomplicated fractures, treated by the most modem methods the mortality was not more than 15 percent.² This change was brought about by improvement in their methods of first aid, operating, splinting, nursing, and after care, of which we were able to take full advantage, for, of the 3,367 men who had fractured femurs in the World War, 917 died, thus giving a mortality of 27.23 percent.³

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When the fractured femur cases were received at a, base hospital, it was always a problem to get them properly adjusted, the cases required immediate change of dressings and such adjustments as would permit them to rest, as they were usually worn out from the journey and had the same dressings on that they started out with. The following extract from the report of the orthopedic consultant at Mesves Hospital Center to the chief orthopedic consultant, A. E. F., is quoted as an example of how the work was planned there: ⁴

The admission of fracture and joint cases was so great during the month of October that it became necessary to establish 16 fracture wards in the various hospitals. Owing to the fact that it was necessary to change the dressings on all of these cases on admission, it was

FIG.77.– Balkan frame, showing suspension apparatus. Thomas splint

impossible for the ward surgeon to adjust splints, erect Balkan frames, and apply extensions. Splint teams were organized, consisting of 1 medical officer, 1 sergeant, and 1 private. As soon as the ward began receiving patients, this team was sent in to erect frames and suspend the cases. Usually this could be done for all the urgent cases in a day. The ward surgeons could easily change the dressings on 52 cases in a half day if all were properly suspended. This allowed him the remainder of the day for the adjustment of apparatus. The industrious medical officer was able to make all of his patients comfortable and secure good alignment under this regime. It was also possible to control sepsis and our records show that the mortality of fractured femurs among our later cases was very low indeed. The rate in our mortality of fractured femurs among our later cases was very low indeed. The rate in our first cases was rather high for the reason that the cases became thoroughly septic before we could arrange to handle them properly. The mortality among all cases was about 17 percent.

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Practically all of the cases of fractured femurs came back from the triage and evacuation hospitals in Thomas splints. After they had been received and examined at the base hospitals, it was often found that the Hodgen splint was better adapted for cases with wounds high up on the thigh or in the groin and consequently the Thomas splint was removed and the Hodgen splint applied.

Very few long Liston splints were used and it was quite noticeable in many of the base hospitals that as the work progressed there were fewer and fewer attempts made to devise any new form of splinting and a greater tendency to use the Thomas splint exclusively. In cases where a Hodgen splint was indicated it was not uncommon to find that the medical officer had bent a Thomas half-ring splint at the knee and applied it upside down with the one-half ring anterior instead of posterior. No elaborate plans were used in connection with the splinting other than suspension by means of the Balkan frame. A few cases, however, with buttock and back wounds, were very difficult to manage. In these cases an effort was made to have the patient persist in pulling himself up off the bed by grasping with his hands a bar that was suspended from the top of the Balkan frame, and if he was able to do this, the changing of the dressings on the wounds was much easier for him.

The position of the leg in fractured femurs varied of course with the location of the fracture. In the upper third, traction, nearly complete abduction and external rotation of considerable degree was insisted upon with the leg in suspension. Until these cases reached a base hospital no special effort had been made to secure apposition of the fragments, the care having been divided between prevention of sepsis and immobilization for the purpose of comfort during transportation. During the first few weeks after our casualties began coming in there was a tendency among some of the surgeons at the hospital to continue to ignore position and to wait for an improvement in the sepsis before attempting improvement in the alignment. It was found out rather early that securing and maintaining the best possible apposition was the best possible treatment for the sepsis. This was shown to be true in many instances and the probable explanation is that when full length of the leg is secured, with only moderate or no displacement, the sheaths of the muscles are taut and the muscle bundles are in normal relation so that there is less opportunity for pus to burrow along the muscle and thus infect new areas.

The observation was repeatedly made that the infection extended along the fascial planes in the limb. Advantage of this fact was taken by changing the position of elevation in the badly infected cases, so that the pus would not gravitate down these planes.

In fractures of the middle third of the femur, great difficulty was experienced in getting the ward surgeon to maintain sufficient outward rotation. The position of 30 to 35 degrees of outward rotation is necessary to secure apposition on account of the fact that the external rotators of the thigh produce nearly complete outward rotation of the upper fragments. It was also necessary repeatedly to insist upon the normal anterior curve of the femur being exaggerated in order to prevent posterior bowing which gives raise to disability. Slight flexion of the knee and thigh was also insisted upon. Many

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FIG. 78.- Fracture of femur showing double extension. Inverted Hodgen splint

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devices were used to prevent lateral bowing which in some cases was difficult to overcome in fractures above the lower third.

Fractures of the lower third of the femur were very trying, and we did not really succeed well with them until after the beginning of the use of skeletal traction by Pearson's modification of the Besley "ice tongs." It is practically impossible to secure apposition in this type of fracture without 70 or more degrees of flexion at; the knee, and it is then very difficult to apply any kind of skin traction.²

In the comparatively few cases in which the ice tongs" were used, tile results were most satisfactory. In the early spring of 1919, after some of our medical officers who had been detailed for service with the British were returned to the American Expeditionary Forces, a number of compound fractures of the lower third of the femur were treated with tongs. In this series no bad effects were noted, and when the tongs were properly applied the patients were entirely comfortable, it being necessary only occasionally to remove and reapply them.

The treatment of compound fracture of the head and neck of the femur on the whole, was rather discouraging. Many of these Cases were Complicated by injuries to pelvic viscera and pelvic bones, and as a result offered very little from the treatment standpoint. They were difficult to care for and often it was not possible, to make them entirely comfortable. Usually they were treated in abduction with the Thomas splint, or some modification of it for support. A plaster of Paris spica was always preferred but, on account of the wounds and suppuration, it could rarely be used. The head and neck of the femur were observed to have very little resistance to infection A through-and-through bullet wound of the head or neck, with no comminution or displacement, and with but little or no apparent infection, would often result in complete destruction of these parts. Abscesses would form in the pelvis in this group of cases, and because they were detected with difficulty amputation was frequently necessary. It was found that these abscesses could be drained successfully ,by following the ilium. Many of these cases that were very septic would finally make good recovery, with healing of all the sinuses.

Very few secondary closures were attempted in compound fractures of any kind, either after the primary operation or after the sequestrotomy. However, experience indicated that under proper conditions a technique could be

FIG.79.– Pelvic lifter

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perfected that would permit secondary closure in a large percentage of compound fractures.

A report of the fracture work in Base Hospital No. 27, Angers, France, which was made to the chief consultant in orthopedic surgery at the time the hospital practically finished its work is quoted in full: ⁵

On July 16, 1918, following the return of the orthopedic surgeon to the hospital, the orhopedic department was made separate from the surgical, and so remained for a period of four months, during which time most of the casualties from the front were received. The department expanded rapidly in size, due to the influx of wounded with compound fractures,

FIG. 80.-  Method of of using pelvic lifter

necessitating a corresponding enlargement of bed space on the third floor of the main building, where the fracture cases had previously been quartered as a part of the surgical service. The first large convoy of fracture cases arrived July 21, 1918, and as these were preoperative and from three to five days from date of wounding, their condition was unfavorable and necessitated extensive and radical operations. Subsequently, many large convoys were received, but none in which the majority of eases had not already been operated. The total number of occupied fracture beds rose from 80 on July 15, 1918, to about 250 by the middle of August and over 300 in September. Likewise, the routine orthopedic cases, now being retained for treatment, averaged about 100 in this hospital, and considerably more in the hospital annex. Aside from these two general types of cases, there was also handled by the department, mostly through individual consultations by the chief orthopedist, a large proportion of surgical wounded presenting conditions threatening deformity, or functional

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derangement, many of which cases were later transferred to the orthopedic service for treatment. The gravity of the cases with fractures and joint wounds, and the demands upon the personnel for their care, soon centralized the department around these cases, and necessitated a change in the fracture wards to a location in the hospital offering more convenience and elasticity for expansion. The fracture service was therefore moved about the middle of August from the third floor of the main building to four connected wards in the principal group of ward barracks, from which as a nucleus the increasing demand for bed space could be met. From the first, attention was put on the simplification and standardization of methods and technique in handling these cases, to insure rapidity in completely caring for each case on admission of a large convoy and for uniformity of treatment throughout. Definite rules and routine were worked out for the management of cases on admission and discharge and for their mechanical and surgical treatment. With the use of standard splints and apparatus, the suspension technique of Blake was modified principally with a view to less complexity of weights and pulleys, all weights being carried to the head of the bed and the trolley suspension abolished. For the arm a right-angled traction bar, attached to the Balkan frame, was designed to take the place of the bed board and found satisfactory. Extrinsic traction, by weight and pulley, was employed in most cases, though the intrinsic method in the Thomas splint, with the splint attached to the running weight, was used in some. This standardized apparatus could be put up rapidly by trained orderlies, allowing the medical personnel freedom to meet the surgical conditions presented by the new cases, the correction of the mechanics to the individual condition following the bedside X-ray examination, after the patient had been suspended.
             
During the first few weeks of this four-months period, great effort was made to elaborate the mechanics in special cases, where unusual bone deformities presented as in fractures of the femur, near hip and knee, and in fractures of the humerus. Much of this was omitted following the adoption of more routine apparatus, being also coincident with the receipt of orders hastening the evacuation of all cases which could not regain "A" class in a reasonably short period. All efforts of the department, therefore, were directed toward preparing cases for early evacuation, and the splinting was correspondingly modified to better meet the demands of transport. The Thomas leg splint almost entirely superseded the Hodgen, while flexion of the knee and flexion and abduction of the hip were limited to 30 degrees. An arbitrary time limit of two months was put on all cases in the orthopedic department, as the maximum allowed patients to regain combat fitness so that practically all fractures and joint wounds were considered cases for evacuation from the day of their admission, and the principal attention of the personnel was directed toward the surgical cleansing of the would (Carrel-Dakin method being employed throughout). It was, therefore, natural that the operative treatment should be largely confined to combating infection, about 100 operations for the establishment of drainage, removal of foreign bodies and devitalized tissue being performed in this four-months period, as compared with 15 secondary sutures. Despite the fact that during the first month many fracture cases were kept for complete consolidation and the return of function, the average length of stay in the hospital for all fractures was six weeks.

The following figures give the number of fractures of each region with the average length of stay in the hospital for the four months, July 15 to November 15, 1918:

CHART

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TIBIA AND FIBULA

It was stated above that the Thomas splint, or its half-ring modification, was used for the first-aid splinting of fractures of the upper two-thirds of the tibia and fibula and the Cabot splint for fractures of the lower third, ankle, and foot. This rule also obtained after the primary operation had been performed at the advance operating station. Extension was made by adhesive strips for the upper leg fractures and very little difficulty was encountered in maintaining sufficient traction in this group of cases. However, in the lower third fractures it was extremely difficult to secure sufficient traction and many methods were used. Strapping or gluing a board to the sole of the foot after the method suggested by Sinclair was probably the most satisfactory, as it was found the rotation of the foot could better be controlled by this plan. In

FIG. 81.- Bridge transportation splint for fracture of tibia

all fractures of the lower extremity an attempt was made to keep the foot at right angles to the leg by applying a strip of adhesive plaster to the sole of the foot and attaching it to the overhead bars of the Balkan frame. Applying a cast to the foot and then making traction over the cast was not at all satisfactory, as it was found that pressure necrosis occurred on the dorsum of the foot in a large number of cases. The use of the ice tongs applied to the os calcis was satisfactory; no bad effects were noted. On the other hand, where a Steinman pin was passed through the os calcis, troublesome osteomyelitis often developed.

Compound fractures of the upper third of the tibia extending into the knee-joint were always serious, and many amputations were done for this type of fracture. In many cases a prolonged attempt to save the leg resulted in loss of the patient.

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In fractures of the middle third, posterior sagging of the tibia too often occurred. This deformity leads to permanent disability of considerable degree, and is of greater inconvenience to the patient than shortening or outward

FIG. 82.- Delbet plaster splint for fracture of tibia

bowing. Internal bowing is also disabling on account of the strain produced on the ankle and foot. This deformity, however, occurred more frequently in

FIG. 83.- Plaster splint for fracture of tibia, permitting mobilization of ankle

the lower third fractures of the tibia. Nonunion was of greater frequency inthe tibia than in any other bone.

Compound fractures of the fibula alone seldom occurred and offered no particular problem when encountered. Usually the fracture of both bones

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was at the same level and the treatment of the fibula was incidental to the tibia. Nonunion of the fibula in the upper lower third and middle third produced but little if any disability and seldom if ever occurred in any other region of the bone.

FIG. 84.- Bridge plaster splint for fracture of tarsal bones

Compound fractures of the tibia and fibula required protection from weight bearing for a long period of time, and this fact no doubt contributed to nonunion. The walking caliper splint was not as effective in protecting these bones as it was in the femur, and no entirely satisfactory plan was worked out, probably the Delbet plaster splint being the best method tried.

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TARSAL BONES

Fractures of the tarsal bones were often extensive. The Cabot splint was admirably adapted for the treatment of these cases. The infection was difficult to control owing to the extensive swelling that accompanied these injuries, with resulting interference with the blood supply. A diseased tarsal bone would seldom regenerate and, as a rule, it would become a sequestrum and be extruded as a whole. Fortunately, the ankle joint rarely became completely ankylosed and where some motion remained the stiffness of the foot was partially accommodated for.

In tarsal bone fractures, as well as in carpal bone fractures, the Carrel-Dakin method of irrigation was not as satisfactory as it was in fractures of the long bones, due to the fact that free drainage of the infected area was not so readily obtained. Late amputation was more frequent in the tarsal fractures than in any other group of cases. This condition resulted from the fact that so much destruction occurred before the infection was controlled that the function of the foot was interfered with to such an extent that an amputation was to be preferred. In the hand injuries, the reverse was true, as almost any portion of the hand and fingers that could be saved was of more value than any artificial hand that has ever been devised.

REFERENCES

(1) Based on Sick and Wounded Reports made to the Surgeon General.
(2) Manual of Splints and Appliances for the Use of the Medical Department of the U. S. Army, 1918. Second Edition. Printed by the American Red Cross, Paris, 1918.
(3) Annual Report of the Surgeon General, U. S. Army, 1920, 277.
(4) History of the Mesves Hospital Center, Part II. On file, Historical Division, S. G. O.
(5) History of Base Hospital No. 27 (Hospital Center, Angers, France). On file, Historical Division, S. G. O.