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Chapter VII



External Skeletal Fixation of Fractures in the Communications Zone

The experience with external skeletal fixation in the management of battle-incurred compound fractures in the Mediterranean Theater of Operations in World War II is of historical interest only. Apparatus for external skeletal fixation became available in the theater for certain general hospitals and a smaller number of specially authorized station hospitals in the summer and fall of 1943. Almost as soon, however, as the method began to be used, it became evident that its indiscriminate use in military surgery was attended with pitfalls and hazards and that its application must be rigidly restricted. For these reasons, it had a very limited use in the Mediterranean theater, and this report chiefly concerns the special hospitals in which it was employed.

The restrictions placed upon the use of external skeletal fixation in combat-incurred compound fractures were specified in Circular Letter No. 48, Office of the Surgeon, North African Theater of Operations, 18 November 1943.2     In substance, they were as follows:

External skeletal fixation is a highly specialized technique of fracture management, to be used only in carefully selected cases, only on special indications, and only by surgeons trained and experienced in its application. If an indication arises for its employment in a hospital whose staff does not include a surgeon with these qualifications, the patient must be transferred to a hospital in which trained personnel is available.

Only under emergency conditions may a patient be transferred from one hospital to another with apparatus for external skeletal fixation in place. If the transfer is not avoidable, he must be assigned to a hospital whose staff includes a surgeon trained in its use. Evacuation to the Zone of Interior with the apparatus in place is not permissible. If further immobilization is required, the patient must be held in an overseas hospital until the pins can be removed and more conventional methods of splinting substituted.


Circular Letter No. 48 also provided that the clinical record of each patient treated by external skeletal fixation must be forwarded, through channels, to the Surgeon, North African Theater of Operations, after treatment had been

1Data for this chapter were collected by Maj. Herbert W. Harris, MC, and Capt. Edwin L. Mollin, MC, 17th General Hospital.
2Sec appendix, pp. 312-316.


completed. The record was to cover all details of the case, including the date and circumstances of wounding; a complete description of the fracture and of the compounding wound if the fracture was compound; the initial treatment; the indications for external skeletal fixation; the length of time required to apply the apparatus and reduce the fracture; the number of roentgenograms required; the date, character, and extent of any distraction observed; the occurrence of infection about the pins; other complications; the date of removal of the apparatus; the subsequent management of the injury; and the disposition and end results.

These instructions, unfortunately, were not universally carried out, and the complete data which it had been hoped would be accumulated in the Office of the Surgeon therefore did not become available. In an effort to supply the deficiency and determine the extent of the usage of external skeletal fixation and the results achieved by it, a survey was carried out early in 1945, on the orders of the Surgeon, in each of the general and station hospitals in which the apparatus had been made available.

Four of the general hospitals in which provision had been made to employ external skeletal fixation treated no cases at all by it. Another hospital used the method in a few cases early in 1943 and had such poor results that it abandoned the technique entirely. The records were not available for some 35 cases treated in 2 general and 1 station hospital which left the theater in August 1944 to support the invasion of southern France.

The final report, therefore, covers only 8 general and 2 station hospitals and includes only 146 cases, all treated in 1944 and all recorded in sufficient detail to permit a reasonably satisfactory analysis. Some 20 other cases treated in these hospitals by external skeletal fixation had to be discarded because of paucity of data. Representative experiences are presented in tables 25, 26, and 27.

After a full year of experience with external skeletal fixation used according to the instructions set forth in Circular Letter No. 48, there was no unanimity of opinion concerning the merits of the technique. The small group of surgeons who had seen no place for it in civilian practice had been unwilling to give it a trial under military circumstances. Surgeons who had had an extensive previous experience with it and had therefore expected that it would have a wide application in both simple and compound combat-incurred fractures for the most part changed their opinion and restricted or discontinued its use. On the other hand, a group of surgeons with limited experience with the technique in civilian orthopedic practice believed that it offered decided advantages in carefully selected cases, and a number of them, as their military experience increased, actually broadened the indications.

Complications. – Drainage from the sites of the pins was fairly frequent in these 146 cases but could usually be terminated by removal of the pins. Osteomyelitis was reported at the sites of the pins in only two cases in the series. In one instance, it developed about a pin far removed from the wound and must be considered a primary infection. In the other case, it extended


from a severely infected compound fracture of the os calcis to a lower pin in the tibia. In both instances, wound healing was obtained after removal of dead bone and the institution of drainage. The only other serious complication in the series was an abscess which developed about a lower femoral pin; it responded promptly to drainage.

TABLE 25. – Essential data on 14 fractures treated by external skeletal fixation, 33d General Hospital, 1944

TABLE: 26. – Essential data on 27 fractures treated by external skeletal fixation, 26th General Hospital, 1944


TABLE 27 – Essential data on 25 fractures treated by external skeletal fixation, 17th General Hospital, 1944


The results of this analysis, together with discussions with the surgeons who had used the method, confirmed the opinion that external skeletal fixation has only a limited application in the management of combat-incurred


fractures in overseas hospitals. Under special circumstances, it was thought to be a useful adjuvant to standard methods of treatment, and, in certain cases it might be the method of choice, but the indications were seldom regarded as absolute.

There were a number of clear-cut contraindications to the use of external skeletal fixation in simple fractures in which it might have been the method of choice in civilian practice. They included (1) the length of time required to insert the pins and reduce the fracture; (2) the exacting care required to avoid loss of reduction and to prevent the development of complications during healing; and (3) the necessity for holding the patient in the hospital in which the pins had been applied until they could be removed. These were all matters of real importance in busy military hospitals.

The application of external skeletal fixation in compound battle fractures was similarly limited although under certain circumstances it was thought that the time and care which the method required might be compensated for by the results that might be achieved.

The World War II experience suggests that this technique might be applicable, in carefully selected cases, in the following situations:

1. Fractures of long bones with severe comminution and loss of substance. Fractures of this kind have always been a problem in military orthopedic surgery. Loss of bone at wounding or the necessary removal at operation of fragments totally devoid of soft-tissue attachments might leave a partial or complete hiatus, sometimes of 2 or 3 inches. In these circumstances, it was difficult to maintain apposition of the fragments by plaster or traction, and comminution made internal fixation impractical. External skeletal fixation permitted stabilization of the fragments in apposition under direct observation. There was some loss of length, it is true, but in the upper extremity this is not a matter of importance. In the lower extremity, loss of length is serious. When it was expected to exceed an inch or an inch and a half it was therefore sometimes considered advisable, even if the fragments could have been approximated, to brace them apart until wound healing had been obtained, in preparation for a bridging bone graft at a later reconstructive operation. In this way, shortening could be minimized. External skeletal fixation sometimes served this purpose very well. It was similarly effective when loss of substance had been extensive in an occasional fracture of a single bone in the forearm or the leg.

2.  Persisting malalinements of fractures. External skeletal fixation proved useful in a few subtrochanteric and supracondylar fractures of the femur in which reduction could not be obtained by skeletal traction, presumably because of persistent and unopposed muscle tension. An analysis of the cases included in the survey showed that this technique had been the method of choice in a number of such fractures after skeletal traction had failed. It was necessary, however, that additional immobilization be provided by skeletal traction or by a hip spica. Stability was lost in a number of cases in which this precaution was not observed.


FIGURE 68. – Management of compound comminuted fracture of left radius, with loss of bone substance and median-nerve palsy, by external skeletal fixation.  A. Compound comminuted fracture of distal third of radius. Note loss of bone substance.  B. Maintenance of reduction of fracture by external skeletal fixation.

Five weeks after the fixation apparatus had been applied, the wounds were well healed-they had been left open at the original operations and were later closed with the aid of pinch skin grafts. The pins were removed 2 months after wounding, after moderate drainage had developed about them. Roentgenograms showed only scanty callus at this time, but the fracture was in excellent alinement, and the patient had good finger motion except for the area affected by median-nerve palsy.

In this case, external skeletal fixation preserved alignment and bone length while the soft tissues were healing. It also allowed motion of the adjacent joints to a much greater degree than would have been possible had the extremity merely been immobilized in plaster.

3.  Compound comminuted fractures of the tibia and fibula. In this type of fracture both maintenance of reduction and wound healing were frequently difficult when the more usual methods of management were employed. In a few cases, the fractures could be reduced under full vision and locked in position by external skeletal fixation. A reinforcing plaster cast was also used. Some surgeons felt that this combined technique produced better results than plaster immobilization alone.

4.  Comminuted fractures of both bones of the forearm. For a number of reasons, these fractures constituted one of the most difficult problems of military surgery. In a few cases, the difficulty was overcome by the use of external skeletal fixation, which produced improved apposition and alinement of the fragments.


FIGURE 69. – Management of segmental compound comminuted fractures of proximal third of left tibia and fibula by external skeletal traction.  A. Roentgenogram of fractures.  B. External skeletal apparatus in place.

When the cast was changed 1 month after wounding, the wound was granulating, but the crest of the tibia was exposed. Ten days later, all bone was covered with granulating tissue, and clinical union was apparent. The pins were removed as soon as the new cast had hardened thoroughly. When the cast was again changed at another hospital 30 days later, the wound was healed, and the fracture site, although not rigidly solid, felt well fixed. In spite of the severity of the injury, length and alinement were preserved in the tibial fracture.

5. Comminuted fractures of the lower radius (fig. 68), in which shortening and collapse of the fragments often introduced a number of problems. External skeletal fixation was occasionally effective in maintaining length and normal joint alinement in both simple and compound fractures with severe comminution. A reinforcing cast was neither necessary nor desirable. When the apparatus was in place, motion of the fingers and of the thumb was possible. The results achieved in this type of injury suggested that external skeletal fixation was sometimes the procedure of preference.

6.  Burns or other wounds which required multiple staged operative procedures and in which repeated access to the wounds was necessary. Windows cut in casts did not always provide the exposure required, and frequent changes of cast would have resulted in loss of position of the fracture, while the manipulations necessary to restore position would have prejudiced the healing of both fracture and wound. External skeletal fixation provided maintenance of reduction while delayed closure, skin grafts, and other procedures were carried out.

7.  Segmental fractures. Segmental fractures (fig. 69) with displaced central fragments are usually difficult to reduce. The two such cases included in this series, one a fracture of the tibia and fibula and the other a fracture of the femur, were both managed successfully by external skeletal fixation.


8.  Resection of the knee and ankle joints (p. 231). In an occasional case of this kind, external skeletal fixation resulted in stable approximation of the bone surfaces and permitted repeated access to the wound for such procedures as were necessary to accomplish wound healing. A reinforcing plaster spica was used.

As this list of indications shows, external skeletal fixation had a limited application in the management of battle fractures, its chief use being on a few specialized indications or as a supplement to other methods. In the great majority of cases, combat-incurred fractures were much better managed by other methods, and there was little or no need for apparatus for this method in a theater of operations.