Medical Science Publication No. 4, Volume 1
SPECIFIC CONSIDERATIONS IN PRIMARY SURGERYOF THE EXTREMITIES*
COLONEL JOHN M. SALYER,MC
CAPTAIN JOHN O. ESSLINGER,MC
Fifty-six percent of the last 7,200 United Nations troops injured duringthe Korean war sustained wounds of extremities. This percentage, whichall will agree is quite considerable, is somewhat lower than was anticipatedin view of past statistics on the anatomical location of war wounds andby virtue of the fact that a significant number of those wounded were wearingprotective nylon vests which have so often afforded protection to the extentthat potential death-dealing missiles have been deflected by or retardedin the nylon armor plates, thus often sparing the upper abdomen and chestof any injury or permitting relatively minor wounds beneath the protectivevest. Nevertheless, a paradox has arisen in that the incidence of extremitywounds has not increased over those percentages determined prior to thepresent armor designed to offer such encouraging and proven protectionto the upper torso.
It would seem reasonable to assume that other body areas, apart fromthe head and chest, will be provided with protective devices in futurewars. It is predicted, although to my knowledge no official overtures havebeen forthcoming, that the next anatomical areas to be given armor coveragewill be the lower half of the lower extremities. Surgeons trained and experiencedin the field of traumatism, not to mention orthopedists who are even moreaware of the danger to this area, view with grave concern and consternationthe surgical and therapeutic problems imposed when open fractures of thelower third of the tibia and fibula are encountered. The relatively poorblood supply and paucity of soft tissues for subsequent bone and tendoncoverage are deterrent factors which spell out an ominous warning thatoccasional serious complications may be expected and the final functionalresults may not always be ideal.
With such traumatic problems the nonambulatory phase, as well as totalperiods of hospitalization, will of necessity be prolonged, although suchunfortunate patients are given the most detailed and
*Presented 22 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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expert surgical and orthopedic care at an early hour and under the bestof professional circumstances. Unduly delayed and/or inadequate débridementof such wounds that confronts the military surgeon during periods of militaryconflict may result in significant infections that may require an amputationor even cost the patient his life. Credit is given to rapid methods ofevacuation, in most instances detailed and meticulous débridementsby competent surgeons, whole blood in adequate quantities, specific andbroad-spectrum antibiotics, and a stringent policy regarding the properapplication of, and the early splitting of, plaster casts and all underlyingcircular dressings down to skin level.
The remainder of this discussion will deal with the forward surgicalcare of extremity wounds-the initial phase in the divisional area; thisincludes care forward to and at first priority hospitals (Surgical Hospitals,Mobile-so called during Korean war). Not all, but most surgeons who havehad experience in the evaluation and surgical care of war wounds will agreethat the professional care given forward to the mobile surgical and evacuationhospitals, i. e., in the battalion aid stations, collecting companies andclearing stations, should provide wound care essentially as follows: Controlhemorrhage; apply temporary splints and first aid dressings; evaluate thepatient as a whole, as well as specific injuries-wound shock being foremostin mind; clear and maintain airway; provide adequate initial shock therapy;control apprehension and pain with barbiturates and narcotics-if woundshock is evident or impending, narcotics are given intravenously and insmall doses; administer tetanus toxoid, institute antibiotic therapy; rendertransportable; triage as to type of selective evacuation; and, last butnot least in importance, make initial entries in the Field Medical Record-theseconcise full-coverage entries will be of inestimable value to medical officersproviding professional care throughout the chain of evacuation and hospitalizations.
All but the most minor of wounds of the extremities, as well as warwounds elsewhere, should only be given initial definitive surgical carewhere the following types of personnel and facilities are available:
1. Surgeons well versed and trained in the care of war wounds.
2. Anesthesiologists and anesthetists available in adequate numbersand provided with proper equipment and anesthesia agents.
3. Whole blood provided in ample quantities.
4. Roentgenographic facilities for wound evaluation and localizationof radiopaque foreign bodies. A small missile producing an apparent minorwound of the thigh has been found to traverse the thigh, peritoneal cavityand terminate above the leaf of the diaphragm, not to mention other bizarremissile phenomena such is intravascular migration.
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5. Ample surgical supplies processed and sterilized as required; suitabledust-protected operating space or rooms, sufficient operating tables, andother essential equipment to perform large numbers of aseptic surgicalprocedures satisfactorily.
The above minimal requirements are not available in advance of the MobileSurgical Hospital.
Early First-Aid Splinting of Extremities
The Army half-ring leg splint has been employed with very satisfactoryresults during the Korean war. We in the Army have had little experiencewith the "light beaverboard trough-type" splint presently usedto some extent by some Navy medical installations. This linear fenestratedsplint would appear suitable in most instances but would seem not to bequite as suitable when traction should be employed, which is frequentlyso necessary. The wooden trough does not appear to be as adaptable forcounter-traction apposition to the ischial tuberosity and pelvis as theKeller half-ring splint. Traction "Army style" is effected byapplying traction straps over laced shoes. Only rarely has traction beenimproperly applied or maintained for sufficient periods to produce blistersand superficial areas of necrosis about the foot and ankle. Well-paddedwire ladder splints are employed for foot and ankle injuries. Adequatesplinting is our primary concern when preparing those with upper extremityfractures for transport to forward hospitals where the first phase of definitivewound care is provided. The arm can be immobilized by bandaging it to thechest with a Velpeau-type dressing. Wire ladder splints are frequentlyof value for fractures of the upper extremity.
Forward Evacuation
The transport of the wounded to the rear or laterally proved to be verysuccessful during the Korean conflict. Ambulances much improved as to comfortover those employed in World War II were employed around the clock, almostentirely at night, when helicopters were employed only on rare occasions.Helicopter and light plane transport for any and all types of battle injuredwas successful to an extent that may never again be realized in futureconflicts-in Korea the United Nations had air supremacy south of the mainline of resistance throughout the entire war. Periodic air raids by theenemy would have made forward air evacuation much less successful as wellas very costly in life and aircraft. It is doubtful if any better methodor mode of forward evacuation will ever be devised for transport of patientswith severely wounded extremities than that afforded by a helicopter ambulance.
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Early Care of Extremity Wounds
Simple and Mixed Soft Tissue Injuries
This implies surgical débridement and complete hemostasis withoutany attempt at primary wound closure. After careful evaluation of the extremityfor possible artery, nerve and bone damage, the extremity is shaved, preparedand draped in accordance with good current operating principles. Compromiseor deviation from such technics should never be condoned. As a generalrule, extremity wounds are extended by adequate longitudinal incisions.Oblique or transverse incisions are only employed on flexion surfaces overlyingjoints. Only a small amount of skin beyond the primary wound should beremoved, as it is vascular, resistant to infection, and should be retainedto facilitate delayed primary closure a few days hence.
Devitalized fascia and muscle are excised as completely as can be determinedafter the deep fascia is incised even beyond the limits of the skin incisions.Metallic foreign bodies are removed as encountered but extensive exploratoryprobing and dissection for purposes of removal of small metallic bodiesis not warranted. Other foreign matter, such as soil, gravel, bits of clothing,boot leather and splinters, is carefully removed with all devitalized tissues.Inadequate surgical care of significant extremity wounds such as not conformingto the above-mentioned concepts of surgical care will result in a woundpabulum most ideal for the growth of virulent bacteria and almost 100 percentof troublesome wound infections. However, a very low percentage of woundsepsis, none of which is likely to be threatening to life or limb, canbe anticipated when such extremity wounds are provided early care by surgeonswell indoctrinated in the care of wounds produced by war missiles and othertypes of destructive forces, be they explosive in nature or inflicted byodd forces of nature. Instillation of antibiotics and chemotherapeuticagents into extremity wounds is almost never recommended.
Mixed Soft Tissue, Joint, Nerve and Vessel Wounds
In addition to the débridement steps listed above, the followingspecific surgical measures are recommended:
Joint Wounds. Massive injury near and involving joints presentsdistinct surgical problems which deserve comment. The joint is irrigatedwith sterile saline solution; foreign matter and devitalized tissue suchas detached cartilage and bone are removed. The synovial membrane and/orjoint capsule should be closed if possible with absorbable suture materialand the remainder of the wound left open. Antibiotics (penicillin and streptomycin)are injected into the joint cavity.
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Nerve Wounds. It is obvious that all structures such as nervesand blood vessels are given the most detailed anatomical considerationduring any type of surgical procedures on extremities. A careful and detailedclinical record is made of the nerve injured or severed and the exact levelor site of injury is accurately recorded. Early primary suture of majornerves is never attempted; neither is it necessary to mark the ends ofnerves as they are readily found at the time of delayed repair by exposingtheir proximal and distal portions beyond the confines of the originalwound and tracing them to the site of injury.
Major Vessel Wounds. This important and interesting problem willbe discussed in detail at this meeting by military surgeons who have madeimmeasurably valuable contributions in this field during the Korean war.It can be stated that when ligation of a severed artery is not indicated,early establishment of the major arterial blood flow to the distal portionof the extremity is attempted as soon as the débridement is completed.End-to-end anastamosis is desired and considered ideal if feasible. Autogenousvein grafts and homologous arterial grafts have likewise given very encouragingresults. The site of repair or vascular graft should be covered with viablemuscle or subcutaneous tissue and the remainder of the wound left open.
Wound Dressing. One layer of fine-mesh dry gauze is employedto cover the entire raw surface of the débrided wound. Fluffed coarse-meshgauze is loosely placed to fill in and extend well above the level of thewound defect. Circular bandages are so arranged that tourniquet-like constrictionwill not result.
Hand Wounds. Early in the Korean conflict, hand wounds were closedprimarily if remaining tissues permitted. This method of management resultedin an infection rate of approximately 90 percent of such wounds. Two yearsbefore the end of the war, it was deemed advisable to advocate a nonclosurepolicy which gave much more encouraging results. Débridement shouldbe performed with the most meticulous care-rash excision of questionablyviable important structures and tissue is not advocated. The retentionof avulsed skin is highly desirable and it should be loosely tacked downby spaced sutures and immobilized by the wound dressing. Such attachedskin will often provide cover for exposed nerves, tendon sheaths, tendonsand other hand structures.
Forward Amputations. Under war conditions, the guillotine, oropen-type amputation, is the procedure of choice as well as the methodthat has given the most satisfactory results. It was indorsed through-outthe Korean conflict. The guillotine, or open, amputation implies a totaldébridement of an extremity hopelessly destroyed by trauma
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or infection or both. Even today it is often a lifesaving procedureregardless of the etiological trauma producing a mangled extremity. Ithas been common surgical knowledge since World War I that the end of theamputation stump must be left open in order to control infection, justthe same as following the débridement of any war wound of an extremity.As ideal as antibiotics are, they have not provided sufficient bacteriostasisto cause military surgeons to alter this policy.
Technic. A tourniquet is always used. The amputation is doneat the lowest possible level consistent with the total removal of devitalizedtissue and without regard to so-called elective sites of operations. Reamputationor revision of the stump is always necessary. Such revisions can be performedin the Zone of Communications or Zone of Interior where surgery can beaccomplished under ideal conditions. The skin incision may be roughly circularor oblique. The subcutaneous tissue and deep fascia are cut at the levelof the retracted skin. Proximal retraction allows the muscle to be severedat a slightly higher level. All structures are again retracted and thebone is sawed without stripping the periosteum. If the lower leg is beingamputated, the fibula is amputated about 11/4to 11/2 inches abovethe stump of the tibia. All major vessels are ligated and the tourniquetremoved, after which complete hemostasis is accomplished. The nerve ispulled down, divided and allowed to retract into the stump. Sterile stockinetteis fashioned over much of the remaining extremity and fixed by means ofskin glue. Minimal gauze dressing is applied to the raw stump surface,and sufficient traction is maintained to cause the stump end to appearas an inverted cone, the bone being at the apex. Constant elastic tractionis maintained from the end of extension splint bars incorporated in a wellpadded plaster cast fashioned to allow the very necessary and only safemethod of bony prominence counter-traction. Injudicious counter-tractionapplied to the soft tissues above the amputated stump will almost alwaysresult in an impairment of the normal venous return and subsequent arterialinsufficiency.
References
1. Bolibaugh, O. B.: Treatment of Gunshot Wounds of theExtremities. Symposium on Military Medicine in the Far East Command, September1951.
2. Bolibaugh, O. B.: Personal communication.
3. Churchill, E. D.: Management of Wounds (Initial andReparative Surgery). Symposium on Treatment of Trauma in the Armed Forces.Army Medical Service Graduate School, Walter Reed Army Medical Center,March 1952.
4. Hagman, F. E.: Notes on the Care of Battle Casualties.Symposium on Military Medicine in the Far East Command, September 1951.
