Medical Science Publication No. 4, Volume 1

DISCUSSION

COLONEL AUGUST W.SPITTLER, MC

My observations on primary surgery as far as the Korean conflict isconcerned were made on the casualties as they arrived at Walter Reed ArmyHospital.

I do not disagree in general with any of the premises that Colonel Salyerand Captain Esslinger brought out but will elaborate a little on them.As far as the wounds in general are concerned, I cannot emphasize too muchthe importance of a thorough initial débridement. When an adequatedébridement was done, a secondary closure was not as imperativeat an early date as is often talked about. Although a closure on the fifthday or soon thereafter gives an ideal result, judgment on those closuresmust be good, as a closure of an infected wound is worse than not closing.When the débridement had been inadequate, closed or not closed,infection had spread up and down fascial planes. The patients, althoughafebrile (due to antibiotics) were weak, pale and anemic. Several severehemorrhages occurred in them on removal of dressings.

Although extremity surgery seems simple, it is a source of our greatestmorbidity and, in many cases, a preventable one if débridement iswell carried out to include all devitalized tissue, entire muscle belliesthat are deprived of blood supply if necessary, and foreign bodies. Tosacrifice bone whether attached or detached is not necessary and makesreconstruction difficult. Bone chips are not dead tissue-they usually surviveif given a clean bed to lie in, or at least provide a lattice work fornew bone formation.

In the phased treatment of fractures, traction on a badly mangled extremityis not as important as actually holding the leg in alignment as there islittle muscle spasm.

Either the half-ring splint or the plywood board splint is effectivefor initial phase. After débridement, plaster is still best. Wehave worked for some time in producing a lighter type of plaster usinga resin mixture in the solution. Unfortunately, no casts made of this materialwere ever on our patients from Korea, although some was sent to Japan forthat use. It is now available mixed in the bandage so that only water andcatalyst need be added.

Remember, an arm only directs the hand. Position of the hand is importantand it should be placed in a position of function.

In the leg-overpull is to be avoided. A slight shortening produces healingmore rapidly.

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Joint Injuries

Early débridement is essential with closure of capsule. I haveseen some joint-injured patients arrive at Walter Reed Army Hospital, however,with synovial drainage from wound and no limitation in joint motion. Spontaneousclosure occurred in a few weeks.

The Hand

There is no difference in the initial surgery of the hand from thatof any other part.

Try not to sacrifice skin. You may need to tack it down. Do not makea tight closure.

Consider-filleting a useless finger to get soft parts to cover restof hand. Try to cover tendon with soft parts.

Do not immobilize too long. Early function is important.

Cover with skin as soon as clean wound is assured. Skin from an abdominalflap or a split-thickness graft may be used at times.

More hands are ruined by complete prolonged immobilization than by earlymobilization.

Amputation

Open amputation-so-called guillotine-is and will be the operation ofchoice for traumatized extremities.

Long skin flaps are not necessary if traction is applied and maintained.Long skin flaps may be retained to cover the condyles of the knee.

Dressing a guillotined stump with the changeable dressings outside ofthe stockinette is advocated.

Traction must be continuous until end of bone is covered.

A guillotine stump is easily converted and is often ready for fittingas soon as an originally closed one, as during the traction stage the adherenceof muscles to the end of bone and the shrinkage desired is accomplished.

Four amputations which are now advocated by us are to be thought ofin considering a primary amputation of any extremity:

1. Syme-or modified ankle disarticulation.

2. Knee disarticulation.

3. Elbow disarticulation.

4. Wrist disarticulation.

An open disarticulation can be done as easily as an above-the-jointopen operation; it is now to be preferred.

In the ankle every effort should be made to save the heel pad as advocatedin the first stage of our staged Syme amputation.

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Internal Fixation

In the seriously comminuted fractures primary internal fixation is notto be considered. Early medullary nailing in communications zone hospitalsin selected cases must be considered for evacuation as well as early returnto duty, particularly if the initial débridement was good and effectivein securing a clean wound.

Bone

No replacement is yet available as good as bone. Banked bone shouldstill be considered for early use. Particularly the types that can be keptsterile at room temperature should be considered for early implantationeven if for later reconstruction only. Bone is a living tissue.

Pearl Harbor experience-7 December 1941, Tripler Hospital whereI was Chief of Surgery.

Problem.

Triage-All wanted to be this officer.
Personalities-All wanted only to specialize.
Shock wards were life savers although Honolulu's blood bank was most effectiveadjunct.
Every doctor wanted to suture wounds. All had to be opened later.
Sulfa drugs were effective.
Records were poor-suggested personnel for this only.
Identity of patients was hard to keep when stripped and unconscious and/orlater died.
Tape or wire recording of records now thought excellent method.