491
SECTION I
GENERAL SURGERY
CHAPTER XVII
END RESULTS, FRACTURES OF LONG BONES
Before entering into the consideration of the end results of the fractures of the long bones that occurred during the World War, it is necessary to give the numbers of fractures involving not only the long bones but others as well, in order that their relative incidence and gravity may be more readily appreciated. This will be done for both battle and nonbattle fractures.
TABLE 28.- Battle fractures, including single and associated fractures a
It is seen from the above table that there were 19,620 fractures of the extremities, as follows:
Femur................................................3,850
Fibula...............................................2,697
Humerus..............................................4,069
Radius...............................................2,475
Tibia................................................4,379
Ulna.................................................2,150
19,620
492
Arranging the figures from the standpoint of the individual, and so as to show not only the single fractures but also those that were associated, we arrive at the result given in Table 29. This table gives the true situation, particularly with respect to mortablity.
TABLE 29. - Battle fractures, long bones, showing both single fractures and those in association, and deaths a
In addition to the fractures incident to battle, there were 39,569 fractures, the result of nonbattle injury. Of these, 31,776 were simple fractures, with a mortality of 664, or 2.09 percent, and 6,006 were compound, with a mortality of 663, or 11.04 percent. With the view of showing the relative frequency during the World War of nonbattle fractures of not only the separate long bones, but also of all the bones reported to have been fractured, the following table has been prepared:
TABLE 30.- Non battle fractures a
Table 31 shows the result, in so far as death and recovery are concerned, in the cases of both battle and nonbattle fractures, and while the men involved were in the military service.
493
TABLE 31.- Battle and nonbattle fractures of long bones, showing immediate result
To determine the end results among as great a number as possible of there covered (from the Army viewpoint) fracture cases shown in Table 31, a statistical study has been made of such of these men as applied for compensation to the Bureau of War Risk, or subsequently, the United States Veterans' Bureau, which replaced the Bureau of War Risk.1This study, which was begun in December, 1919, by the Surgeon General, United States Public Health Service, acting for the Bureau of War Risk under the Treasury Department, was completed by the United States Veterans' Bureau.' It extended over a six-year period, ending January 1, 1926, and shows the progress and end results of the cases in question.
From the first, the importance of an individual study of the fractures of the long bones among veterans of the World War was recognized, so the use of a specially designed form was authorized to report the desired information whenever the condition was revealed at the time of physical examination of veterans applying for compensation. This form is as follows:
494
VETERANS BUREAU, MEDICAL DIVISION. Form 2540.
REPORT ON FRACTURES-LONG BONES
CHART
495
Since, in the tables which follow, the compensation rating is the index of the disability, it is necessary to know what the schedule of ratings comprises, in order properly to understand the tables. The following ratings, in force in United States Veterans' Bureau, is the outcome not only of experience in the bureau but also of expressed opinions of various leading surgeons in the United States; in addition, the schedule of ratings of England, Francee, Belgium, and Canada were taken into consideration in its adoption.
RATINGS OF AMPUTATIONS, FRACTURES, AND THEIR SEQUELAE
In general, loss of muscle substance, cicatrices, and atrophies, when having effect upon functions, from 10 percent to 25 percent should be added to the specific rating.
CHART
496
CHART
(Extension from a position of complete flexion is unrestricted excepting through the arc specified.)
The axis of 180° corresponds to the axis of the proximal long bone on which the distal long bone moves in the arc of a circle. Extreme flexion on the forearm is approximately at an angle of 45? Extreme flexion of the leg is approximately at an angle of 45 °.. Extreme flexion of the leg is approximately at an angle of 75 ?. Complete extention of either forearm or leg is at 180 ?.
Where a partial disability results from an injury to both members, involving bilateral function, 20 percent of the total rating, provided by the present schedule for the partial loss of bilateral function, will be added to the sum of the ratings for impaired function in both members.
Nonunion of bones:
Rating to be equivalent to temporary partial rating for amputation at site of nonunion, except ulna, which is to be rated 10 per cent.
Faulty unions rate on percentage of loss of function comparable to limitation of motion of contiguous joints.
Subluxations comparable to ankylosis at favorable angle.
Acute osteomyelitis, acute bursitis, acute synovitis, acute tenosynovitis, rate temporary total.
Chronic "ditto," rate on sequelae.
Persistent dislocations, rate 25 percent less than loss of limb at joint affected.
Loss of pronation and supination rate 15 percent.
497
CHART
The subjoined statistical tables comprise three groups. The first group, Tables 32 to 39, gives general information concerning the men who suffered a fracture of one or more long bones; the second and third groups cover changes in degree of impairment, from the date of injury to January 1, 1926.
Table 32 shows the bones involved, as well as the deaths. In this and subsequent tables, figures for veterans of both the Navy and the Marines have been included, since, in the United States Veterans' Bureau no distinction is made between these services and the Army. The number of cases that originated in the Navy is 859; in the Marines, 562. Of the total number of cases in Table 32, 4,519, or 19.69 percent, had simple fractures; 18,435, or 80-31 percent, had compound fractures. It is noteworthy that in the column for fractures involving either the tibia or the tibia and fibula, the 6,620 cases include all fractures of the tibia and also all cases of major fracture involving the tibia and fibula. This remark is equally true of the column for the radius or radiusand ulna.
Table 33 shows that 69.05 percent of the injured veterans were under 30 years of age. The fact that there was such a large number of these men under the age of 30 increased the possible economic benefits from rehabilitation.
498
The large number of serious complications, infections, and associated conditions, shown in Table 34, reveal the severity of the fractures.
Table 35 shows that it has been possible to place 15,597 of the claimants, or 67.95 percent, with disability due to fractures of the long bones, on a permanent rating. It is necessary to explain here that a permanent rating is not awarded until it is indicated that the disability has reached a stationary level and is reasonably certain to continue throughout the remainder of the claimants life. Most of the 433 cases on a "temporary total" basis are under hospital treatment.
TABLE 32.- Fractures of long bones of United States veterans of the World War, by type of fracture, showing bone or bones involved, and deaths, as of January 1, 1926 a
499
TABLE 32.- Fractures qf long bones of United States veterans of the World War, by type of fracture, showing bone or bones involved, and deaths, as of January 1, 1926-Continued
TABLE 33.- Fractures of long bones of United States veterans of the World War, by age group and bone or bones involved, and deaths, as of January 1, 1926 a
503
TABLE 35- Fractures of long bones of United States veterans of the World War, by character and degree of disability, bone or bones involved, and deaths as of January 1, 1926- Continued.
TABLE 36- Fractures of long bones of the United States veterans of the World War, by bone and joints involved, showing conditioin on first examination, as of January 1, 1926 a
507
Tables 40 to 73, inclusive, show the character and degree of impairment for each long bone or for associated bones, according to the progress made at intervals of three months. Separate tables have been prepared for each bone when there was a series of 100 cases or more to each 10 per cent.
FEMUR FRACTURES
The femur fractures number 5,138, or 23 percent of the total fractures, and comprise the most serious group of injuries, not only because of the pro-longed duration of time required to reach a stationary level but also because of the very high degree of disability. Of the 5,138 cases, 259, or 5 percent, required a period of 2 years to reach their stationary level; 435, or 9 percent, required three years; 637, or 12 percent, required four years; 1,185, or 23 percent, required five years; and 2,622, or 51 percent, required more than five years. Thus 26 percent of the changes in rating occurred before the end of the fourth year, so that 74 percent of the femurs required more than four years to reach a stationary level. These cases of fractured femurs were rated as follows: Two hundred and seventy, or 5 percent, were less than 10 percent:1,673, or 33 percent, between 10 and 29; 726, or 14 percent, between 30 and 49;1,671, or 33 percent, between 50 and 79; 484, or 9 percent, between 80 and 99;314, or 6 percent, were rated 100. Amputations of the thigh contributed largely to the higher ratings for, among the 1,671 cases rated 50-79, there were1,122 amputations; among the 484 rated 80-99 there were 443 amputations; and among the 314 rated 100 there were 173 amputations. Of the 141 fractures rated 100 percent yet not amputated, 53 were under hospitalization. It should be stated that 100 percent is the rating awarded hospital cases. Shortening occurred in 2,155 or 41.94 percent of these cases, which also combined to increase the rating. The severity of many of these injuries was increased further by the complication due to an injury of an associated nerve in 418 cases.
TIBIA AND FIBULA FRACTURES
Tibia and fibula fractures number 4,485, or 20 percent, of the total fractures. They make up another important group in which 226, or 5 percent, required two years to reach their stationary level; 453, or 10 percent, required three years; 562, or 13 percent, required four years; 1,027, or 23 percent, required five years; and 2,194, or 49 percent, required more than five years. Thus 28 percent of the changes in rating occurred before the end of the fourth year, and 72 percent required more than four years to reach a stationary level. Their degrees of rating are as follows: Seven hundred and sixty-four, or 17 percent, were less than 10; 1,968, or 44 percent, were between 10 and 29; 1,272,or 28 percent, between 30 and 49; 244, or 5 percent, between 50 and 79; 21,or 1 percent, between 80 and 99; and 216, or 5 percent, were 100. Amputations of the lower leg contributed to the higher ratings. Among the 1,272 cases rated 30-49 there were 906 amputations; among the 244 cases rated 50-79 there were 86 amputations: among the 21 cases rated 80-99 there were 15amputations: and among the 216 cases rated 100 there were 134 amputations. Of the 82 fractures rated 100 percent yet not amputated, 58 were under hospital care. There were also 273 associated nerve injuries. For nonunion, 97
508
operations were performed in which bone grafts were employed; in 60 cases Lane plates were used. Shortening occurred in 982 cases, which also increased the ratings.
TIBIA FRACTURES
Fractures of the tibia number 2,289 or 10 percent and are somewhat less serious than those of the previously mentioned bones; 118, or 5 percent, required two years; 212, or 9 percent, required three years; 266, or 12 percent, required four years; 478, or 21 percent, required five years; and 1,129, or 49 percent, required more than five years; 86, or 4 percent, unclassified; thus 26 percent of the changes in rating occurred before the end of the fourth year and 74 percent required more than four years. Their degrees of rating were as follows: Five hundred and ninety-eight, or 26 percent, were less than 10; 1,314, or 57 percent, were between 10 and 29; 196, or 8 percent, between 30 and 49; 107, or 5 percent, between 50 and 79; 15, or 1 percent, between 80 and 99; and 59, or 3 percent, were 100. In 160 cases there was an associated nerve injury.
FIBULA FRACTURES
Improvement begins earlier in these cases which number 1,243 or 6 percent; 89, or 7 percent, required two years to reach their stationary level; 123, or 10 percent, required three years; 153, or 12 percent, required four years; 221, or 18 percent, required five years; 454, or 37 percent, required more than five years; 203, or 16 percent, are unclassified; thus 29 per cent of the changes in rating occurred before the end of the fourth year, and 71 percent required more than four years. Their degrees of rating were as follows: Five hundred and ten, or 41 percent, are less than 10; 616, or 49 per cent, between 10 and 29; 88, or 7 percent, between 30 and 49; 20, or 2 per cent, between 50 and 79; 4, or 0.4 percent. between 80 and 99; and 5, or 0.6 percent, were 100. In 164 cases there was an associated nerve injury.
HUMERUS FRACTURES
These cases number 4,328, or 19 percent, and make up another group of severe disabilities; 214, or 5 percent, required 2 years to reach their stationary level; 303, or 7 percent, required 3 years; 492, or 11 percent, required 4 years; 954, or 22 percent, required 5 years; 2,365, or 55 percent, required more than ; years. Thus only 23 percent of the changes in rating occurred before the end of the fourth year, and 77 percent required more than 4 years to reach a stationary level. Their degrees or rating were as follows: Four hundred and sixteen, or 10 percent, were less than 10; 1,752, or 40 percent, were between 10 and 29; 734, or 17 percent, between 30 and 49; 637, or 15 percent, between 50 and 79; 709, or 16 percent, between 80 and 99; and 80,or 2 percent, were 100. Amputations of the upper arm contributed to the higher ratings. Among the 637 cases rated 50-79 there were 55 amputations; among the 709 cases rated 80-99 there were 602 amputations; among the 80eases rated 100 there were 31 amputations. The severity in this group was very largely increased because of an associated nerve injury in 1,086 cases, for which many operations have been performed. Also, more than 250 operations were performed for nonunion, in which bone grafts, Lane plates and Wire sutures were used.
509
RADIUS AND ULNA FRACTURES
Radius and ulna fractures number 2,340, or 10 percent of the total fractures. In this group 132 cases, or 6 percent, required 2 years to reach their stationary level; 185, or 8 percent, required 3 years; 311, or 13 percent, required 4 years; 538, or 23 percent, required 5 years; 1,154, or 49 percent, required more than 5 years; 30, or 1 percent, were unclassified. Thus 27 percent of the changes in rating occurred before the end of the fourth year and 73 percent required more than 4 years to reach a stationary level. Their ratings were as follows: Three hundred and ninety-nine, or 17 percent, were less than 10 percent; 1,003, or 43 percent, were between 20 and 29; 294, or 12 percent, between 30 and 49; 581, or 25 percent, between 50 and 79; 24, or 1 percent, between 80 and 99; 39, or 2 percent, were rated 100. Amputations of the lower arm contributed to the higher ratings. Among the 581 cases rated 50-79 there were 383 amputations; among the 24 cases rated 80-99 there were16 amputations; and among the 39 cases rated 100 there were 22 amputations. There were also 417 associated nerve injuries. For nonunion 104 operations were performed, in which bone grafts were employed in 82 cases and Lane plates and wire sutures in 22 cases.
RADIUS FRACTURES
Radius fractures numbered 1,356, or 6 percent, of the total fractures;110, or 8 percent of the cases, required 2 years to reach their stationary level;109, or 8 percent, required 3 years; 145, or 11 percent, required 4 years; 300,or 22 percent, required 5 years; 591, or 44 percent, required more than 5 years; 101, or 7 percent, were unclassified. Thus 27 percent of the changes in rating occurred before the end of the fourth year and 73 percent required more than 4 years. Their ratings were as follows: Three hundred and twenty-four, or 24 percent, were less than 10 percent; 745, or 55 per cent, between10 and 29; 158, or 12 percent, between 30 and 49; 111, or 8 percent, between50 and 79; 5, or 1 percent, between 80 and 99; 13, or 0.9 percent, were rated 100. In 272 cases there was an associated nerve injury.
ULNA FRACTURES
Ulna fractures numbered 1,169, or 5 percent of the total fractures; 60, or percent of the cases, required 2 years to reach their stationary level; 83,or 7 percent, required 3 years; 129, or 11 percent, required 4 years; 230, or20 percent, required 5 years; 498, or 43 percent, required more than 5 years;169, or 14 per cent, unclassified; thus 23 percent of the changes in rating occurred before the end of the fourth year and 77 percent required more than 4 years. This large percentage is due to the fact that in 347. or 33.68 percent of eases, there was an associated nerve injury which materially delayed the recovery. Their ratings were as follows: Two hundred and forty-seven, or 21 percent, were less than 10; 664, or 57 percent, were between 10 and 29;169, or 14 percent, between 30 and 49; 76, or 7 percent, between 50 and 79; or 0.4 percent, between 80 and 99; 8, or 0.6 percent, were 100.510
512
TABLE 42.- Fractured femur, United States veterans of the World War, rated 80-49 percent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a
513
TABLE 43.- Fractured femur, United States veterans of the World W1ar, rated 50-79 percent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a
521
TABLE 51.- Fractured fibula, United States veterans of the World War, rated 10-29 percent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a
525
TABLE 55.- Fractured tibia and fibula, United States veterans of the World War, rated 50-79 percent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a
541
TABLE 71.- Fractured radius and ulna, United States veterans of the World War, rated 30-49 percent disabled on first examination, showing interval elapsing between injury and last rating and degree of disability on last rating, as of January 1, 1926 a
544
TABLE 74.- Fractures of the long bones, United States veterans of the World War, showing the number and percentage of cases which reached their stationary level after periods of 2, 3, 4, 5, for more years, as of January 1, 1926
TABLE 75.- Fractures of the long bones, United States veterans of the World War, showing the change in percent of impairment on first examination by the United States Veterans Bureauu, and on the last examination prior to January 1, 1926.
546
The changed ratings, as shown in Table 75, may be arranged in three groups: (1) Diminished ratings, which indicate an improvement; (2) stationary ratings; (3) increased ratings, which indicate not only that there was no improvement in the cases concerned but also that they had assumed a more serious character. This grouping is as follows:
CHART
The following data have been arranged to show the percentage of improvement, as the result of fractured long bones among the United States veterans of the World War, on the first and on the last examination prior to January 1, 1926. As may be seen, the tabular matter summarizes the data of Tables 40 to 73, and of Table 75.
CHART
Finally, a group of 4,647 cases of fractured femur was studied with the view of showing the relationship of changes in ratings to the time when the injured veterans had their first examinations. This study is given in Table 76. This table shows that, of the 4,647 cases in which the femur alone was fractured, 3,352 cases, or 72 percent, were examined and rated within 12 months after injury. Of these cases, 1,227, or 37 percent, were given a disability rating of
10-29, and 1,239, or 37 percent, were rated totally disabled. Of the 1,227 cases rated 29 on first examination, there was a change in rating of only 11
TABLE, 76.- A study of 4,647 single femur fractures among the World War veterans, showing the changes in ratings by six-month intervals from the Veterans Bureau's first examination after injury, as of January 1, 1926 a b
547
percent over a period of four years. Of the 1,239 cases rated totally disabled on first examination, 337 cases, or 27 percent, improved in the first 6 months; in the following 6 months, 416, or 34 percent, improved; 199, or 16 percent, were improved 30 months after injury. Among the totally disabled cases originally examined by the United States' Veterans' Bureau within a year after injury, a reexamination 5 years after injury revealed that 1,124, or 91 percent, showed definite signs of improvement; only 70, or 5 percent, showed no improvement. It will be noted that 778, or 17 percent, were first examined by the United States Veterans' Bureau 18 months after injury, and 344, or 7 percent, were rated first 24 months, and 173, or 4 per cent, were rated first 30 months or more after injury.
Table 76 shows further that there is a significant decrease in the degree of disability in those cases which came to the bureau 12 months after injury, as compared with those who applied for relief at a later date. This degree of improvement is well illustrated in the totally disabled group by a comparison of those cases included under the claimants' first examination 12 months after injury with those applying for relief for the first time 18 months or 24 months after injury. This comparison shows also that at the end of 4 years the cases received within 12 months revealed an improvement of 86 per cent; those received 18 months, 77 percent; those received after 24 months, 62 percent; those received 30 months, 45 percent; while of those received after 36 months, only 14 per cent improved. The same condition also exists in the degree of disability obtaining three years after injury.
The conclusion that the earlier the application for relief the more rapid the degree of improvement is apparently given greater emphasis through a study of conditions existing at the end of eight years. For instance, of those patients reporting within two years 95 percent bad improved at the end of eight years; among those patients who delayed as much as three years in reporting for relief the number of improved cases dropped to 51 percent. This decrease in per cent of cases is particularly significant because five years had elapsed in those cases received three years after injury, which period was sufficient to accomplish practically the maximum improvement in the cases reporting for relief earlier.
REFERENCES
(1) Letter from the Director, United States Veterans' Bureau, Washington, May 26, 1926, to Lieut. Col. F. W. Weed, M. C. Subject: Statistical data. On file, Historical Division, S. G. O.
