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SECTION II
ORTHOPEDIC SURGERY
CHAPTER IV
ORTHOPEDIC SURGERY IN EMBARKATION HOSPITALS, A. E. F. a
The experience of those of our orthopedic surgeons who served first in Great Britain and then in France showed that the problem of dealing with the war wounded from the orthopedic standpoint was somewhat as follows: In general these cases were fractures, both simple and compound; joint injuries; peripheral nerve and spinal cord injuries; soft-part injuries, with tendency toward contracture deformity; static disabilities of the trunk and extremities(spine, sacroiliac, feet, etc.); amputations; and the making and application of all splints, braces, and prosthetic devices.
Wounded soldiers returning from the front (either directly or through evacuation hospitals) early began to give evidence of the need of orthopedic treatment. Even the early convoys to the United States showed that more careful splinting and preparation of the patients otherwise than as had been done would be necessary if the American wounded were to be properly transported from France to the United States. Accordingly, the organization of the orthopedic service in base hospitals was thoroughly arranged during the summer of 1918, with the following objects in mind: (1) To treat surgically, splint, and otherwise deal promptly with those who could soon be returned to duty as class A or B. (2) To prepare as many of the class D patients as possible for early, safe, and comfortable transportation to the United States.(3) To arrange suitable hospital facilities and care for serious cases that must be treated and their reconstruction begun in France.
Most of the American wounded who belonged in the first group were returned to duty without coming to base hospitals at all. A considerable number, however, with strains, dislocations, fractures, sacroiliac injuries, weak foot, flat foot, and even minor amputations, came to base hospitals and were discharged to duty after a few weeks' treatment.
Patients in the second group for whom it was desirable to arrange transfer to the United States as soon as possible, presented a large and difficult problem. It was found that patients arriving at base hospitals were often in poor surgical condition as regards drainage, position, and immobilization. It became the special duty of the orthopedic consultant to locate and deal with these patients before convoy lists for evacuation to the United States could be made up. At the Savenay hospital center (Base Hospitals Nos. 8, 69, 88, etc.) and more or less throughout Base Section No. 1 (Base Hospital No. 101, at St. Nazaire; Nos. 11, 34, and 38, at Nantes; No. 27, at Angers) the plan worked out for dealing with these cases was as follows: (1) Cataloguing and inspection every orthopedic patient as he entered the hospital. (2) The written opinion of
a The data in this chapter are based on The History of the hospital Center, Savenay. Part 11, 98-146. On file Historical Division, S. G. O.
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every medical officer as to the patients that he saw. (3) Centralized operating, splint, anal plaster-of-Paris rooms to which patients were brought for treatment.(4) A card-index catalogue, with a follow-up system by which recommendations made by medical officers were checked up anal controlled until the patient was pronounced fit for transfer.
The first centralized splint room, established at Base Hospital No. 8, Savenay, about September 1, 1918, proved one of the most helpful features. In the course of a few days it reached a capacity of from 30 to 50 patients daily.
Much has been said and written about the use of plaster of Paris in war injuries. The technique employed at Savenay was as follows: Wounds were carefully dressed, the entire extremity was covered with cotton wadding, and muslin or gauze bandage applied evenly and smoothly; then the plaster was put on firmly but not too tightly; large windows were cut over all open wounds and over patellas and heels; casts were not split. Plaster of Paris was used especially for fractures of the femur, leg, and upper arm.
From September to December, 1918, about 1,000 plaster casts per month were put on and practically all sent to the United States. No complications as to casts were reported and in general the patients were found to have traveled safely and comfortably. For patients who had to have manipulative correction of deformity existing at the time of arrival at Savenay, plaster was the ideal splint because of the better immobilization and protection against motion irritation of injured and infected parts.
The following circular letter indicates exactly how patients were to be cared for at Savenay during September, 1918, and later:
From: The consultant in orthopedic surgery, Hospital Center, Savenay.
To: All medical officers.
In dealing with patients with bone and joint injuries, amputations, tendon injuries, or inflammations, soft-part injuries with contraction or impending deformity, spine injury, flat feet, etc., please observe the following points:
1. Medical officers will be supplied each morning with index cards containing for patients admitted during the past twenty-four hours, blanks for name, diagnosis, etc. Medical officers are to add to these cards by marking under the heading " Condition," whether the patient
1. Requires no splint
2. Is wearing satisfactory split;
3. Requires change of splint or operation;
4. Without splint but splint required.
In case of "3"or "4" specif y the patients requirement under the heading of "Notes" or on the reverse of the slip.
2. Amputation cases arc to be reported separately on special slips, or brought to the attention of the consultant by reporting patient's name and ward.
3. Under the heading "Diagnosis," the diagnosis number (as indicated on Special Diagnosis Table already furnished) is to be entered, e. g., 17 for GSW elbow joint.
4. The buff cards must be completed and turned in to the orthopedic office on the same day they are received. There must be no exception to the rule.
5. In the case of patients who are to be splinted in the wards the wardmaster's report is to be sent to the orthopedic office as soon as the application is finished.
6. If any patient requires operation recommendation for such operation must be sent to chief of surgical service, base hospital. The medical officer in charge of the ward will be notified as to the place, time, and by whom the operation is to be performed. No operation by any member of the orthopedic staff is to he arranged in any other way.
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7. Ambulatory patients requiring splints are to be referred to the splint room for the application of splints or plaster between the hours of 1.30 and 4.30 p. m. daily. All medical officers are requested to accompany and to apply splints and plaster to their own patients if they care to do so. Field medical cards should accompany patients so that proper entries can be made at the time treatment is given
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8. In sending in reports it should be specified in every case whether or not the patient must be detained in the hospital for treatment and if so, for what length of time.
At Savenay the first special wards to be provided were those for fractures of the femur and for amputations. These were provided during September. The obvious advantages of this plan led to the approval of the commanding officer, early in October, of a larger plan, by means of which more than 1,400 beds were set aside in Base Hospital No. 8, with special wards for leg fractures below the knee (64 beds), gunshot wounds and fractures of the upper extremities(256 beds), gunshot fractures of the femur (196 beds), and amputation (250 beds).
The following arbitrary diagnosis table was used to save writing out diag-noses in full:
TABLE OF DIAGNOSIS
CHART
As a result of the experience in several thousands of cases the suggestions made in the following paragraphs were developed for practical use with just these points in mind and in the same order.
HEAD INJURY, WITH PARALYSIS
Treatment required: Splinting to prevent drop-foot knee contractions, abduction, and flexion deformity of thigh. Splints required right-angle foot and leg splints, double or single plaster-of-Paris spica. The number of this class of cases was 5 per 1,000 total number of battle injuries in the given hospital.
GUNSHOT WOUNDS OF THE NECK, WITH NERVE INJURY, ULNAR PARALYSIS
(Musculospiral paralysis, ulnar paralysis, median paralysis, deltoid paralysis.) Splint required: Hand cock-up splint, airplane splint. In these conditions it is important to bear in mind that many of these nerve injuries
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are only partial and become complete in time through failure to splint early. If the necessary nerve and muscle tissues are conserved, during the entire period of convalescence, an entirely unexpected amount of function will be found to be present at the end of treatment. Failure to maintain in relaxation, muscles involved in even temporary paralysis, results in quite unnecessary permanent disability. One of the points to be constantly borne in mind in the splinting of war injuries is that it is necessary to protect against overstretching muscles or muscle groups for which the nerve supply has been temporarily or permanently cut off. This is of the greatest importance in cases which, within two or three months' time, require neuroplastic or tenoplastic operations. The number of this class of cases was 5 per 1,000 total number of battle injuries in the given hospital.
GUNSHOT WOUNDS OF THE SHOULDER, WITH FRACTURE
Immediately upon arrival at base hospitals either the airplane splint or a plaster-of-Paris jacket including the affected arm should be applied. In a considerable number of these cases, arthrodesis of the shoulder is the end to be sought. For this purpose, plaster of Paris is the ideal device. The upper arm should be at an angle of from 500 to 600 from the trunk, the arm carried well forward, the elbow at a right angle, the hand supinated and dorsally flexed. This position should be maintained from 12 to 16 weeks. This gives a very full range of motion for the upper arm and much earlier healing than treatment in any other splint. When preliminary healing with flail shoulder has been permitted arthrodesis of the shoulder should be sought by secondary surgical treatment along similar lines. The number of this class of cases was 5 per 1,000 total number of battle injuries in the given hospital.
GUNSHOT WOUNDS OF THE UPPER ARM, WITH FRACTURE OF THE HUMERUS
Practically all gunshot fractures of the humerus are received at base hospitals in the straight Jones splint, with the elbow straight and the hand pronated. For purposes of transportation and during the first two or three weeks following injury this splint has much to commend it. It is very commonly poorly applied. Enough traction should be used to keep the ring firmly in the axilla and to contribute to the immobilization of the entire arm. Care must be taken to avoid the application of too much traction. Several cases have been seen in which 1 or 2 inches have been added to arms with humerus fractures by excessive traction in the splint. Not very much traction is necessary. Immediately upon arrival at a base hospital the straight splint should be removed and the elbow flexed with the hand supinated. The Jones humerus traction splint may be used as an ambulatory splint or with the patient in bed and the arm suspended. Often plaster of Paris can be used to advantage. There was some disposition to question the propriety of flexing elbows in fractures of the lower third. It is especially important to do so, however, even with fractures in which the lower fragment can not be entirely controlled. Further modification of the arm at the point of callus is easier than if bony ankvlosis of the elbow appears. The number of this class of cases was 75 per 1,000 total number of battle injuries in the given hospital.
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GUNSHOT WOUNDS OF THE ELBOW
In general, the same remarks apply as for fracture of the humerus. It is important to remember that extremely serious damage to the elbow joint muscle considered not as a contraindication to flexion, as has often been the case, but as an indication. Secondary surgery following complete ankylosis of the elbow is sometimes necessary to provide rotation of the forearm. This can be accomplished by removal of the head of the radius to a point below the orbicular ligament. Various operations have been performed for mobilizing stiff elbows. In general, it may be said, however, that for most severe injuries of the elbow joint, ankylosis in the position of election has been proved superior to even the fairly successful mobilized elbow joint. The number of this class of cases was 50 per 1,000 total number of battle injuries in the given hospital.
GUNSHOT WOUNDS OF THE FOREARM, WRIST, AND HAND, WITH FRACTURE
For early treatment three principal considerations are essential: Immobilization, supination of the forearm, and dorsal flexion of the hand. This injury was one of the commonest fractures (200 per 1,000 total battle injuries in the given hospital) and one of the most difficult to care for. In old cases nonunion of the radius and ulna was rather common. Immobilization is the answer. No other splint is so satisfactory for the forearm as plaster of Paris. In wounds of the wrist and mnetacarpals a straight arm-and-hand splint was common used. This splint and the Jones full cock-up splint, except for very short periods, should be entirely discarded. The full cock-up position should be used, but with a splint which permits full flexion of the fingers. If there is a tendency toward contracture deformity of the fingers, they should be kept in the extended position a short time every day.
GUNSHOT WOUNDS OF THE MEDIAN, MUSCULOSPlRAL, AND ULNAR NERVES
The arm and forearm splints required are the same as in gunshot wound of the brachial plexus in the neck. Injuries to these nerves occur either independently or associated with fracture of the humerus. The nerve injury may also be complete division or only a partial division or contusion. The accompanying paralysis in any case must always be splinted in the same way as long as it exists and until complete recovery results either spontaneously or following surgical treatment. Operative reunion of completely divided nerves can be undertaken only after some weeks of sound healing. The rule of the British was 6 to 12 weeks. It was also suggested by the British that 1 to 2 weeks' massage of the wound area as a preliminary to operation would serve to indicate whether or not operative trauma would be tolerated. Extensive loss of nerve tissue opens up also the question of tendon transference in these cases, as does also extensive loss of muscle tissue. Careful splinting after all operations and the best methods of electrotherapy, massage, and vocational therapy must all be employed, particularly in these cases, to obtain the best ultimate result. The number of this class of cases was 85 per 1,000 total number of battle injuries in the given hospital.
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GUNSHOT WOUNDS AND OTHER INJURIES OF THE SPINE
The indications in either spine injuries or in secondary Pott's diseases (a few cases of which were seen) are usually for fixation, either in a plaster jacket or on a Bradford frame, for the transportation of these cases. By making use of the retaining straps on a rigid litter these patients can travel quite safely and comfortably. In very few of the cases seen was any immobilization or protection of any kind provided. In a few cases in which adequately early immobilization was used, early recovery from the paralytic symptoms was observed. Laminectomy must he done in carefully selected cases. The number of this class of eases was 10 per 1,000 total battle injuries in the given hospital.
GUNSHOT AND OTHER FRACTURES OF THE HIP
Early and adequate splinting of gunshot fractures of the hip has yielded some of the most brilliant results in the treatment of war conditions. The mortality has been greatly reduced for both transportation and treatment in base hospitals. No other single factor has contributed so much to the satisfactory results as the Thomas thigh traction splint. It is unfortunately true that the efficiency of the splinting has not always been maintained between the front lines and the hospitals farther back. The Thomas splint should be applied and cared for always in the same manner. The introduction of individual methods invariably leads to a loss of efficiency, as patients pass from the hands of one surgeon or hospital to another. The following points must be observed: A long splint and a well-fitting ring must be selected. It must be bent to an angle of 10? to 15? at a point 1½ inches above the level of the knee joint. Having regard for wounds, the adhesive traction bands (of Sinclair glue or moleskin plaster) must include as much skin of the leg and thigh and extend as high as possible. The traction ropes for twisting attached to the lower end of the adhesive, should be of ¼-inch rope or of four-ply muslin fastened very securely into the adhesive, so that it will not give way under a pull of even 15 to 20 pounds. Muslin hammocks of not more than 4 inches in width should he placed across the splint for its entire length at a sufficient tension so that the leg rides well on the top of the splint. The splint is then put on and the traction strap is tied firmly over the lower end with the ring tight against the tuberosities of the ischium. A right-angle foot piece is put on and the foot and knee bandaged in such a way as to put the entire extremity at rest in the splint. The twisting of the traction bands should have attention once or twice daily. The lower end of the splint should be tied to the outer end of the foot of the bed in such a position that the lower end of the femur rotates slightly outward. The foot of the bed should be raised 12 inches so that the patient's body acts as a counterweight to pull against the anchored splint. By following exactly this technique it was possible at the Hospital Center, Savenay, to demonstrate an average gain in length of more than three centimeters in a series of over 300eases. In dealing with open wounds in this splint, it is only necessary to release one or two of the 4-inch hammocks. Care must be taken so that the entire area of the fracture is not moved or allowed to sag below the level of the
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anterior of the femur. In fractures of the neck, as soon as feasible, good traction and slight abduction having been maintained in the meantime, a plaster-of-Paris spica, with full abduction, should be applied. The Thomas double abduction splint should not be used except by those experienced in the use of this particular device. In complete destruction of the neck, with loss of substance, early excision of the head through a posterior incision is advised. Following the operation, also as soon as the wound permits, a plaster spica with full abduction should be used. Departure from the principle enunciated above for special purpose should seldom be made; lowering the foot of the bed or raising the head are only justifiable under exceptional circumstances. The number of this class of cases was 10 per 1,000 total battle injuries in the given hospital.
GUNSHOT AND OTHER FRACTURES OF THE FEMUR
All of the remarks made above with reference to the application of the Thomas splint apply to fractures of the shaft. An astonishingly large number of femur fractures of the shaft apparently well splinted at the front, arrived at the end of 6 to 12 weeks with from 1 to 3 inches of shortening. A large amount of this must be charged to failure to make efficient use of the Thomas splint. This splint, either with or without overhead suspension in the Balkan frame, must be considered to have proven by far the best method of treatment. The number of this class of cases was 75 per 1,000 total battle injuries in the given hospital.
GUNSHOT WOUNDS OF THE KNEE-JOINT
Omitting from the present discussion the question of open or closed treatment of knee-joint injuries at the front, one must consider the treatment of septic knee joints by immobilization or with motion, and by drainage in the later severe septic cases. By the work of Willems it has been adequately shown that certain acute septic knees can be treated to best advantage with adequate drainage and active motion. It is obvious, however, that this motion must be intelligent and carefully controlled. It is not to be construed that such patients man be permitted to travel either from one hospital to another or overseas without such immobilization either in a T'homas splint or plaster-of-Paris splint as to protect against traumatism. Any of the septic cases may require additional drainage. All the methods, including reflection of the pattella, have been tried. One of the most valuable incision Is for draining the popliteal space was worked out and used. It consists of about a 4-inch incision along the inner and posterior border at the upper end of the tibia. This is followed up through the space under the insertion of the popliteus into the knee-joint and drains one of the most dependent and inaccessible synovial spaces in the joint. This incision may he extended upwards over the back of the internal condyle. By keeping in close contact with the bone, the entire popliteal area can be drained with much less risk to the vessels than through any posterior incision. The number of eases of this class was 25 per 1,000 total battle injuries in the given hospital.
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OTHER DERANGEMENTS OF THE KNEE-JOINT
One of the constant orthopedic problems arising out of military service is that ordinarily placed under this rather vague heading. This class of cases, which numbered 10 per 1,000 total battle injuries in the given hospital, includes damage to the external and internal semilunar cartilages, rupture of or damage to the crucial ligaments or the extrinsic ligaments of the knee-joint. Treatment involves modification of boots, removal of loose bodies or of semilunar cartilages and even, in some cases, reconstruction of new crucial ligaments from hamstring tendons. Differential diagnosis of these conditions presents some difficulties. An operation should not be done until not only a diagnosis has been made but also the possibilities as to operative results following operations for comparatively trivial conditions have been seen. The experience of civil practice has shown the wisdom of resection and arthrodesis for prolonged infections which eventuate in tuberculosis.
GUNSHOT WOUNDS OF THE THIGH AND LEG, WITH NERVE INJURY
These patients usually present themselves with foot-drop due to injury of the sciatic or external popliteal. Such cases must always be carefully splinted to maintain the foot at a right angle. For patients able to walk the right angle posterior splint of the British or the modification of the French splint with the double lateral iron outside the shoe should always be used to protect the patient against foot-drop. Walking patients should always wear a simple right-angle splint at night. Injuries of the anterior crural are rarely seen. When found, however, a long splint should always be worn to protect the knee which is inclined to genu recurvation. The number of cases of this class was 50 per1,000 total battle injuries in the given hospital.
GUNSHOT WOUNDS OF THE LEG, WITH FRACTURE
This was one of the commonest of the war injuries (100 per 1,000 total battle injuries in the given hospital), and one of the most difficult to treat satisfactorily. Adequate fixation with the Thomas splint or with the ordinary posterior thigh and leg splints was rare. Especially was this the case when patients were being moved about. It is especially in this classification that plaster of Paris may be and should be used. It is the only device that uniformly provides length, position, and immobilization.
GUNSHOT WOUNDS OF THE FOOT AND ANKLE
Adequate fixation of these wounds with the foot at right angles to the leg and slightly inverted must be the invariable rule. Practically all of these wounds, even including those of the toes, cause much disability. Where there is extensive damage to the calcaneum or the metatarsus, amputation must frequently be considered. When the angle joint only is involved, astragalectomy with adequate drainage, will often give a good result. After the period of active treatment, the use of right-angle foot splints as either inside or outside irons, or with double lateral irons as so extensively practiced by the British, is to be
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highly recommended. These should be used until stability of the foot and ankle is well reestablished. The number of this class of cases w as 120 per 1,000 total battle injuries in the given hospital.
SOFT-PART WOUNDS, WITH DAMAGE TO MUSCLES AND TENDONS OF THE UPPER AND LOWER EXTREMITIES
These wounds, especially in the vicinity of joints, contributed a very large share of the serious war wound deformities (125 per 1,000 total battle injuries in the given hospital). It should always be remembered that any deformity of this sort represents healing in in malposition that could have and should have been prevented in the first instance by proper splinting. Contracture deformity of the knee from posterior thigh and leg wounds was especially common. This and associated foot-drop may always be prevented by the simple expedient of applying suitable apparatus before malposition develops and continuously until healing is complete.
