CHAPTER III
Splinting in the Combat Zone
CLASSIFICATION OF MILITARY SPLINTING
The exigencies of military surgery in World War II required, as already noted, that all care of battle casualties be rendered in phases, in installations located, equipped, and staffed for various specific missions. The splinting of bone and joint injuries was similarly timed. It was necessarily interrupted for each phase of surgical management. It was carried out with materialand facilities that varied according to the mission of the installationat which the care was rendered. It was provided again, with a new objective,after each phase of treatment had been completed.
By a process of evolution, splinting in overseas military surgery in World War II (table 1) was eventually classified as follows:
1. Emergency or first-aid splinting, which was provided within the divisional area of the combat zone as an integral part of resuscitation and to render the casualty transportable to a hospital equipped for surgery.
2. Splinting after initial wound surgery, which was provided in an evacuation hospital or, as indicated, in a field hospital. It was not intended to obtain or maintain reduction of fractures. Its objective was to facilitate transfer of the wounded soldier to a fixed hospital in the communications zone.
3. Splinting after reparative surgery, which was applied in a fixed hospital in the communications zone. It was sometimes designed to achieve reduction of fractures. It was always designed to maintain reduction and to provide prolonged immobilization. As a matter of convenience, it will be discussed under the headings of the management of regional and special injuries.
4. With an occasional exception, such as fractures of the femur and of the hand, splinting for transportation to the Zone of Interior did not represent a special type. The casts applied after reparative surgery were sometimes changed before the casualty was returned to the United States, for reasons of cleanliness or because the casts had become too loose to be effective. As a rule, however, the definitive splinting applied for the fracture in the fixed hospital served until the cast was removed in the hospital in the Zone of Interior in which treatment would be continued.
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EMERGENCY SPLINTING
Historical Note
In World War I,1 splints and other appliances used by the United States Army Medical Corps were not standardized until late in 1917. A board appointed by General Headquarters, American Expeditionary Forces, to investigate and report upon the advisability of standardization suggested that a manual of splinting be prepared for the use of medical officers. The manuscript was approved by the commanding general, American Expeditionary Forces, 9 September 1917, and 6 weeks later the Manual of Splints and Appliances for Use of the Medical Department of the United States Army was delivered to supply depots in France. The printing of the manual, as well as the manufacture and procurement of the recommended splints and other appliances, was then the responsibility of the American Red Cross.
A second board of officers was appointed in October 1918 to revise the manual on splinting and to examine the necessity for changes in the splints and other appliances in use. Although the board completed its work in only a few days, the second edition of the manual was not ready for distribution until 1 February 1919, more than 2 months after the end of World War I.
No significant changes seem to have been made in the methods prescribed in this manual until 11 September 1940, during the prewar mobilization of the United States Army. This was 15 months before the entry of this country into World War II. The manual issued at this time (Medical Field Manual, FM 8--50, Splints, Appliances, and Bandages) served as the textbook for the training of officers and enlisted men of the Army Medical Department during the period of mobilization and for the first 2 years of United States participation in World War II.
The methods described in this manual were based on the use of the splints standardized in the Army Tables of Equipment (then called the Basic Equipment List) before the beginning of mobilization. These methods were naturally modified in the light of experience in overseas theaters, but no formal revision of the manual was issued until 15 January 1944.
Splinting is mentioned only incidentally, and with almost no details, in Orthopedic Subjects,2 one of the Military Surgical Manuals prepared by the Committee on Surgery of the Division of Medical Sciences of the National Research Council, which appeared in 1942.
Improvised splinting was not mentioned in the manuals prepared in World War I. It seems to have been included for the first time in the second(1931) edition of the Military Medical Manual. It was only briefly discussed
1 The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 549-590.
2 Orthopedic Subjects. Prepared and edited by the Committee on Orthopedic Surgery of the Committee on Surgery of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals. Philadelphia & London: W. B. Saunders Co., 1942.
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in this edition and was mentioned with similar brevity in each of the subsequent editions of this manual, including the sixth, which was issued in 1944.
The Medical Field Manual (FM 8-50) issued in 1940, also contains no mention of improvised splinting. The 1944 revision, entitled "Bandaging and Splinting," contains no direct text references to improvisations, but illustrations show the use of sticks as splints for the forearm and the use of a coat and a shirttail as slings. Soldiers Handbook (FM 21-100), issued 23 July 1941, contained a brief but excellent paragraph on the subject. First Aid for Soldiers (FM 21-11), issued 7 April 1943, contained a detailed description and many excellent illustrations of improvised methods of splinting. Long before this date, however, intensive and thorough instruction in improvised methods had been given to Medical Department enlisted men of the Regular Army, both before and during the period of mobilization and after the entry of the United States into the war.
Equipment
Standard United States Army equipment for emergency battlefield splinting in World War II included hinged half-ring leg splints; hinged full-ring arm splints; wire ladder and basswood splints; and triangular, roller, and Carlisle compressed bandages.
This equipment, while it was generally efficient, was extremely cumbersome. Throughout the war, the desire was repeatedly expressed, and the need was clearly evident, for a light, readily adjustable, easily transportable, universally applicable splint which medical aidmen could use on the battlefield. At the end of the war, this need had not yet been satisfied.
General Considerations
The emergency splinting of a fractured extremity had as a chief objective the preparation of the wounded man for his transportation, with minimum discomfort, from the battlefield to a hospital in which he would receive surgical care. It was also an important part of first-aid management. It minimized or prevented shock in bone and joint injuries. It reduced the need for narcotics. It was thus an essential step in the resuscitation which had to be accomplished before surgery could be undertaken.
Reduction of the fracture was not an objective of emergency splinting. The purpose of emergency splinting was to prevent additional damage to the soft parts by fragments of bone and to keep the patient as comfortable as possible while he was on his way to the evacuation hospital. The criteria of its success were therefore comfort and relief from pain during transportation.
Medical aidmen, during their training, were always instructed that it was desirable, when possible, to "splint `em where they lie" and to use standard methods of splinting. As a practical matter, neither of these instructions was always possible of accomplishment. For a variety of reasons, it was sometimes more expeditious to bring the wounded man to the battalion aidstation on a
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litter. The chief of these reasons was that delay on the battlefield might have resulted in additional hazards to the casualty as well as risk to the aidmen themselves. In the battalion aid station, the environment was safer; better equipment was available; and the splinting, which could be applied deliberately, was frequently more precise and more accurate than splinting applied nearer the front. None of these reasons, however, was an indication for failure to splint the wounded man on the battlefield whenever that was possible.
Improvised splinting, as already mentioned, was taught along with standard methods during the period of training. The ingenuity of the United States Army medical aidman, when he found himself in circumstances of stress, often went beyond his formal teaching. A fractured lower extremity (fig.10),for instance, was bandaged to a rifle, to a handy board, or to a limb from a nearby tree. A fractured upper extremity was held against the chest by the field jacket after the upturned shirttail had been fashioned into a sling. These and other improvisations proved extremely satisfactory, and, when they were adequate, they, like more conventional splinting, were left undisturbed as the casualty was evacuated through the successive echelons of the division medical battalion.
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If for any reason either improvised or conventional splinting did not seem adequate, it was adjusted or replaced at the battalion aid station. All splints were carefully inspected at each subsequent installation and were adjusted as necessary, but they were not removed or replaced except for good reason. Even if it was necessary to remove the dressing and inspect the wound, it was seldom necessary to remove the splinting to accomplish this purpose.
Regional Emergency Splinting
Upper extremity. - Well-padded coaptation basswood or wire ladder splints furnished satisfactory emergency splinting in injuries of the bones and joints of the forearm and hand (fig. 11). It was promptly learned that a sling composed of a triangular or roller bandage must be added to keep the patient comfortable (fig. l1C).
Difficulties frequently developed when the hinged full-ring arm splint was used under battlefield conditions for fractures of the humerus. This splint proved undesirable in almost every respect. Many of the wounded soldiers complained of constant discomfort when they were put up in it with traction applied by means of a hitch placed about the wrist and fastened to the end of the splint. The full elbow extension produced by traction predisposed to angulation of the fragments, and the angulation, in turn, introduced risk of damage to the brachial artery and the main nerve trunks. Still another dangerous possibility from pressure of the ring was injury, which might be irreparable, to the axillary contents.
For these various reasons, the hinged full-ring arm splint was employed less and less during the course of the Tunisian campaign, but it was still occasionally used in the theater, in spite of instructions to the contrary, until December 1944, because new units coming from the United States had been taught to apply it.
Eventually, this splint was completely replaced for fractures of the arm and shoulder joint by two other methods which were simple to apply and which provided maximum relief of pain and discomfort. Both held the elbow in about 90° flexion.
1. In the first of these methods, a Carlisle pad was placed in the axilla and a triangular bandage was applied as a sling to hold the elbow at, or almost at, a right angle. A second triangular bandage was used to bind the arm, in this position, against the chest, and was reenforced by a few turns of a roller bandage. During the latter part of World War II, this simple method came to be considered the method of choice for emergency splinting of fractures of the humerus and for fractures about the shoulder.
2. The second method of emergency splinting (fig. 12) required the use of a padded wire ladder splint extending from the tip of the shoulder down the posterior aspect of the arm and forearm to the hand. The arm was held at the side, with the elbow almost at a right angle; then the splinted arm and forearm were bandaged against the chest by a roller or triangular bandage.
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Lower extremity. - Either single or double wire ladder splints, well padded, were used for fractures of the foot and ankle (fig. 13). Often a single splint was sufficient; it was passed down the back of the leg, around the heel, and up the plantar surface of the foot. If false motion or instability at the site of the fracture was present with a single splint, a second was passed down one side of the leg, around the plantar surface of the heel, and up the other side of the leg. The foot was splinted at right angles to the leg, and roller bandages were used to hold the splint or splints in position.
The half-ring leg splint proved, on the whole, quite satisfactory for fractures of the leg, knee joint, thigh, and hip joint (fig. 14). Three triangular bandages served as slings for the fractured portion of the extremity and two others for the intact portion. The foot was held almost at a right angle by a foot support, and the distal end of the splint was elevated by another foot
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support, this one being turned downward. Late in the war, a single gadget slipped over the end of the splint took the place of both supports. A standard webbing strap was placed about the heel and ankle and fastened to the end of the splint, thus providing moderate fixed traction. The strap was applied with the shoe on, but the shoelaces were then loosened or cut, to allow for possible swelling of the ankle and foot.
A casualty was not comfortable during evacuation in the half-ring leg splint unless the distal end of the splint was elevated and made secure. This was accomplished by fixing the lower half of the foot support used to maintain elevation of the distal end of the splint in the bar by which the splint was attached to the stretcher. The bar was standard equipment.
A number of other precautions were necessary when the half-ring leg splint was used:
1. Deflexion or unfolding of the hinged half ring, with sagging of the upper end of the splint, was likely to result in a painful drag on the thigh. This could be almost entirely prevented if care was taken to see that the half ring was folded completely into the 90° position when the splint was applied.
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2. If the injury was near the hip or the knee, the splint was bent 15° to 20° at the knee before it was applied, so that those joints would be put up in some degree of flexion.
3. In fractures of the lower third of the femur, the popliteal vessels had to be protected against injury from the sharp bony fragment likely to project posteriorly. The risk of injury to the popliteal artery was decreased if the extremity was put up in slight flexion at the knee instead of in complete extension.
4. Pressure necrosis, which was a possibility underneath the strap crossing the foot, was guarded against by avoiding strong traction. Strong traction, as a matter of fact, was not required, since the objective was merely to immobilize the fracture, not reduce it. The results were therefore accomplished by moderate or even minimal traction. It. was necessary to inspect the strap at each halt in the line of evacuation, to be sure that pressure had not become excessive.
TRANSPORTATION SPLINTING
The routine use of plaster of paris for transportation splinting in the evacuation hospitals of the combat zone in World War II was a major advance over the methods of splinting used in World War I, when for all practical purposes only the splints and appliances described in the manual issued in 1917 (p. 31) were provided in forward areas and plaster was seldom used. 3
Medical planning for World War II contemplated the use of plaster in the forward zone, partly because United States surgeons were fully trained in plaster techniques and partly because these methods had been used with satisfaction in forward installations during the Spanish Civil War as well as in Allied forward hospitals before the entry of the United States into the war. Standard United States Army Medical Department equipment for hospitals in the combat zone therefore included ample supplies of plaster of paris and sheet wadding, in addition to standard splints. Portable fracture tables became available after the Tunisian campaign in 1942-43. Up to that time, some hospitals were supplied with Meyerding sacral rests. Those which did not have them made use of wooden blocks, tin cans, and other improvised substitutes, which were more or less satisfactory. The chief objection to these improvisations was that they were wasteful of personnel. At least one person was required to hold each lower extremity while a hip spica, for instance, was being applied.
3 It should be remembered that the First U. S. Army functioned in World War I for only about 11 weeks, from 2 September to 11 November 1918. The number of casualties during this period was large but amounted to only a small fraction of those sustained in the European theater or Mediterranean theater during World War II. There was no consultant system in World War I, except on paper, until hostilities were almost concluded. Those of us who served in World War I, I have found, cannot recall seeing any circulars or directions concerning the proper splinting for evacuation of wounded. The Army ring splint was used to evacuate patients from field hospitals to evacuation hospitals, and, in many instances, it was doubtless reapplied before they were sent to the rear from evacuation hospitals. Plaster-of-paris splints, however, were also used. I recall applying them myself, and I have checked with a fellow medical officer who served in a nearby evacuation hospital and who spent his entire time applying plaster-of-paris splints to immobilize fractures for evacuation. [ Editors note]
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General Considerations
The objective of transportation splinting in a forward hospital was to maintain gross normal alinement of the injured extremity, to immobilize the adjacent joints in the position of function, and to accomplish these purposes without causing nerve or circulatory damage or causing pain by pressure on bony prominences.
Some of the techniques used in the hospitals of the combat zone early in the North African experience proved completely unsatisfactory and dangerous as well. Among them were skintight, unpadded plaster casts and skeletal fixation with incorporation of transfixion pins or wires in the cast (p.55).
The ideal transportation splint proved to be a well-padded plaster-of-paris cast which held the fracture in grossly normal alinement and which immobilized the joints above and below the injury ill the position of function. Once the lesson was learned, no exceptions were permitted to the rule that all circular plaster casts applied to the extremities must be split or bivalved in the operating tent of the forward hospital before the patient was taken off the operating table. There were two reasons why it was not safe to postpone this procedure: (1) There were no ward officers in the usual sense of the term in forward hospitals, and the splitting or bivalving of the cast was therefore the responsibility of the surgeon, who could not count on time to leave the operating room to split casts on the ward; and (2) theoretically, provision had to be made for a tactical situation which might demand immediate evacuation and allow no time for such details as splitting casts.
Plaster casts for transportation purposes were made relatively thick and heavy, to prevent breakage after they had been split or bivalved. Muslin bandages were wound around them snugly after they had been split, to protect their integrity and increase their stability.
After the cast had been applied, a diagram was drawn on it showing the location and general contour of the fracture (fractures), the location of the wounds of entry and exit, and the extent of the skin loss. Those who cared for the casualty in the course of his evacuation, as well as those who received him in the general hospital, thus had a readily available source of information concerning his injuries.
The application of good transportation splinting often required the help of several persons. A single assistant could not possibly support a lower extremity in which both the tibia and fibula were fractured so that the fragments were kept in satisfactory alinement, while at the same time the foot was kept in 90° dorsiflexion, in neutral version, and the knee in mild flexion. An attempt to put the lower extremity in plaster with aid from a single assistant who grasped the toes and provided both elevation and traction almost invariably resulted in immobilization with posterior bowing, with the foot in plantar flexion and inversion and the knee in complete extension. This is as pernicious a position as can be imagined for immobilizing an extremity with a fracture of the tibia and fibula. Properly, the plaster was applied for such an injury
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while one assistant supported the fracture and another held the foot in correct position.
Improvised methods (fig.15) were designed to reduce the number of helpers necessary after initial wound surgery, personnel shortages always being a problem. Thus the use of a narrow, removable support of flexible metal under the knee while the cast was applied to the lower extremity kept the joint in slight flexion and made it possible for a single assistant to support the fractures of the lower leg in reasonably good alinement and at the same time hold the foot in the position of function (fig.15A).
A plaster Velpeau or shoulder spica was extremely useful in transportation splinting for injuries of the upper arm and shoulder but was difficult to apply because of lack of standard equipment. The hinged full-ring arm splint, although unsatisfactory for the purposes for which it was intended(p. 34), was very useful in the application of plaster about the shoulder(fig. 15B). The end of the splint was placed on the operating table and the ring on some convenient available support, such as a sawhorse. The patients head rested comfortably in the ring during the application of the cast. The splint was easily pulled out from beneath the cast after the plaster had hardened. A long, narrow board or a narrow strip of strong metal could also be used in this fashion (fig. 15C), but it was less convenient for the surgeon and considerably less comfortable for the patient.
If the hand was suspended from a stand used for intravenous therapy by a roller bandage tied about the thumb and fingers, long arm plaster casts could be applied for fractures of both bones of the forearm with the fragments ill reasonably good position and the wrist and elbow joints in the position of function.
These are merely examples of some of the shortcuts and improvisations employed. They were highly advantageous when casualties were heavy, demands urgent, and surgical personnel in short supply. Numerous others were devised as special necessities developed.
Regional Splinting
Arm and shoulder joint. - For several years before the war, the hanging plaster cast had been popular in the United States for fractures of the humerus and injuries about the shoulder joint. It was therefore natural that it should have been rather widely used in the early stages of the North African campaign. It soon became evident, however, that while this cast might be satisfactory in civilian practice, it was not an adequate transportation splint in military circumstances. Reports from general hospitals which received casualties put up in hanging casts were always to this effect. Most patients with fractures of the humerus were necessarily transported recumbent after initial wound surgery, with the result that the traction produced by the weight of the cast in the hanging position was lost and little immobilization was maintained during transportation. Ambulance rides over rough terrain helped to increase the
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loss of immobilization and added to the patients discomfort. Because of universally adverse criticism, the hanging cast was seldom used after the first months of 1943.
In the early North African experience, fractures of the humerus were also immobilized by the so-called U-plaster cast, which the British had used widely in the Middle East. It was not satisfactory and was soon discarded. Another, later method, which also never achieved popularity among United States Army medical officers, was the so-called elephant-tusk splint (fig.16), which was introduced during the Italian campaign. Because it could be removed and replaced, it was theoretically useful (1) in injuries of the arm or shoulder associated with chest injuries which required thoracentesis and (2) in vascular injuries which required repeated inspection of the entire arm and forearm.
The plaster Velpeau and the shoulder spica both proved excellent transportation casts, and one or the other was always used after this fighting for Cassino and Anzio began in the winter of 1944. Both maintained the arm at or near the side and the elbow at 90°. This position permitted transportation with minimum discomfort.
The plaster Velpeau (fig. 17) was, for a number of reasons, the better of the two techniques: It provided maximum comfort. It was easy to apply and remove. It fitted within the bars of the hitter, which was an important consideration in comfortable transportation. If thoracentesis was necessary for an associated chest injury, access to the chest could be provided by windows cut into the cast. If radial-nerve paralysis was present, excellent temporary support could be provided for the thumb and the proximal phalanges of the fingers by extending the plaster sufficiently to hold them in extension. When the plaster Velpeau was applied correctly, it was not necessary to split it, since it did not completely enclose the arm.
There were, it is true, some theoretical objections to the use of a plaster Velpeau for transportation splinting. The chief was that the adducted position of the arm at the side was unsuitable for fractures of the upper third of the humerus. This was not a sound argument, for two reasons. The first was that a surgeon in a forward hospital was not concerned with the definitive reduction of fractures. The second was that the comfort provided by the cast predisposed to muscular relaxation, so that it was the exception, at the general hospital, not to find the upper humeral fragment adducted and in reasonably good alinement with the distal fragment.
The shoulder spica (fig.18) provided just as comfortable transportation as the plaster Velpeau in injuries of the arm and shoulder, but it had a number of disadvantages in a forward hospital: The spica had to be applied with special precautions, preferably with the arm in the position of internal rotation at the shoulder and with the elbow and arm held anteriorly rather than laterally. Otherwise, the cast would not fit within the bars of the litter or cot, and the elbow would project and might be traumatized during transportation. Finally, the spica required more personnel for its application, and the use of more plaster, than the Velpeau.
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FIGURE 17. Plaster Velpeau bandage for injuries of shoulder joint, arm, or elbow
A. Diagrammatic showing of steps of application of plaster Velpeau. For several reasons, this cast provides excellent transportation splinting for fractures of the humerus. It can be constructed from only 2 plaster slabs and 2 or 3 rolls of plaster bandage. There are no points of stress, so breakage need not be feared. The entire hand, if desired, can be left free.
B. Plaster Velpeau used as transportation splinting for compound fracture of lower third of humerus. The hand in this case projects farther forward than usual.
C. Plaster Velpeau applied in evacuation hospital after initial surgery for compound fracture in region of shoulder. Note data on cast.
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FIGURE 18. -Application of shoulder spica for injuries about shoulder joint and of arm.
A. Diagrammatic showing of shoulder spica so applied that forearm and elbow are held forward and therefore within bounds of litter bars. Note that the circular portion of the cast about the arm has been split.
B. Shoulder spica applied in evacuation hospital, following initial surgery for compound fracture of humerus with injury to radial nerve. Note support temporarily provided for thumb and proximal phalanges of fingers. Note also data on cast.
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Forearm and elbow joint. - The preferred transportation splint for wounds of the forearm and elbow joint was a plaster cast extending from the upper arm to the proximal palmar crease. It was so applied that the elbow was held at 90°, the forearm in mid pronation, and the wrist in slight cockup. A sling provided additional immobilization and at the same time added to the patients comfort. It was particularly important that the sling be supplied when the casualty had no other injury. Under these circumstances, he would be treated as walking wounded, and without a sling the hand would be in the dependent position and would rapidly become edematous.
If there was no radial-nerve injury, all casts applied to the upper extremity were trimmed away to the proximal palmar crease, to permit active use of the fingers and thumb. Particular care was taken to avoid restriction of motion in the metacarpophalangeal joints. If radial paralysis was present, the plaster was extended beyond the palmar crease, to support the proximal phalanges of the fingers in some degree of extension, and the thumb was immobilized in partial abduction and extension. The distal phalanges of the fingers were left free for active motion.
Thigh and hip. - Although the hinged half-ring traction splint was standard United States Army equipment, it was seldom used in transportation splinting, even during the early stages of the North African campaign.
During both phases of the Tunisian campaign, United States Army medical officers had ample opportunity to observe the British use of the Tobruk splint. This splint, so named because it first came into use during the evacuation of Tobruk, was practically always used by the British for transportation splinting of fractures of the femur, and its use was recommended in the preparatory United States Medical Department directives 4 for the invasion of Sicily. United States Army surgeons who served in Sicily never liked the Tobruk splint for fractures of the femur. They found it difficult and time consuming to apply and did not regard the immobilization provided as satisfactory. For these reasons, the Tobruk splint was not generally accepted in the Mediterranean theater during the remainder of World War II, even after its application had been greatly simplified and it had proved highly effective for transportation splinting in injuries of the knee (p. 49)and the lower third of the femur.
In spite of the unpopularity of the Tobruk splint, every United States Army military surgeon should have been familiar with it. It was far more desirable than the hip spica when injuries of the large bowel for which colostomy had been performed were associated with fractures of the femur. It was particularly useful for fractures of the lower third of the femur and wounds of the knee joint. It was also useful when either plaster or water was in short supply or when speed of application was important.
4 (1) Circular Letter No. 13. Office of the Surgeon, North African Theater of Operations, 15 May 1943, subject: Memoranda on Forward Surgery. (2) Circular Letter No. 16, Office of the Surgeon, North African Theater of Operations, 9 June 1943, subject: Memoranda on Forward Surgery Especially Applicable to Amphibious Operations. (See appendix, pp. 299-303 and 304-307, respectively.)
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Early in the North African campaign, the single hip spica was widely used for fractures of the femur and fractures about the hip joint. Later, the double spica (fig. 19) came into general use. It was really a spica and a half, since the cast on the uninjured side was carried only to the knee. On the injured side, the cast extended from the foot to the costal margin. A plaster slab extended beyond the toes. The plaster was molded about the pelvis and was trimmed low in front, to permit the injured man to sit semi erect during travel. Knee spread was held to a minimum, so that the cast would fit between the bars of the litter or cot on which the casualty was transported. Such a spica cast emerged as the recommended transportation splinting for fractures of the femur.
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Certain precautions were necessary in the application of the spica. In fractures of the upper third of the femur, the hip and knee were both flexed at 35° to 40°. In fractures of the lower third, in order to guard against pressure in the popliteal space by rotation of the lower femoral fragment, the knee was flexed at 30° to 35°, which required a compensating degree of flexion of the hip. Care was taken to insure that the heel and buttock were held in the same horizontal plane when the cast was applied. Otherwise, the upper rim of the cast could produce uncomfortable pressure against the back or the abdomen when the patient was recumbent in bed oron a cot and the heel and buttock necessarily assumed the same plane.
If the spica was bivalved from toes to hip, cross sticks were incorporated between the thighs both anteriorly and posteriorly. As a rule, it was necessary to split only the leg section of the spica, on the outer aspect, and a single anterior cross stick was then all that was necessary.
Knee joint - Satisfactory methods of transportation splinting for wounds of the knee joint were slow in developing. Long leg casts were used in the early days of the North African invasion and continued to be used by most surgeons in forward areas until the spring of 1944. This technique was employed in spite of the early British experience, which had showed that the hip spica was preferable for such injuries, and in spite of reports from United States Army general hospitals to the effect that casualties transported in long leg casts often suffered a great deal of pain.
The hip spica began to be used for injuries of the knee joint in the latter part of 1943, but it was employed only sparingly until the spring of 1944. Then its use was recommended officially, as part of the effort to improve the results in wounds of the knee joint. The long leg cast, however, was easier to apply and it continued to be used frequently, especially when casualties were heavy. This was unfortunate, for, even when injury to the adjacent bones was minimal, adequate immobilization of the knee was of paramount importance in reducing the risk of infection. It was also essential if the patient were to travel comfortably. These criteria could not be met by use of a long leg plaster cast.
It was eventually found that a single hip spica, well molded about the pelvis, with the hip and knee joints each held in 15° to 20° flexion, provided the most satisfactory kind of transportation splinting for an injury about the knee joint. The portion of the spica encircling the trunk was kept narrow and did not extend above the costal margin, so that the soldier might sit semi erect without discomfort, as in spicas applied for fractures of the femur.
The simplified form of the Tobruk splint (fig.20) could be used as a substitute for the plaster hip spica for wounds about the knee joint, and its ease of application often made it a desirable substitute. Because it had proved so unsatisfactory in its original form for fractures of the femur, it never became widely popular for this purpose in Fifth U. S. Army hospitals. The simplified form of the Tobruk splint was, however, recommended for
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wounds of the knee joint by the consultant in surgery, Seventh U. S. Army, just before the invasion of southern France.
In the original Tobruk splint, traction was provided by strips of adhesive plaster passed down each side of the thigh and leg. A long leg plaster cast, which included the foot, was applied over these strips, which emerged from the cast just above the malleoli. The injured extremity in the plaster cast was then placed in a Thomas splint and the traction strips were tied to the end of the splint. Traction was provided by means of a windlass. Additional turns of plaster were passed around the leg and the bars of the splint.
In the simplified Tobruk splint (fig. 20), the traction strips of adhesive were placed down each side of the extremity, as in the original technique, and the limb, heavily covered with sheet cotton, was placed in an Army half-ring splint. The traction strips were then passed around the footrest, which supported the foot at about 90°, and were tied to the end of the splint. Tongue depressors passed between the traction strips just proximal to the distal end of the splint served as windlasses to provide some traction. Several turns of plaster were next applied loosely about the limb and the splint, from just above the malleoli to the groin. They were molded about the uprights and along the posterior and anterior surfaces of the thigh and leg. The distal end of the splint was elevated by means of a second foot support, which was turned downward. A figure-of-eight plaster bandage bound the foot to the foot support. This precaution, which prevented rotation of the leg, increased the patients comfort.
The full-ring Thomas splint would have been more satisfactory to use with the Tobruk splint than the half-ring splint, but the latter had been standardized equipment since the beginning of World War II, and the full-ring splint was not available in evacuation hospitals. Deflection of the half ring at any time after it was applied caused the upper end of the plaster to press against the thigh and produced considerable discomfort. This could be avoided by fixed traction on loops of a bandage passed through the half ring. The ends of the loops of bandage were incorporated in the plaster about the thigh and the half ring was thus stabilized in the correct position.
Surgeons of the forward hospitals of the Fifth and Seventh U.S. Armies who used the Tobruk splint by the modified technique just described were almost unanimous in stating that it can be applied more quickly and more easily than a hip spica.
Leg, ankle joint, and foot. - Fractures of bones of the leg, ankle joint, and foot were put tip in molded plaster casts (fig. 21). If only the bones of the foot were broken, the cast was stopped at the knee. For injuries about the ankle and for fractures of the tibia, fibula, or both bones, it was carried to just below the groin. The foot was held at 90°, in neutral version, with the arches well molded. A plantar slab extended beyond the toes, to protect them from the pressure of blankets and from other trauma during transit. Hyperextension of
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the toes was avoided. The knee was immobilized in about 15° flexion. Failure to provide this small degree of flexion increased the difficulty of obtaining fixation of the foot at the proper angle, since complete extension of the knee increased the tension on the gastrocnemius muscle.
