CHAPTER V
Regional Compound Fractures
Part I. Compound Fractures of the Humerus, Radius, and Ulna 1
GENERAL CONSIDERATIONS
Compound fractures of the bones of the upper extremity were frequent, as is shown by the experience of two general hospitals which functioned in the Mediterranean theater. These bones were injured in 992 (34.1 percent) oh the 2,911 compound fractures treated at the 45th General Hospital during 1944, and in 685 (37.1 percent) of the 1,844 compound fractures treated at the 21st General Hospital over the same period. When the 332 fractures of bones of the hand are excluded, composite figures for the two hospitals show that the bones of the arm and forearm were involved in 1,098 (23.1 percent) of all the compound fractures treated in them during 1944. Of these injuries, 322 were compound fractures of the humerus, and 338 were compound fractures of the radius, ulna, or both bones.
Compound fractures of the long hones of the upper extremity offered a peculiarly attractive field for the application of the principles and procedures of reparative surgery. They are therefore discussed in considerable detail. The management of injuries of the hand is not considered in this volume. These injuries are discussed in detail in the volume on hand surgery.
PROBLEMS OF MANAGEMENT
Certain special problems of management presented themselves in compound fractures of the upper extremity:
1. The major objective of the management of all wounds of the arm and forearm, including all compound fractures, was maximum restoration of the function of the hand. This function varies from the finer precision movements to grasping with strength. It was therefore essential, in addition to repair of the bony framework and skin covering, that the integrity of muscle, tendon, and nerve be restored, as nearly as possible, to its original state or that it be otherwise compensated for, and that early motion, particularly of the fingers,
1 Data for this section were collected by Maj. Joe M. Parker, MC, and Capt. Francis R. Crouch, MC, 21st General Hospital; Capt. John W. Rovane, MC, 300th General Hospital: Maj. William H. Ferguson, MC, Capt. Robert B. Goltschalk, MC, and Capt. James H. Flynn, MC, 33d General Hospital: and Lt. Col. George A. Duncan, MC, 45th General Hospital.
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be instituted, to minimize fixation of joints, muscles, and tendons. The overwhelming importance of function of the hand always had to borne in mind, therefore, when the management of compound fractures and other injuries of the arm and forearm was determined upon.
2. A severed nerve in the arm or forearm or a severed tendon or tendons in the forearm was sometimes of greater importance than the associated compound fracture or fractures. In the staging of reparative-surgery procedures, however, the repair of nerves and tendons was postponed until the wound had healed and there had been optimal restoration of the bony framework (fig. 39). Nerves and tendons could then safely be repaired through a healed wound. These operations were functions of hospitals in the United States. The necessities of concurrent injuries therefore sometimes determined the method of fracture management and sometimes dictated the plastic procedures which might be necessary to accomplish wound healing in injuries of the upper extremity.
3. Bone loss with resulting partial or segmental defects was not infrequent, particularly in the humerus, and called for special methods of fracture management (figs. 43 and 44. also figs. 37 and 38).
4. Immobilization of the upper extremity is difficult, a circumstance which made maintenance of reduction of certain fractures, particularly those of the humerus and of both bones of the forearm, correspondingly difficult.
5. In spite of the serious problems of management presented by compound battle-incurred fractures of the upper extremity, the favorable factors on the whole outweighed the unfavorable. The richly vascularized muscular sleeve about the whole circumference of the arm and upper forearm predisposed to rapid healing of both wounds and fractures and to minimal infection. Similarly, except in the lower forearm, there is a paucity of dense fascia and tendons and therefore an absence of tissues with poor blood supply and a correspondingly limited resistance to infection. The well-developed muscular sleeve just described facilitated the coverage and revascularization of bones denuded at wounding and further denuded at surgery. Dead space was readily obliterated, and adequate drainage could be secured with equal ease. Maintenance of full bone length in this region was relatively unimportant from the standpoint of future function. Finally, bone and nerve surgery could be performed at the same operation or in stages, according to the necessities of the special case.
GENERAL PRINCIPLES OF MANAGEMENT
Unless serious associated injuries required longer stays in evacuation hospitals, soldiers with wounds of the upper extremity usually reached general hospitals within 2 to 4 days after initial wound surgery. Since blood loss was considerably less severe than in compound fractures of the femur and of the bones of the leg, little time had to be spent in elaborate preoperative preparation. Transfusions in the amount of 500 to 1,000 cc. usually restored the
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hematocrit reading to the 40 regarded as optimal before reparative surgery. Most casualties therefore reached the operating room by the 7th day after wounding and seldom later than the 10th day. This meant that practically all surgery could be done within the optimum period. In a series of 147 compound fractures of the humerus, for instance, to be reported later in this chapter (p. 130), reparative surgery was done on an average of 6.5 days after wounding.
A study of peripheral-nerve function was part of the preoperative survey in wound of the arm and forearm, but final appraisal was made in the operating room, after the cast had been removed and before anesthesia was begun. The status of nerve function could thus be determined with absolute certainty when the extremities were unhampered by supporting casts or dressings.
Wound management. — Wound management in compound fractures of the upper extremity followed the general principles of reparative surgery. The wound was widely exposed, so that inspection to the depths was possible and the fracture could be fully visualized. Any residual devitalized tissue was excised. Small, totally separated fragments of bone were removed. The decision as to fracture management was made, and internal fixation, if it was the method selected, was carried out.
Whenever possible, the wound was closed by accurate approximation of the soft parts, to achieve obliteration of dead space, coverage of denuded bone, or protection of nerves and blood vessels from possible damage by bone fragments. Buried cotton sutures were employed in one hospital during the last 6 months of the war. Drainage was employed routinely in the first days of the reparative-surgery program. Later, it was provided only on specific indications, which existed in perhaps 70 percent of all cases.
When incomplete initial surgery had resulted in a clinically dirty wound, so that extensive additional excisional surgery was required, closure was usually postponed for several days, to be certain that the wound was clean. Whenever possible in these circumstances, the bone was covered by muscle, in an effort to effect as rapid revascularization of the bone as possible.
Splinting. ? The general principles of splinting were applied in immobilization of the extremity after reparative surgery. All plaster casts, including hanging casts, were trimmed at the proximal palmar crease unless specific indications existed for immobilization of the fingers. Precise splinting, which permitted active motion of the fingers, was provided in associated radial-nerve injuries, so as to avoid continuing stretch of the paralyzed muscles and yet permit a full range of active motion (fig. 45). It was not considered necessary to employ special splinting for median- or ulnar-nerve palsies.
After the early healing phase in compounding wounds of the forearm and immediately after reparative surgery in wounds above the elbow, full and active finger motion was encouraged as part of routine postoperative management. If nerve, muscle, or tendon injuries prevented full and active motion of all the joints of the fingers, the fingers were moved passively many times daily, in order to prevent fixation.
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FIGURE 43 ? Management by delayed internal fixation of compound comminuted fracture of shaft of right humerus, with segmental loss of bone and laceration of median and ulnar nerves. Ligation of the brachial artery and vein was necessary at initial wound surgery, at which the severed median nerve was approximated and the ends of the severed ulnar nerve were tagged with wire sutures. A. Anteroposterior roentgenogram showing compound comminuted fracture of right humerus, before reparative surgery. Note bone loss and resulting defect. Totally loose bone fragments were removed at the reparative operation. B. Lateral roentgenogram of fracture. C. Anteroposterior roentgenogram of fracture after internal fixation with 3 wire sutures, 23 days after wounding. At this operation, the end of each fragment was squared to provide a maximum surface for the bony contact achieved by the fixation procedure. The resultant shortening was about 2 inches. The wound was left open for the next 7 days, then was partially closed by suture and a skin flap was rotated so as to cover all denuded bone. D. Lateral roentgenogram showing fracture after internal fixation. This view, like the anteroposterior view C, shows the fragments in good contact with each other. E. Anteroposterior roentgenogram made in Zone of Interior hospital 3 months after wounding. The fracture united promptly, without sequestration or removal of metal, and wound healing was also satisfactory. F. Lateral roentgenogram made in Zone of Interior hospital.
In this case, all residual devitalized tissue was excised at wound revision. Twelve days later, apposition of the fragments of bone was obtained by surgery on the bone. Eight days later, wound closure was accomplished, the open wound having provided drainage in the interval between the operations. The aggressive surgical approach prevented almost certain nonunion of the fracture, while the procedures undertaken for wound healing made it possible to undertake nerve surgery soon after the patient reached the Zone of Interior. (This case was managed by Maj. Herbert W. Harris, MC, at the 17th General Hospital.)
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FIGURE 44. – Management by delayed internal fixation of compound comminuted fracture of right humerus with segmental loss of bone and laceration of radial nerve. A. Anteroposterior roentgenogram of fracture of humerus after approximation of fragments by two wire sutures at reparative surgery. Note that contact between the fragments is only minimal. B. Lateral roentgenogram of fracture shown in view A. C. Lateral roentgenogram made in Zone of Interior hospital 8 ½ months after wounding, showing nonunion of fracture of humerus. The wounds healed well, but bone grafting was necessary to secure union of the fracture. Definitive suture of the radial nerve was carried out at the same operation.
Although the approximation of fragments in this case did not lead to union, the procedure employed provided a chance for union to occur and facilitated later reconstructive surgery. Without internal fixation, nonunion was inevitable because of the segmental bone loss at wounding. (The case was managed at the 21st General Hospital by Maj. Joe M. Parker, MC, and Lt. Col. Henry G. Schwartz, MC.)
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FIGURE 45 – Splinting for paralysis of radial nerve. A. Hanging cast utilized for reduction of fracture of humerus. Note fingers relaxed, in functional position. B. Complete flexion of fingers and thumb by power of median- and ulnar-nerve supply. C and D. Closeups showing elastic supports to prevent continuing stretch of paralyzed muscles. Note discarded plasma tubing, used in preference to the elastic cord which was supplied for traction. Tubing is more effective because it stretches snore readily. A piece of string tied to the plasma tubing passes between the third amid fourth fingers and is attached to a portion of a tongue depressor. The cuff around the thumb is made of adhesive tape.
COMPOUND FRACTURES OF THE HUMERUS
The material on compound fractures of the humerus is based on surveys from three hospitals, as follows:
271 compound fractures of the humerus treated at the 21st General Hospital in Italy and later in the European theater of Operations during 1944 and 1945.
221 compound fractures of the humerus analyzed from the 1944-45 disposition-board proceedings at the 300th General Hospital in the Mediterranean theater.
147 compound fractures of the humerus treated at the 33d General Hospital in 1944 and 1945, during the last 9 months of the war.
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Compound fractures of the humerus are most conveniently discussed according to the location of the fracture. In the 337 cases from the 300th and 33d General Hospitals in which these data were stated, the injuries involved the shoulder joint and the proximal end of the humerus in 18 percent, the shaft from the surgical neck to the supracondylar level in 65 percent, and the distal end and elbow joint in 17 percent.
Fractures of the Proximal End of the Humerus
Several particularly important observations, with correspondingly important therapeutic implications, were made in compound fractures of the proximal end of the humerus with involvement of the shoulder joint. These observations included the following:
Dislocations of the head of the humerus were very frequently associated with compound fractures of the head and neck (fig. 46). They were overlooked at the initial operation in a large proportion of the cases encountered early in the war. In one group of 24 consecutive injuries of the proximal head of the humerus with involvement of the shoulder joint, there were 8 associated dislocations. When the frequency of the association was realized, it became common practice to obtain stereoscopic roentgenograms of all fractures about the shoulder joint before reparative surgery. The dislocation was usually anterior, and, if the head of the humerus was split longitudinally, the fracture surface was found resting on the anterior lip of the glenoid. Closed reduction was not possible in this type of case. Instead, it was necessary to restore the normal regional relationships by open operation on the fracture dislocation.
Concurrent injury to the major nerve trunks was not frequent, but the wounds were frequently so located that damage to the axillary nerve seemed highly probable. Nothing could be done about such an injury, as this nerve is too small to be attacked directly and repair was therefore out of the question. It was the general practice, in order to preserve any undamaged nerve supply for the deltoid, to employ an anterior approach to the fracture, with reflection of the deltoid, and often with utilization of a portion of the compounding wound.
If the head of the humerus was not too badly comminuted, the usual procedure was to maintain reduction by 1 or 2 screws or by wire sutures. When the comminution was so extensive that reduction was impossible, the dislocated head was excised, and the upper end of the shaft of the humerus was placed against the glenoid. If enough of the head remained intact to permit partial restoration of the cartilaginous relationship of the shoulder, with a decrease ill the articular surface of the head, observations at operation showed that the remnant of the surface of the head glided well through a fair range of motion. The end results of this technique are not known.
When both the head of the humerus and the glenoid process were so completely shattered that it was impossible to reorganize any articular mechanism in the shoulder joint at reparative surgery, the wound was left open because
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the extensive damage to the articular cartilage probably made prolonged drainage inevitable. The best plan of management was to immobilize the shoulder in plaster in the position of function, in the expectation that spontaneous fusion would occur.
Fractures of the Shaft of the Humerus
Compound fractures of the shaft of the humerus included a wide variety of injuries. The compounding wounds varied considerably in size, depending upon the type and velocity of the missile and the extent of the initial debridement. Bone injuries ranged from incomplete cortical fractures to avulsions of several inches of the shaft. As a rule, the extent of bony damage paralleled the extent of soft-tissue damage.
Wounds in this area were likely to be clinically clean. It was usually possible, without undue difficulty or further trauma, (1) to explore them adequately and to remove devitalized tags of tissue, totally loose fragments of bone, and other foreign material; and (2) to appraise the extent of bone damage and determine possible nerve damage.
After the type of fracture management had been decided upon and internal fixation, if it was indicated at this time, had been carried out, the wounds were closed by the layer-suture technique. Wound closure was carried out as part of reparative surgery in about 70 percent of all fractures of the shaft of the humerus. A certain number of the remaining cases were left unsutured because the wounds were of small size. The others were closed or grafted at a staged procedure. As already noted, it was unusual to find any evidence of infection in wounds of thus area of the humerus or any considerable amount of retained foreign material or necrotic tissue. When these circumstances were encountered, the usual secondary excisional surgery was performed, and closure was delayed for 5 to 7 days after operation.
Methods of fracture management in compound injuries of the shaft of the humerus depended upon whether or not bone loss had occurred.
Fractures without bone loss. – In fractures without bone loss, the hanging cast was frequently used whenever this patient could be ambulatory (fig. 47). It was replaced by the shoulder spica (fig. 48) in cases of massive soft-tissue injury or in cases in which distraction of the humeral fragments had occurred or seemed likely to occur. In addition to its advantages from the therapeutic standpoint, the hanging cast converted a bed patient into an ambulatory patient, permitting him to go to mess and to the latrine and generally to take care of himself. These were considerations of no little importance in a busy general hospital with limited manpower. Patients were comfortable in the cast and quickly learned how to lie down and rise from the bed without assistance and without discomfort. During periods of temporary recumbency soon after wounding, reduction was maintained by traction, which was provided by a weight extending from a plaster loop at the elbow over a pulley at the foot of the bed. Later, the elbow was merely supported by a pillow.
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If the fracture was in the lower portion of the shaft, alinement was best maintained by placing the forearm in complete pronation, as a precaution against outward bowing at the fracture site. The cast was made lighter than in civilian practice and was never weighted, since badly comminuted battle-incurred fractures with associated soft-tissue damage were easily distracted.
In the early days of the North African campaign, the shoulder spica was frequently used for fractures of the shaft of the humerus, and some surgeons continued to use it in all cases of this kind. Those who tested the hanging cast, however, usually came to prefer it. The spica was difficult to apply satisfactorily with the patient recumbent, and, even when it was applied snugly with the patient erect, it was not at all unusual, 10 to 14 days later, to find that it had become loose and that the fragments were angulated. In a busy overseas theater, a cast which had to be replaced at frequent intervals was open to serious objection. United States experiences in civilian practice would have suggested a wider wartime use of the shoulder spica. It was widely used in the Spanish Civil War, as well as by British surgeons in the North African theater.
It was the general opinion in the Mediterranean theater that the hanging cast, in addition to being more comfortable for the patient than the shoulder spica, gave better results from the standpoint of bony alinement and main-
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FIGURE 47. - Hanging cast used for fracture of humerus. A. Cast with patient erect. Note plaster loops for sling and for traction in recumbency. Wrist is free, but hand is supported by plaster extension. B. Patient recumbent. Traction from loop is utilized in this position. Only 4 or 5 pounds are necessary. Note folded towel supporting arm.
tenance of the position of the fragment. Instances were recorded in which reduction was accomplished satisfactorily by the hanging cast after skeletal traction had failed. Many patients were evacuated before any opinion about union could be expressed, but results were generally good in the cases held long enough for observation.
The hanging cast was often used for transportation to the Zone of Interior. Patients with injuries of the humerus, with or without involvement of the shoulder joint, were seldom in condition to travel before the third or fourth week after wounding. By this time, the bony fragments were usually beginning to unite, and transportation in this type of cast was regarded as entirely proper.
Fractures with bone loss. – There were two important considerations in fractures of the shaft of the humerus with bone loss. The first was the amount of bone lost and the degree of shortening which would result if the bone ends were approximated without replacement of the segmental deficit. The second was the probability of sound primary healing of sutured soft parts, to facilitate bone grafting at an early date. These considerations were necessarily weighed against each other in deciding whether to accomplish repair by internal fixation, to overcome the segmental defect, or by other measures in cases of bone loss.
If shortening did not exceed 3 to 4 cm., good contact of the bone ends could usually be attained by means of 1 or 2 wire sutures (fig. 37). Sutures were used in preference to plates because they could be inserted with little or no periosteal stripping. When they were supplemented by firm external splinting, the fracture was well immobilized (figs. 38, 43, and 44). With this technique, reparative surgery of the soft tissues was accomplished without
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FIGURE 48. – Well-applied shoulder spica cast for fracture involving shoulder joint. If shoulder fusion is anticipated, the degree of abduction is debatable.
difficulty. In the occasional case in which contact of the fragments had been particularly satisfactory, a hanging cast was employed. Most often, however, a shoulder spica was used.
If bone loss was so extensive that shortening in excess of 4 cm. would be required to obtain contact of fragments, it was considered preferable to accomplish healing of the compounding wound and return the patient to the Zone of Interior, with the idea that bony continuity would be restored at a later reconstructive operation. This may or may not have been a better plan than internal fixation of the fracture with wire sutures to obtain contact of the fragments.
Internal fixation was employed in only a small proportion of the fractures of the shaft of the humerus encountered in the Mediterranean theater (p. 199). When it was used, plating was usually avoided, for the obvious reason that stripping of the periosteum would have introduced fresh trauma and would have enhanced the possibility of sequestration.
In the 271 compound fractures of the humerus analyzed at the 21st General Hospital, internal fixation was used 22 times but was accomplished by plating only twice; wire sutures were used 15 times and multiple screws 5 times. In the 147 cases treated at the 33d General Hospital, internal fixation was also used 22 times and was accomplished by plating 5 times; wire sutures were used 9 times, and sutures and screws were used in combination 8 times.
Associated nerve injuries. – In all compound fractures of the shaft of the humerus, the possibility of an associated nerve injury existed and had to be taken into account in the preoperative evaluation of the patient. Radial-nerve injuries were by far the most frequent, as the following figures show:
In the 271 fractures of the humerus treated at the 21st General Hospital, there were 108 nerve injuries, including 70 injuries of the radial nerve, 30 of the ulnar nerve, and 8 of the median nerve. Injuries of the radial nerve were present in half of all fractures of the middle third of the shaft.
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In the 147 fractures treated at the 33d General Hospital, there were 66 nerve injuries, including 36 injuries of the radial nerve, 20 of the ulnar nerve, and 10 of the median nerve.
Radial-nerve injuries were thus present in 25.4 percent of these two series (106 of 418 cases), ulnar-nerve injuries were present in 11.9 percent (50 cases), and median-nerve injuries were present in 4.3 percent (18 cases).
Because nerve injuries are treated in detail in the neurosurgical volume of the clinical history of World War II, only brief mention need be made of them here. The important considerations in nerve injuries were that (1) the possibility of the injury be borne in mind in the preoperative survey, as has already been emphasized, and (2) that, when clinical paralysis was present, the necessity for exposure of the nerve at operation be considered. The preoperative estimate, as a practical matter, was made on the basis of demonstrable motor and sensory deficits.
Combined nerve and bone surgery proved so successful when it was tried tentatively that during the last 9 months of the war it became common practice at reparative surgery to expose the involved trunks in all instances of peripheral-nerve palsy, to permit precise determination of the damage, unless–
1. A sufficiently detailed note on the record showed that the nerve had been visualized intact at initial surgery.
2. The location of the wound and of the fracture made it anatomically unlikely that the nerve had been injured. In such cases, a diagnosis of nerve injury was sometimes made, but returning function usually became evident in 2 to 3 weeks. This happened in seven cases, for instance, at the 2lst General Hospital.
The status of the nerve was usually determined by inspection after it had been exposed, though in some cases an injection of physiologic salt solution was employed as an aid in determination of intraneural continuity. If the nerve was found severed or so severely traumatized that, although it was intact, physiologic interruption had evidently occurred, the extent of the damage was evaluated, and the possibility of approximating the nerve ends after resection of the damaged portion was determined. The technique of fracture management was often influenced by this decision.
If the divided nerve ends could apparently be brought together without tension, internal fixation, even if plating was necessary, was sometimes employed, so that staged nerve repair could be carried out as promptly as possible. Of the 22 internal-fixation operations performed at the 21st General Hospital, an associated nerve injury arid the desirability of early repair were the indications in 15 (fig. 39).
If comminution precluded fixation of the fractured bone, 1 cm. or more of the length of the arm was often deliberately sacrificed by removal of loose fragments, in order to accomplish stable internal fixation and permit nerve repair to be undertaken within the optimal period of 3 weeks after wounding. If a nerve deficit existed, a section of the fractured shaft of the humerus,
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sometimes up to 4 cm., was excised, so that the ends of the damaged nerve could be brought together.
Definitive nerve suture was never performed at the first operation of reparative surgery. Nerve surgery at this operation never went beyond the loose approximation of the ends of the nerve by a single suture, and even this procedure was by no means the rule. Definitive repair was undertaken at a later date, through a healed wound. What could be accomplished at the staged nerve operation, however, often depended upon what had been done about the fracture at reparative surgery.
In view of the very poor results which were being reported after nerve grafting in the Zone of Interior and the relatively or actually good results being achieved by the combined procedure described, this new and radical approach to fractures of the shaft of the humerus associated with nerve injuries was regarded as fully justified. Obviously, the close cooperation of orthopedic surgeons and neurosurgeons was essential for the best results.
The majority of the combined procedures in this series were undertaken in injuries of the radial nerve. Relatively few were undertaken for injuries of the median and ulnar nerves, which, though probably of greater importance functionally, were less frequent.
Fractures of the Distal Portion of the Humerus
In fractures of the distal portion of the humerus involving the elbow joint, the extent of the injury again determined the technique to be employed.
Fractures of the condyles, if they were not too greatly comminuted, were reduced as anatomically as possible and were often fixed internally, to facilitate early motion. This was a consideration of the utmost importance in the restoration of function.
T-fractures, with separation of the condyles, were often held in reduction by two screws or by a combination of wire sutures and screws. This area of the humerus, fortunately, usually tolerates without difficulty the manipulation and stripping of the periosteum necessary for accurate reduction of the fragments. It was occasionally necessary to shift flaps of skin in order to close the tissues over exposed bones or joints. One case was observed in which a thick flap of skin was utilized to seal the elbow joint, which was preserved with only this covering.
Markedly comminuted fractures about the elbow, with destruction of the condyles of the humerus and the upper ends of the radius and ulna, permitted little choice in fracture management. The technique employed depended upon the condition of the compounding wound. Clean wounds of the elbow with marked comminution were treated by delayed closure. At one hospital, if infection was present, resection of the elbow joint was sometimes performed. The wound was closed with drainage or was left open and closed at a later operation. The flail elbows which resulted from these operations did not seem to be satisfactory while the patients remained under observation and were
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probably no more satisfactory later. The value of this procedure, therefore, was debatable except as a means of controlling severe infection and avoiding amputation.
Fractures of the lower end of the humerus were associated with more ulnar and with fewer radial-nerve lesions than fractures of the shaft. Wounds characterized by avulsion of the medial epicondyle were so frequently accompanied by ulnar-nerve paralysis that accurate appraisal of possible nerve damage was a routine step in their management.
Results of Reparative Surgery
As in all compound fractures, the compilation of end results was impossible overseas in fractures of the humerus. The great majority of patients were transferred to the Zone of Interior before complete wound healing or complete union of the fracture had occurred. There was, however, general agreement in the theater that, in terms of wound healing and in the maintenance of satisfactory reduction of fractures until union was in progress, the reparative surgery of compound fractures of the humerus had produced excellent results. In many cases, wound healing was complete within 3 weeks of wounding, and in many others it was complete at this time except for small areas of granulation. It appeared that, if the plastic and other procedures necessary to achieve skin coverage had been correctly performed, only sequestrating bone retarded wound healing.
An analysis of the 147 cases treated at the 33d General Hospital 2 provides support for these generalizations. They were classified as follows:
27 cases with massive soft-tissue destruction and, in most instances, severe bone comminution (group A).
69 cases with moderate soft-tissue damage and severe comminution of bone (group B).
51 cases with minimal soft-tissue damage and minimal comminution of bone (group C).
Treatment was regarded as successful in these cases if the wound was completely healed or if only small areas of healthy granulation tissue were present, so that the fracture site was well sealed off. Fracture management was regarded as successful if adequate apposition and alinement of fragments were maintained until union had occurred or until the patient was transferred to the Zone of Interior. Management was regarded as unsuccessful (1) if the fracture site was not sealed off and there was a sinus or opening wound leading to it and (2) if satisfactory reduction of the fracture was not maintained under the circumstances just described. Classification of results as unsuccessful because of a persisting sinus to bone set rather rigid qualifications for wound healing, particularly in comminuted fractures, in which many bone fragments are partially denuded at wounding and therefore are potential sequestra. The
2 A total of 151 cases were treated at the 33d General Hospital, but 4 cases were omitted from the analysis, 2 in which amputation was necessary because of circulatory gangrene, and 2 others in which no followup could be secured.
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data available in the series of compound fractures of the humerus analyzed from the 33d General Hospital (tables 4, 5, and 6) deserve certain brief comments.
The results were tabulated from the standpoint of wound revision as the first step of reparative surgery because they improved as time passed and revision of the wound became more complete. Early in the experience, the depths of the wound, including the fracture site were not routinely exposed.
TABLE 4 – Results in relation to procedure and wound healing in 147 compound fractures of the humerus treated at the 33d General Hospital 1944-45
TABLE 5. – Results in relation to technique and status of fracture in 147 compound fractures of the humerus treated at the 33d General Hospital 1944-45
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TABLE 6. – Results in relation to wound healing and status of fracture in 147 compound fractures of the humerus treated at the 33d General Hospital 1944-45
Totally detached bone fragments and dead tissue were therefore left in situ in many cases. At this time, revision was limited to the trimming of tags of devitalized tissue along the wound edge. Later, the importance of insuring that the wound was free of all devitalized tissue before repair was undertaken became generally recognized. It then became routine to expose the depths of the wound by gentle retraction, evacuate old blood clot, and excise necrotic tissue and bone fragments totally devoid of soft-tissue attachment. Considerably better results were produced under this new policy (table 4).
In 5 of 13 wounds in which healing was classified as unsatisfactory, a typical osteomyelitis was present, of the type frequently seen in battle-incurred fractures and always characterized by heavy drainage and rather extensive sequestration. Union is known to have occurred in some of these cases in spite of these unfavorable circumstances.
Some information is available from other hospitals to supplement the material presented in these tables from the 33d General Hospital. It is known, for instance, that in 112 of the 128 compound fractures treated while the 21st General Hospital was functioning in the hospital center at Naples, the wounds were completely healed or almost completely healed when the patients were evacuated to the Zone of Interior.
In 116 cases managed at the 300th General Hospital, later information showed that, when the patients were considered ready for evacuation to the United States 90 to 120 days after wounding, complete healing had occurred in 94 cases, and in 11 others, while there were some areas of granulation, there was no opening to the fracture site. In nine cases, there were sinuses to the bone, and there were two instances of osteomyelitis, in both of which the fracture site was infected and sequestration was occurring.
Since the combined bone-nerve reparative regimen placed emphasis on early wound healing, so that nerve suture might be performed through a clean surgical approach within 3 to 4 weeks after healing, information concerning
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this point is of interest. In the 116 cases for which information is available in the series from the 300th General Hospital, 30 of the wounds (26 percent) were healed within 3 weeks, and 41 others (35 percent) within a total of 4 weeks. Sixty-one percent of the wounds were thus healed within the optimal time for nerve suture. Eight other wounds were healed within 5 weeks, but no information is available for the remaining cases.
COMPOUND FRACTURES OF THE RADIUS AND ULNA
The statistical material on compound fractures of the bones of the forearm is based on the following surveys:
243 compound fractures - l12 of the radius, 97 of the ulna, and 34 of both bones observed at the 21st General Hospital in Italy and later in Europe during late 1944 and 1945.
272 compound fractures - 113 of the radius, 107 of the ulna, and 52 of both bones, analyzed from the 1944-45 disposition-board proceedings at the 300th General Hospital in the Mediterranean theater.
319 compound fractures - 136 of the radius, 124 of the ulna, and 59 of both bones, treated at the 45th General Hospital. Both the 1944 and 1945 admissions are included in thus series.
This makes a total of 834 compound fractures of the bones of the forearm - 361 of the radius, 328 of the ulna, and 145 of both bones. Not all data are available in all series.
Wound management in compound fractures of the bones of the forearm followed the principles generally employed in reparative surgery. The technique varied, for anatomic reasons, according to the portion of the forearm in which the fracture was located. Although the structures of the upper half of the forearm are more tendinous than those of the upper arm, no special difficulties were usually encountered in that area. As the wrist is approached, muscle is replaced by fascia and tendon, both of which are structures with little power to resist infection, because of their poor blood supply. For these reasons, wounds in this area were sometimes necrotic and sloughing when the patients reached the general hospital. Closure could not be considered in such cases until after further excisional surgery, and delayed closure frequently required split-thickness skin grafts or sliding or advancement of skin flaps.
Fracture management. – Fractures of a single bone usually presented no problem in fracture management, for, just as in fractures of a single bone of the leg, the intact bone served as a splint for the fractured bone, and displacement was seldom significant. Procedures to achieve reduction were necessary only in fractures about the joints and in an occasional instance of narrowing of the interosseous space. In the 209 compound fractures of the radius or of the ulna observed at the 21st General Hospital, cast immobilization, with no effort at further reduction, was all that was necessary in 190. This was a typical experience.
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Fractures involving the olecranon process required anatomic reduction and fixation to restore joint congruity. Wire-suture fixation was often useful.
Fractures of the head of the radius were best managed by excision of the comminuted fragments. This procedure removed a potential nidus of infection and eliminated a handicap to future function of the elbow.
Fractures of both bones of the forearm in the upper third often presented problems in the maintenance of reduction (fig. 49). When soft tissue was available for early wound healing, it was often a good plan to place a long plate on the ulna, to serve as a strut for the comminuted fragments, as well as to maintain length and alignment in the injured bones. This was not always possible, however. The subcutaneous position of the ulna often created difficulties in wound healing when only skin was available for coverage of the bone and metal. In spite of these problems, repair of soft parts of the upper forearm was usually successful if excisional surgery was complete and soft-tissue loss was not excessive.
If the contour of the fracture permitted rigid stabilization of both bones and if soft parts for adequate coverage were available, stabilization by multiple screws or plates was often useful. Thus procedure accomplished anatomic reduction, avoided encroachment of the bones on the interosseous space, and permitted earlier pronation and supination.
In comminuted fractures of both bones without bone loss, skeletal traction with a wire through the distal ends was occasionally used to accomplish adequate reduction. In comminuted fractures of both bones with bone loss, internal fixation, usually by wire sutures, was used to approximate the fragments. Comminuted fragments of one bone were occasionally removed to permit approximation of the fractured ends of the other. As a rule, however, this was not advisable because of the successes attained in bridging defects with bone grafts at reconstructive surgery.
In the distal portion of the forearm, because of the relatively superficial position of the bones, internal fixation by plating was performed only on special indications (fig. 50). It was essential that sufficient soft tissue be available for closure.
Combined bone-nerve injuries. – Peripheral-nerve injury was almost as common in wounds of the forearm as in wounds of the arm. In the 243 fractures observed at the 21st General Hospital, the radial nerve was injured 28 times, the ulnar 32 times, and the median 25 times, a total incidence of more than a third. Nerve lesions in the forearm were more often incomplete than in similar lesions in the upper arm.
All 28 of the radial injuries just mentioned occurred in the upper forearm, in which combined nerve and bone operations are likely to be technically difficult if not entirely impractical. In these cases, approximation of the nerve ends was frequently of less importance because the principal deficit could be overcome later by some reconstructive procedure at the wrist, usually a tendon transplant or a fusion operation. Repair of the median and ulnar nerves was,
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FIGURE 49. – Unsuccessful management of compound comminuted fracture of upper third of right radius (head) and ulna (just distal to coronoid process). Anteroposterior and lateral roentgenograms of fractures after incomplete manipulative reduction at reparative surgery in general hospital. Note angulation of ulna and loose fragments of radius. The fracture united in this position, and 6 months after wounding rotation was almost nil and elbow motion was limited to 10° to 15°.
In this case, the wound healed satisfactorily, but osteotomy was eventually necessary to correct the malunion of the ulnar fracture. If the loose fragments of the upper radius had been removed and the ulna plated in good alinement at reparative surgery, prompt healing could have been anticipated. for skin and soft parts were available for a satisfactory wound closure. This procedure would have permitted reasonably early elbow motion and would probably have produced an improvement in the end result.
however, a matter of paramount importance, and in this series from the 21st General Hospital the bony structure was deliberately shortened five times, and the fractures were plated to facilitate later nerve suture. None of the bone defects thus created exceeded 3 cm.
Nerve and tendon operations in the lower forearm were always performed in the Zone of Interior.
Results. – Although no statistical data were available on the results accomplished in reparative surgery of compound fractures of the forearm, it was generally acknowledged that neither the healing of compounding wounds nor the reduction of fractures was as satisfactory as corresponding results in compound fractures of the humerus. For this, there were a number of explanations, including the exposed position of fracture sites in the ulna, the abundance of poorly vascularized fascial and tendinous structures in the distal portion of the forearm, and the paucity of well-vascularized soft tissue in this area.
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FIGURE 50. – Management of compound comminuted fracture of distal third of left radius and ulna by delayed internal fixation. Reparative surgery, 11 days after wounding, consisted only of manipulative reduction of the fractures and partial wound closure. The wound healed only in part, and necrotic bone presented through an opening in it. A. Anteroposterior and lateral roentgenograms of fractures of radius and ulna 1 month after unsuccessful manipulative reduction. Note poor alignment of fractures and destruction of bone. B. Anteroposterior roentgenogram showing same fractures 3 ½ months after wounding and 5 weeks after they had been plated in reduction. Apposition and alignment are now good. The shortening from necrosis and bone loss was about 3 inches. C. Lateral roentgenogram taken at same time as view B. D. Anteroposterior and lateral roentgenograms 6 months after fractures had been plated. Removal of sequestra and metal was necessary to accomplish wound healing.
In this case, failure to achieve adequate reduction and wound healing after the first operation of reparative surgery indicated the necessity for additional surgery long before it was performed. In spite of the delay, however, arid the infection, correct reparative surgery was eventually responsible for an excellent result. (This case was managed at the 300th General Hospital by Maj. Spencer A. Collom, Jr., MC.)
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Although results in compound fractures of the forearm were not as good as those obtained in similar injuries of the upper arm, later results were known to be far superior to those obtained before the program of reparative surgery was introduced in the Mediterranean theater. It is known, for instance, that 84 of the 319 soldiers treated at the 45th General Hospital (approximately 26 percent) were returned to duty within the 90- to 120-day holding period in this theater. These are excellent results, and there is no reason to believe that they were not generally duplicated.
CONCLUSIONS
As this limited analysis has shown, the objectives of reparative surgery in compound fractures of the humerus and the bones of the forearm (minimal infection, optimal fracture reduction, early wound healing, maximal functional recovery) were apparently achieved in a large proportion of these injuries. In many of the casualties, the additional reconstructive surgery which would have been necessary under the old plan of management was not necessary under the new plan. In other cases, the reconstructive phase of surgery was expedited, and the necessity for multiple operations was decreased. The mission of overseas surgery was thus largely accomplished in battle-incurred compound fractures of the upper extremity managed in the Mediterranean Theater of Operations.
Part II. Compound Fractures of the Femur 3
GENERAL CONSIDERATIONS
According to the machine records of the Mediterranean Theater of Operations as they were available for examination in July and August 1945, fractures of the femur made up 12.7 percent of the principal diagnoses of battle fractures at the time of dispositions by the various general hospitals in the theater. This is in general agreement with the experience of the 45th General Hospital in the year 1944, which can be assumed to be representative. In that year, fractures of the femur accounted for 11.3 percent of all compound fractures managed on the orthopedic section of this hospital. When only compound fractures of the extremities were considered, the incidence increased to 12.6 percent. When fractures of the bones of the hand and the foot were excluded, the incidence of compound fractures of the femur rose to 19.2 percent.
In World War II, just as in World War I, a battle-incurred compound fracture of the femur was properly regarded as one of the most serious skeletal injuries which a soldier could sustain. In World War I, there were 971 deaths
3 The statistical data in this section were collected by Capt. John J. Modlin, MC, Maj. Joe M. Parker, MC, and Capt. Russell J. Crider, MC, 21st General hospital; Col. Francis J. Cox, MC, 24th General Hospital; Maj. William R. Ferguson, MC, 33d General Hospital: Maj. Irvin Cahen, MC, 64th General Hospital; Maj. Spencer A. Collom, Jr., MC, and Maj. William M. Ewing, MC, 300th General Hospital; Maj. Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, MC, 23d General Hospital; and Lt. Col. George A. Duncan, MC, 45th General Hospital.
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(25.2 percent) in the 3,850 recorded femoral fractures.4 These fractures constituted 23.6 percent of all recorded battle fractures (16,339). In a study made in Fifth U. S. Army mobile hospitals in 1945, 114 of the 1,450 deaths (including deaths on arrival) (7.9 percent) were attributed to compound fractures of the lower extremity. It seems fair to assume that the great majority of these injuries were fractures of the femur. The World War II figures do not include traumatic amputations of the thigh, which may have been included in the figures for World War I.
Compound fractures of the femur furnished major problems in both forward and fixed hospitals. Considerable time and effort were required for their management; in view of their frequency, this was a very practical consideration in overseas hospitals. In forward hospitals, even when experienced surgeons were in charge, 2 hours was regarded as acceptable operating time for initial surgery, counting from the time the wounded man was placed on the operating table until the transportation spica was applied.
Large amounts of blood had usually been lost in compound fractures of the femur, and shock was correspondingly severe. Massive transfusions were necessary for resuscitation in evacuation hospitals, as well as for protection during initial wound surgery. In 100 consecutive compound fractures of the femur managed at the 16th Evacuation Hospital, 28 patients required from 1,500 to 2,000 cc. of whole blood before and during the operative procedure (p. 68).
Large quantities of blood were also required in preparation of these patients for reparative surgery at general hospitals. In 50 casualties received at the 23d General Hospital from evacuation hospitals on the Anzio beachhead, the hematocrit reading was under 30 in 38 cases. In another group of 242 casualties received at the 21st General Hospital, the great majority had to be given 2,000 cc. or more of blood before the hematocrit reached 40, the desirable preoperative minimum. Fifty-three casualties treated at the 300th General Hospital required an average amount of 1,900 cc. of blood during the preoperative and postoperative periods.
Even in civilian practice, simple fractures of the femur may be difficult to manage. Battle fractures were often severely comminuted and were complicated by one or more large compounding wounds. If infection had become established, additional problems were introduced. Erosion of a femoral artery was always a possibility in such cases, and amputation occasionally had to be considered for lifesaving reasons. Battle fractures, therefore, presented exceedingly difficult problems of management. Even seasoned ward surgeons were overtaxed and exhausted by the long hours of work required later in the care of these patients on the wards. Carelessness in any regard could result in loss of reduction or in retardation or failure of wound healing.
The wards devoted to fractures of the femur, with their forests of Balkan frames and their mazes of splints, ropes, pulleys, and weights, were, however, among the most interesting in the hospital. Fractures of the femur were of
4 Walker, John B.: End Results, Fractures of Long Bones. In The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 491-547.
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special interest for another reason: this was the one type of fracture held long enough in a theater of operations to permit evaluation of the union of the fracture and healing of the compounding wound.
SURVEY OF RESULTS, SPRING, 1944
Balanced-suspension skeletal traction was from the beginning the standard method of management of femoral fractures in the general and station hospitals of the Mediterranean theater. In a few instances, only a plaster hip spica was used, but this was unusual.
The results obtained by these techniques during 1943 and the first months of 1944, although relatively satisfactory, were regarded as less than optimum in many instances. Adequate reduction was usually secured with skeletal traction, but it was frequently not ideal, and the alinement obtained in fractures of both the upper and lower third of the femur often left much to be desired. While healing of the compounding wounds by granulation eventually occurred in the majority of cases, the process was undesirably slow and often was attended with heavy scar formation. The incidence of deep-seated abscesses in the posterior fascial planes was not unduly high, though it increased early in 1944, during the attacks on Cassino and at the Anzio beachhead. It was generally observed that infection was most frequent when the fracture had not been reduced or well immobilized or had been distracted and when repeated manipulations had been undertaken to correct these errors. It was often difficult to maintain reduction while the necessary dressing of large compounding wounds was carried out. The location, magnitude, and condition of these wounds complicated the management of the fracture and played a part in the establishment of infection.
During April and May 1944, a survey of fractures of the femur was conducted in six general hospitals and in a station hospital which was then serving as a general hospital in the Naples area, in order to appraise the results of the methods of management employed before the regimen of reparative surgery had been instituted. All of the soldiers studied had been wounded at least 50 days earlier, during the mountain and beachhead fighting in Italy in January, February, and March. They had been cared for under relatively adverse conditions, in overcrowded field and evacuation hospitals which were exposed to enemy artillery fire, including that of the “Anzio Annie” railroad gun. Many had been evacuated over water. They had then been treated in crowded general hospitals, some of which were staffed by surgeons relatively inexperienced in military surgery. During this period, the incidence of clostridial myositis reached its height in the Mediterranean theater, and the hazard of this complication was added to the other problems of fractures of the femur.
A total of 235 patients with fractures of the femur was included in the survey. Three (1.3 percent) died after admission to general hospitals, and amputation was required in two other cases (0.85 percent).
In the remaining 230 cases, adequate reduction had usually been achieved, thought the position was not optimal in certain subtrochanteric fractures,
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fractures of the distal third, and fractures characterized by loss of bone substance. In some cases, the use of the flexed knee position and of tight popliteal slings for fractures of the lower third of the femur had given rise to such complications as skin irritations; thrombophlebitis; arid inability to extend the knee after the fracture had united, because of prolonged stretch of the quadriceps muscle. On the whole, the methods employed had not been conducive to early, maximum return of motion in the knee joint. This was partly because of prolonged knee flexion, partly because of heavy scarring in the thigh, and partly because quadriceps and knee exercises had been inadequate.
Forty-two cases (17.9 percent of the total 235 cases) were either infected at the time of the survey or had been considered infected between the 30th and 50th days after wounding. This number included three cases complicated by clostridial myositis, which in each instance had appeared soon after the patients reached the general hospital. Criteria of infection were purulent exudate draining copiously from the fracture site; purulent collections in fascial planes; or daily temperature elevations, usually to 101 0 F. or over, with malaise, anemia, and other evidences of toxemia. At the time of the survey, sinuses to the fracture site were present in 23 cases.
In each of the 42 infected cases, the infectious process had been managed by apparently adequate drainage The fact that sinuses to the fracture site were present in only 23 cases 50 days or more after wounding was taken to mean that in the 19 other cases infection had been controlled and that the fracture site had been sealed off by the healing process. Unfortunately, no data were collected on the number of completely healed wounds, chiefly because the objective of the survey was an investigation (1) of the incidence of infection involving fracture sites and (2) of the sequelae of infection.
The survey of these 235 compound fractures of the femur led to the following conclusions:
1. In the light of the severity of these battle-incurred injuries, it was scarcely to be expected that the proportion of either deaths or amputations could be materially reduced below the present levels.
2. The incidence of infection was relatively low, as was the incidence of sinuses to the bones, but further improvement in both respects seemed possible.
3. Better reduction in so-called problem fractures seemed possible of achievement, as well as faster healing of compounding wounds, with minimal scar formation.
4. Improvement in the range of knee motion and in quadriceps-muscle tone seemed possible if more active attention were devoted to both points.
SOURCE MATERIAL
The observations in the remainder of this chapter were either made personally or were derived from reports submitted by the chiefs of orthopedic sections of various general hospitals in Italy, as follows:
164 compound fractures of the femur treated at the 24th and 64th General
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Hospitals, plus 535 additional cases studied from the proceedings of disposition boards on file in the Office of the Surgeon. This is a total of 699 cases (series A).
482 compound fractures of the femur treated at the 21st, 33d, and 300th General Hospitals (series B).
Not all data were available in all cases.
High-explosive shells and mine fragments accounted for the injury in 464 of the 699 cases in series A. Small-arms fire accounted for 222 cases (32 percent), and accidental causes for the remainder. The proportion of injuries attributable to small-arms fire in this combined series is somewhat higher than the proportion estimated for battle wounds in general.
The location of the femoral fracture in the 1,181 cases making up series A and B was the proximal third in 331 cases (28 percent), the middle third in 466 cases (39 percent), and the distal third in 384 cases (33 percent). There was thus no great variation in the involvement of the various levels of the bone. Since it is likely that fractures at the junction of the middle third with the upper or the lower segment were classified as fractures of the middle third, the chances are that each third of the bone was affected in almost equal degree.
In the 535 compound fractures of the femoral shaft making up the disposition boards` material in series A, all but 8 of which were combat incurred, there were 41 injuries (7.7 percent) to the sciatic nerve or to the peroneal or the tibial nerve below the bifurcation of the sciatic nerve. Thus was almost precisely the same as the 7.1-percent incidence in 133 compound fractures of the shaft included in series B, from the 33d General Hospital. In both series, some of the nerve injuries were incomplete.
THE PROGRAM OF REPARATIVE SURGERY
In spite of the usual severity of their wounds and the frequent necessity for a somewhat prolonged stay in forward hospitals after initial wound surgery, soldiers with fractures of the femur generally reached fixed hospitals in the rear within 5 or 6 days after wounding. Those with associated injuries of the abdomen, chest, or head usually did not become transportable as soon. The great majority of these patients, in spite of the intensive preoperative preparation necessary, could usually be submitted to reparative surgery before the 10th day after wounding (the so-called golden period). In one group of 168 cases, for instance, 57 patients (34 percent) underwent reparative surgery on or before the 7th day after wounding, and only 11.6 percent were not operated on until after the 10th day.
Anatomic conditions and the conditions of the battle-incurred fracture and the compounding wound were both favorable and unfavorable for the application of the program of reparative surgery to the management of compound fractures of the femur. Favorable factors were as follows:
1. The regional anatomy was generally favorable, there being a large amount of highly vascularized soft tissue in this region and only a small amount of easily exposed fascial and tendinous tissue. Fascia latter could therefore be
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partly excised without seriously affecting function. The heavy soft tissue of the thigh aided in the obliteration of the dead space by pressure dressings. Dependent drainage could be surgically established through posterior fascial planes if a posterior wound was not available.
2. Loss of bone creating a complete segmental defect was uncommon in compound fractures of the femur. When there was partial bone loss, fragments of bone and periosteum left in situ appeared to have excellent powers of regeneration.
3. If internal fixation was indicated, it was facilitated by the size of the femur, while the depth of the location of the bone made it certain that denuded bone and metal would be well covered by soft parts.
4. Plastic procedures designed to accomplish wound healing were facilitated by the abundant, loose skin of the thigh.
Against these favorable factors were the following unfavorable circumstances:
1. Missiles frequently followed paths through the thigh that, because of difficulties of operative position and approach, made them relatively inaccessible. Anatomic considerations made deep exposure of the thigh difficult. As a result, even after what seemed adequate initial surgery, some devitalized tissue almost invariably remained in the wound.
2. The extensive intermuscular fascial planes of the posterior thigh permitted proximal gravitation of purulent exudate.
3. Although immobilization was essential in the management of the femoral fracture, it prejudiced the ultimate range of knee motion. Knee function is an important criterion in the evaluation of end results, and from this standpoint the results achieved in femoral fractures were sometimes less than optimal.
TECHNICAL CONSIDERATIONS
The surgery of battle-incurred compound fractures of the femur followed closely the general pattern for the reparative surgery of compound fractures (p. 83). With the soldier anesthetized, the transportation splinting provided by the forward hospital after initial surgery (usually a 1 ½ hip spica but occasionally a Tobruk splint) was removed in the operating room. A Kirschner wire was inserted in the lower femur or proximal tibia, its location being determined by the level of the fracture and the site of the wounds. The extremity was then placed in the 90-90-90 position (fig. 51). This operative position, developed by Maj. Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, MC, at the 23d General Hospital, was invaluable for reparative surgery of battle fractures of the femur. It permitted free circumferential access to the thigh and also provided adjustable balanced skeletal traction as an aid to operative reduction of the fracture.
The depths of the wound and the fracture sites were exposed by gentle retraction. Old blood clot, residual devitalized tissue, and totally free bone fragments were removed.
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FIGURE 51. – Suspension traction in 90-90-90 position for operation on compound fracture of femur. Kirschner wire shown in upper tibia may also be placed in lower femur. If skeletal traction is not feasible the same position may be maintained by the use of slings under the leg. The 90-90-90 position is an excellent operative position for reparative surgery its injuries of the thigh and femur, since it provides full circumferential access to the part.
A study of the fracture contour by direct vision, together with a study of the roentgenograms, determined whether some form of internal fixation should be employed or whether skeletal traction alone should be depended upon to achieve reduction of the fracture.
Internal Fixation
The contour of only a minority of the fractures of the femur permitted the effective use of internal fixation. In the majority of cases, therefore, balanced-suspension skeletal traction was the method employed for fracture reduction (figs. 33 and 35). When internal fixation was applicable, it was performed through the compounding wound only if adequate access to the fracture site was permitted (figs. 31 and 35). The standard anterolateral approach was sometimes used but, more frequently, the posterolateral fascial plane was selected (figs. 52 and 34). This plane was considered advantageous because it gave excellent exposure of the shaft of the femur and it could be used for dependent drainage. Moreover, the trauma of the operative procedure was posterior to the bone, and the products of the resulting devitalized tissue were therefore easily drained away.
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The objections to the periosteal stripping necessary in internal fixation were well recognized. On the other hand, the highly vascularized muscular bundles surrounding the femur favored the early reattachment of soft parts to the denuded bone, and there was little hesitancy in performing the stripping required when internal fixation appeared to be useful. Multiple screws were employed in the relatively few fractures with an obliquity permitting stable fixation (figs.31 and 35). In a larger group, plating, often augmented by additional screws, provided stable fixation (fig.39). A stabilized internal fixation was considered advantageous for a number of reasons: (1) Optimal reduction of the fracture was assured; (2) subsequent wound care was facilitated; (3) earlier, intensive exercises for the knee joint were possible; and (4) the patient could be transported to the Zone of Interior at an early date, without fear of loss of apposition or of alinement of the fracture. Condylar fractures of the femur were preferably fixed internally to restore joint congruity and to maintain reduction during early joint exercises (fig. 53). The advantages offered by a stabilizing internal fixation thus appeared to outweigh the disadvantages of additional trauma within the wound and the necessary denudation of bone.
In severely comminuted fractures, the judicious use of wire sutures allowed major fragments to be held in apposition. This type of fixation was particularly applicable in fractures with partial loss of substance. It was also valuable ill some cases of established infection, in which it was recognized that periosteal stripping should be restricted. The following experiences proved these points:
Capt. John J. Modlin, MC, at the 21st General Hospital, used wire-suture fixation in 33 of a series of 138 fractures of the femoral shaft. In this particular experience, the indications were broadened because of a heavy flow of casualties that made it impossible to render all of the necessary attention to details required for the management of fractures of the femur in balanced skeletal traction. The wire sutures insured apposition of the fragments, and, even thought the balanced-suspension skeletal traction could not be adequately adjusted during the first few days after operation to obtain good alinement, it was possible to correct the alinement later. Had apposition of the fragments not been maintained by the wire suture, it is doubtful that late reduction would have been possible.
Maj. Irvin Cahen, MC, 64th General Hospital, reported that internal fixation was used as part of the first reparative operation in 14 of a series of 79 battle fractures of the femur. The fixation was obtained by plating in 8 cases, by multiple screws in 4, and by wire sutures in 2.
In a followup study on delayed internal fixation of battle fractures in the Zone of Interior made by the theater consultant in orthopedic surgery (p. 189), it was found that the procedure had been performed at the first operation of reparative surgery in 93 (64 percent) of 146 fractures of the femur managed by this method. The fixation in this group was by plating in 41 cases (44 percent), by multiple screws in 39 (42 percent), arid by wire sutures in 13 (14
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percent). The remaining fixations were performed after adequate reduction had not been achieved by skeletal traction.
Wound Management
After the method for maintaining fracture reduction had been determined and internal fixation, if it had been chosen, had been effected, drainage of residual dead space and wound closure were undertaken. Suture of the compounding and operative wounds was performed to the extent that was surgically feasible and was compatible with adequate drainage (figs. 31, 33, 34, and 35). These wounds were not sutured with the major objective of protection of exposed bone. The objectives of wound closure in compound fractures of the femur were early wound healing and minimal scar formation, both of which have a beneficial effect on future function.
Drainage. – It was considered important that some opening, preferably dependent, remain in the wound in most eases to provide a route of egress for the products of possible decomposition of residual devitalized tissue or blood clot. The necrotizing effect of purulent exudate deep in the thigh could thus be avoided. Only very occasionally was drainage omitted.
If posterior wounds were present, they were used for drainage. Otherwise, the posterolateral fascial plane between the biceps femoris and the vastus lateralis was freely incised (figs. 52, 30, 34, and 35). This plane served well for drainage of compound fractures between the level of the base of the trochanter and the level just distal to the junction of the middle and lower thirds of the femur. In high fractures involving the trochanteric region, it was necessary to sever a portion of the glutens maximus if dependent drainage was to be obtained and the hazard of a pocket of purulent exudate beneath this muscle was to be avoided.
Dependent drainage in the distal third of the thigh was difficult unless a posterior wound was present. Maj. Herbert W. Harris, MC, at the 17th General Hospital, reported some success with a posterolateral incision supplemented by a medial incision anterior to the hamstring muscles. Col. Francis J. Cox, MC, at the 24th General Hospital, considered drainage absolutely essential and established it in all cases. In his technique, the linea aspera was incised, so that there was free communication between a medial thigh space and the posterolateral fascial plane. Maj. Newton C. Mead, MC, at the 12th General Hospital, preferred direct posterior drainage through a channel passing between the hamstring groups to drainage through the posterolateral fascial plane. Fingertip dissection was used from the fracture site to the posterior skin, which was then incised. Damage to the sciatic nerve was thus avoided In Mead`s experience, this method was effective and was not attended by complications.
A posterolateral fasciotomy used for internal fixation was frequently left unsutured for a few days, in order to provide the free drainage permitted by an open wound.
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While adequate drainage was considered indicated and important in all these injuries, it was of paramount importance in the presence of dirty wounds and established infection. If considerable dead tissue had been found (and excised) wound closure was postponed. In these cases, suture was often performed several days later, when the wounds were clinically clean.
Postoperative Management
The great majority of the patients with fractured femurs were placed in balanced-suspension skeletal traction immediately upon their return to the ward. This was true even of those whose fractures were stabilized in reduction by internal fixation, in order to facilitate the wound care and to permit an intensive program of knee-joint exercises. The Kirschner wire used in maintaining the operative position in the operating room usually sufficed for traction on the ward. If a different location appeared desirable, a new wire was inserted immediately. The theoretical objections to the location of the wire in either the lower femur or the tibia were disregarded, and the site was chosen that appeared to be the most effective for reduction of the fracture. In general, the lower femur was the location for the wire in fractures of the upper half of the bone and the tibia for fractures of the lower half.
An important early development in the reparative surgery of compound fractures of the femur was the introduction of two-wire or double skeletal traction for fractures of the distal third of the femur (fig. 54). The tibial wire for longitudinal traction was supplemented by a femoral wire for vertical traction, which served to lift the ever-troublesome distal fragment into alignment. This simple method, developed by Captain Modlin and Major Cahen, at separate hospitals, went far to solve the problem presented by lower-third femoral fractures.
Table 7 shows the location of the wires for traction in 613 compound fractures of the femur. These data do not include cases in which skeletal traction was used after internal fixation.
TABLE 7. – Location of Kirschner wire for skeletal traction in 613 compound fractures of femur
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FIGURE 54. – Diagrammatic showing of two-wire skeletal traction for battle fracture of femur. A. Deformity on admission to fixed hospital. B. Incomplete reduction in skeletal traction with wire in tibial tubercle. C. Adequate reduction after additional wire has been inserted in lower femoral fragment and vertical lift has been secured.
Technique of balanced-suspension skeletal traction.—Four methods of balanced-suspension skeletal traction for fractures of the femur were used in the Mediterranean theater. Each offered certain advantages and disadvantages. It was considered desirable that flexion of the knee be held to 15 0 or 20 0 in order to avoid continuing stretch on the quadriceps muscle, prevent fixation of the ligaments of the knee joint while the joint was in flexion, and facilitate quadriceps-setting exercises. The degree of flexion of the knee was therefore an important consideration in the selection of the method of balanced-suspension skeletal traction.
The four techniques of balanced-suspension skeletal traction included -
1. The Army half-ring splint with Pierson attachment (fig. 55). This method was applicable to fractures of the shaft requiring the pressure of a sling posteriorly as an aid in the maintenance of reduction. It was the preferable method of splinting for two-wire traction for fractures of the lower third of the femur. An outstanding advantage was that it permitted active and passive knee motion with little or no strain at the fracture site. The principal
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FIGURE 55. – Balanced-suspension skeletal traction by means of half-ring leg splint and Pierson attachment. Note balance as patient raises himself for bedpan. Knee flexion shown is more than advisable.
disadvantages of the method were pressure of the ring on wounds high in the thigh and the inaccessibility of posterior wounds for necessary dressings. The pressure of the ring posteriorly could be avoided by placing it anteriorly. Major Mead made effective use of this modification of the method in fractures of the upper third of the femur with posterior wounds. Pressure of the ring on the anterior superior spine of the ilium was prevented by increasing the weight lifting the upper end of the splint. Access to posterior wounds was easier but still awkward.
2. The Navy (Joldersma) method (fig. 56). This method was excellent for fractures of the upper third of the femur and could be used for the majority in the upper half. After the development of two-wire traction, it was used for some fractures of the lower third. The application of the original setup was cumbersome, but the modifications by Captain Modlin (fig. 57) and Major Albert O. Linch, MC (fig.58), were excellent simplifications. The principal advantages offered by the Navy method of splinting were ready access to all surfaces of the thigh for subsequent wound care, the ease of nursing care, and the comfort experienced by the patient.
The great disadvantage of the Navy method was that it did not permit knee-joint exercises. Therefore, after sufficient healing of the wound and formation of so-called chewing-gum callus formation at the fracture site, this method was preferably replaced by the Army half-ring splint with Pierson
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FIGURE 56. – Navy traction for fracture of femur. A. The canvas sling around the posterior thigh is a standard part of the equipment supplied with a Balkan frame. A weight of only 3 or 4 pounds is sufficient to support the thigh. The excellent balance between the traction and the leg suspension maintains alignment, and elevation of the foot of the bed provides countertraction against the weight of the body. B. Details of leg suspension in Navy traction shown in view A. Canton flannel is applied over sheet wadding, each turn overlapping all but about one-quarter inch of the preceding turn. Internal or external rotation of the lower femoral fragment is obtained, in Navy parlance, by moving the pins “inboard” or “outboard.” The string, which is of smooth material, glides easily through the safety pins and rings on the crossboard. Note the excellent functional position of the foot.
3. The 90-90-90 method (fig. 59). This method, developed by Maj. Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, MC, at the 23d General Hospital, and mentioned as an excellent operative position (p. 142), was sometimes used for fractures of the upper third of the femur. Its principal advantage was that, like the Navy method, it provided access to wounds high in the posterior thigh. Its outstanding disadvantage was the prolonged flexion of the knee to 90 0. There was also danger of distraction. As a technique of balanced-suspension skeletal traction for compound fractures of the femur, the 90-90-90 method had only a limited application. When it was used, it was preferably replaced by a conventional method after 2 or 3 weeks. As a rule, an orthopedic section did not use both the Navy method and 90-90-90 (vertical) traction, since the Navy setup appeared to offer all the advantages of the 90-90-90 method without its disadvantages.
4. Russell traction. This method, which was used very occasionally for fractures of the tipper third of the femur, offered no advantages over those already described.
Captain Modlin and Capt. Russell J. Crider, MC, at the 21st General Hospital, in a series of 185 compound fractures of the femur, employed the Army half-ring splint with Pierson attachment in 107 cases (58 percent) and the Navy method in the remaining 78 cases (42 percent). Major Cahen, in
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a smaller group of 45 fractures, used the former method in 26 cases, the latter in 17, and Russell traction in 2 cases.
Quadriceps exercises and knee motion. - The early, definitive reduction of fractures of the femur after balanced traction was instituted was considered important in the prevention of deformity and sepsis. Repeated manipulations of the fractures and major adjustments of the traction setup were traumatizing to tissue and prejudicial to healing of the wounds. Quadriceps exercises and a program for knee motion were desirable as soon as the wounds had healed sufficiently and fracture reduction would not be disturbed. In internally stabilized fractures, these objectives could be accomplished about 10 or 12 days after the operation. In fractures managed entirely by skeletal traction, exercises and movement were usually postponed until about 3 or 4 weeks after repair of the wound.
Ideal program. - An ideal program for the management of femoral fractures in skeletal traction, developed by Captain Modlin at the 21st General Hospital in Naples, was as follows:
The anesthesia provided for the surgery of the fracture and wound was continued on the ward while the balanced-suspension skeletal traction was set up. The fracture was manipulated into apposition and alignment, and the traction apparatus was adjusted to maintain the correct position. Roentgenograms were made immediately. If they showed that adequate reduction had not been achieved, the fracture was remanipulated, and the apparatus was adjusted again. Adequate reduction was usually achieved by these procedures, but additional roentgenograms were made the following day, and, if needed, further adjustments of the traction apparatus were made. This routine was followed daily, if necessary until satisfactory reduction had been achieved. Thereafter, each traction setup was inspected carefully several times each week, and checkup roentgenograms were made every 7 to 10 days.
The patients were all placed on a high-protein, high-caloric diet. The hemoglobin, plasma-protein and hematocrit values were checked at intervals
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of 3 or 4 days, and blood-replacement therapy was employed to correct deficits.
A supervised program of quadriceps and knee bending exercises was begun at the earliest practical time. This was usually about 3 weeks after wounding. The physical therapists attached to the hospital visited the femur ward 3 times weekly to supervise the program, but exercise periods were conducted daily under the observation of the ward nurses. Competitive exercises among the soldiers with femoral fractures were helpful in stimulating interest.
This regimen was observed to pay dividends in excellent fracture reductions, minimal infection, and good knee motion.
Duration of traction . - Skeletal traction for fractures of the femur was preferably maintained until after clinical stability had become evident and there was roentgenologic evidence of bony union of the fracture or, in the exceptional case, until hope of union in the theater had been abandoned. The usual time in traction for compound fractures of the upper and middle thirds of the femur was about 10 or 11 weeks, although when casualties were heavy the time in traction sometimes had to be shortened. Fractures in the lower third of the femur appeared to unite rapidly and usually required only 6 to 8 weeks in traction. The longer period was considered absolutely necessary in fractures above this level, to avoid late angulation. The late weeks of traction were utilized to improve the range of knee motion.
When sufficient union of the fracture had occurred to permit the discontinuance of the traction, a1 ½ plaster hip spica extending only to the iliac crests was applied as transportation splinting for the transfer to the Zone of
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Interior. A follow up study in the Zone of Interior in 1945 (p. 189) revealed instances of fractures of the femur which had been removed from traction before firm union and which had bowed during transportation in the cast. Several of these fractures had become fixed in angulation during that period. These observations were added evidence that a hip spica will not prevent angulation of a fracture of the femur and that a period of 10 to 12 weeks in traction is required for the majority of these injuries if the optimal result is to be achieved.
Captain Modlin and Captain Crider at the 21st General Hospital reported that in 177 compound fractures of the femur observed at that hospital the average duration of skeletal traction was 12 weeks. Maj. William R. Ferguson, MC, at the 33d General Hospital, reported an average traction time of 90 days in 140 fractures. In the 535 fractures of the femur studied from the proceedings of disposition boards on file in the Office of the Surgeon, Mediterranean Theater of Operations, the average time in traction was only 5.6 weeks. It. is known, however, that traction was prematurely discontinued in many of these cases becaus eof the stress of heavy casualty loads.
Other methods of fracture management. - A small but definite number of fractures of the femoral shaft were not adequately reduced in skeletal traction. In these cases, if it appeared that satisfactory apposition and alinement could be achieved by an open reduction and internal fixation, the necessary surgery was carried out. Faulty reduction of the fractures was not accepted if it could be prevented by open reduction and internal fixation. Either the old compounding wound was reopened or a separate operative incision was made. The internal fixation and the subsequent management of the soft-part wound conformed to the basic principles already described.
Ideally, of course, the compounding wounds were healed by the time that operative intervention for the unreduced fracture had been selected, so
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that the operative procedure was carried out not on a fracture that was still compound but, in a restricted sense, on a simple fracture. The hazard of infection was therefore minimal. The unreduced fracture was, however, likely to be associated with an unhealed, draining compounding wound or wounds, and not infrequently definite wound infection was present. As a result, the majority of late internal fixations of fractures of the femur were performed in the presence of unhealed wounds. In the 146 internally fixed compound fractures of the femur surveyed in the Zone of Interior (p. 194), 53 (36.3 percent) were performed at a secondary operation of reparative surgery. The compounding wounds were recorded as healed at the time of the fixation in only 5 cases (3.4 percent). They were unhealed in the remaining 48 cases.
Two other methods of managing these major skeletal injuries were used infrequently. One was immobilization in a plaster cast, the other, external fixation.
Plaster hip spicas (usually the 1 1/2 spica, though in one hospital a complete double spica was used) were employed in a few selected cases in which apposition and alinement were excellent on admission. Bone loss, in which distraction of fragments was feared if traction were employed, formed another indication for the application of a plaster hip spica. Several surgeons in the theater preferred the hip spica for fractures associated with a well-drained established infection. Occasionally, heavy casualties and a demand for hospital beds influenced the adoption of the plaster spica as the method of fracture management because it permitted early transfer to the Zone of Interior.
In spite of the usefulness of the plaster hip spica in occasional special cases, observations over the theater led to the conclusion that balanced-suspension skeletal traction, with or without internal fixation, was the preferable method of management in the overwhelming majority of compound fractures of the femur.
External skeletal fixation was not a popular method. In the series analyzed, it was employed only19 times (table 8).
Distribution of Methods of Fracture Management
Table 8 shows the methods of fracture management used in the several series forming the basis of this study. Although skeletal traction was employed after the great majority of internal fixations, the data for this technique include only cases in which skeletal traction was used without internal fixation
Table 9 shows the type of metallic internal fixation employed in 284 cases in these series. The21st General Hospital series is unusual in that 40 of 74 internal fixations of fractures of the femur (54 percent) were performed with wire sutures. This relatively high incidence has already been explained (p. 146). The24th General Hospital also employed wire-suture fixation in a high percentage of cases.
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TABLE 8. - Selection of methods of fracture management in 1,063 compound fractures of femoral shaft
TABLE 9.- Techniques of internal fixation in 284 fractures of femoral shaft
APPRAISAL OF RESULTS
Casualties with fractures of the femur remained in general hospitals a sufficiently long time to allow an appraisal of wound healing (table 10) and, usually, of union of the fracture. Even patients treated by stabilizing internal fixation of the fractures remained for several weeks, and traction for those treated by other methods was continued for 8 to 12 weeks. A fairly long term appraisal of results was possible. Important data on the results achieved from the viewpoint of an overseas theater concerned the deaths, amputations, healed wounds, wounds healed except for small granulated areas without sinus formation to bone, sinuses to bone, infected fractures, and the quality of fracture reductions.
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In September 1944, a survey was made in seven general hospitals in Naples and Rome to gather data on the results achieved in compound fractures of the femur after the institution of the so-called reparative triad; that is, penicillin, blood replacement, and precise surgery. The evaluation was made on each patient by the chief of the orthopedic section of the hospital, after overseas management had been completed and transfer to the Zone of Interior was imminent.
Data secured in the 277 cases of compound fractures of the femoral shaft reported in this survey follow:\t
| Number | Percent | |
| Deaths......................................................... | 2 | 0.7 |
| Amputations (exclusive of those caused by damage of major vessels at wounding).... | 2 | .7 |
| Infection at some period more than 30 days after wounding (as evidenced by fever and purulent drainage from fracture site)............ | 35 | 12.6 |
| Sinus formation to fracture site at time of disposition.................................................. | 29 | 10.5 |
A comparison of these data with those gathered on a similar group before the advent of penicillin, full blood replacement in the fixed hospital, and reparative surgery (p. 139) revealed no appreciable change in the incidence of deaths and amputations. The incidence of persistent sinus formation was about the same in each group. There was, however, a smaller proportion of infected fractures at some period 30 days after wounding (12.6 percent against 17.9 percent).
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Persistent sinuses were undoubtedly indicative of sequestrum formation and were not necessarily a criterion of failure of management. In severely comminuted fractures, with many partially denuded fragments, some sequestration was often inevitable. During the survey in the Zone of Interior in early 1945 (p.191), it was repeatedly observed that sound wound healing followed removal of sequestra, provided that reasonably healthy soft tissues were available. Therefore while sequestration was undesirable, its development did not necessarily prejudice the end result.
An accurate appraisal of the quality of reduction of the fractures of the femoral shaft in the series studied was not possible. It is known that adequate reduction was achieved in the great majority of all cases. Improvements in techniques of skeletal traction and the use of an aggressive surgical approach, combined with internal fixation if it was thought advantageous, prevented malposition and malalignment. The concept of the management of these injuries was that (1) the fractures should be reduced and maintained in reduction by whatever means were required;(2) that this objective could be reached without endangering life or limb; and (3) that wound healing would seldom be retarded but, if it were, that the end result, as measured by the function of the extremity, would still be greatly improved. Inadequate fracture reduction was therefore seldom accepted, and the statement that fractures of the femur were usually adequately reduced is regarded as justified.
Data concerning the healing of the wounds in these series have been compiled in table 10. Healing in wounds with small granulating areas was considered satisfactory; there was no opening to the fracture site in these cases, and healing processes had converted the compound fracture into a simple fracture. It is known that many wounds in which granulating areas were recorded on disposition in the theater were healed when the transportation plaster hip spicas were removed in named general hospitals in the Zone of Interior. Infected wounds presented profuse, purulent drainage from the fracture site. These fractures were usually those associated with severe damage and loss of soft tissue. The heavy drainage probably indicated relatively heavy sequestration. Non union of the fracture was not necessarily present.
CONCLUSIONS
The regimen of reparative surgery as applied to battle-incurred fractures of the femur in the Mediterranean theater and as evaluated overseas produced minimal sepsis, improved reduction of fractures, earlier wound healing with minimal scarring, and improved quadriceps power and range of knee motion without increased morbidity or mortality. Morbidity, in fact, appeared to have decreased. The final appraisal of the end results could be made only in the Zone of Interior, after the function of the extremity had been resumed. It is believed, however, that the regimen paid rich dividends in the prevention of deformity and the functional restoration of these severely wounded extremities.
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Part III. Compound Fractures of the Tibia and Fibula5
Although results in certain compound fractures were reasonably satisfactory when the program of reparative surgery was introduced in the Mediterranean theater in the spring of 1944, fractures of the tibia and fibula were not included in the group. The management of the fractures of one bone (the tibia or the fibula) seldom offered difficulties. The management of fractures of both the tibia and the fibula constituted a major problem, which cried aloud for solution, and it is fortunate that both bones were injured in not more than a quarter of all wounds of the leg.
The results being obtained in the theater in the spring of 1944 in fractures of the tibia and fibula did not meet the standards considered desirable and possible in the overseas management of these injuries. For this failure, there were a number of reasons:
1. When manipulation and traction, correctly applied, had failed to achieve adequate reduction, the failure was frequently accepted as the best that could be achieved under the circumstances because operative interference was considered too hazardous. The fear of infection was easy to understand, for there had been a fairly high incidence of locally necrotizing wound infection in wounds involving these fracture sites.
2. Wound discharges often pooled in dead spaces about unreduced fractures of the tibia.
3. Even when healing by granulation proceeded at a rate accepted as normal, it was a slow process and was always attended with scar formation, often of massive degree.
4. When tibial cortex was left exposed, in the expectation that it would be covered by granulations, sequestration almost invariably resulted.
THE REPARATIVE-SURGERY PROGRAM
Compound fractures of the tibia and fibula therefore seemed, at least at first glance, to offer a peculiarly fertile field for the application of the new program of reparative surgery. Its components--surgical closure of compounding wounds; adequate reduction of fractures, by surgical measures if necessary; and dependent drainage of residual dead space--were all designed to overcome the chief failures of the earlier, nonoperative plan of management, with healing by granulation. The situation, however, was not as hopeful as it seemed. All the factors which were so favorable to the program in fractures of the femur were unfavorable in fractures of the tibia and fibula because--
1. Injuries of these bones were frequently associated with a significant degree of bone loss. This fact accounted for delays in union and for many
5 The statistical material in this section was provided by Maj. William R. Ferguson, Mc, and Capt. Robert B. Gottschalk, MC, 33d General Hospital; Lt. Col. George A. Duncan, MC, Maj. R. D. Butterworth, MC, Maj. Benjamin W. Rawles, Jr., MC, and Capt. Beverly B. Clary, MC, 45th General Hospital; Maj. Joe M. Parker, MC, and Capt. Francis R. Crouch, MC, 21st General Hospital: and Maj. Otto E. Autofrance, MC, 6th General Hospital.
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instances of nonunion and was a serious consideration in an extremity in which full weight bearing and almost full length are essential for normal gait.
2. Many difficulties layin the way of obtaining and maintaining reduction and fracture union in an extremity in which excellent alinement is almost essential for normal gait. In civilian practice, delayed union or nonunion is not infrequent in fractures of the bones of the leg.
3. The large anteromedial surface of the tibia lies just under the subcutaneous tissue. As a result, the cortex was often exposed at wounding. Since there are no highly vascularized tissues in this area--even the covering skin is thin and light--closure of compounding wounds located over the anteromedial surface of the tibia was always difficult. In addition, there was frequently a significant loss of tissue at wounding, so that closure without tension was often impossible.
4. Posterior dependent drainage of residual dead space was always difficult to obtain in this area unless there was a large compounding posterior wound.
5. The type of combined bone and nerve surgery which gave such excellent results in compound fractures associated with nerve injuries in the upper extremity was not practical in the leg. Fortunately, the incidence of these combined injuries, while somewhat greater than in compound fractures of the femur, was considerably less than in compound fractures of the shaft of the humerus.
These unfavorable factors, while they did not prevent the full utilization of the program of reparative surgery in compound fractures of the bones of the leg, obviously handicapped it before it was instituted.
ANALYSIS OF CASES, 1944-45
The observations in this chapter, in addition to the personal observations, are based on the following collected data:
347 fractures of the tibia, fibula, or both bones treated from June 1944 through May 1945 at the 33d General Hospital.
638 fractures of the tibia, fibula, or both bones treated at the 45th General Hospital during 1944.
279 fractures of the tibia or the tibia and fibula treated at the 21st General Hospital during the last 6 months of its operation.
219 fractures of the tibia, fibula, or both bones treated at the 6th General Hospital from July through December 1944.
654 fractures of the tibia, fibula, or both bones studied from the proceedings of disposition boards in the Office of the Surgeon, Mediterranean Theater of Operations, and filed after 1 May 1944.
Practically all of these 2,137 fractures were managed after the reparative-surgery program became effective throughout the theater in the spring of 1944. As usual, not all desired data were available in all series.
All the hospitals from which material was procured functioned in the Mediterranean theater. The material from the 21st General Hospital, which served as one of the supporting hospitals in the invasion of southern France, also
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covers the period after December 1944, at which time it came under the Chief Surgeon, European Theater of Operations.
Fractures of the bones of the leg were the most frequent fractures encountered in the Mediterranean theater. The 638 cases handled at the 45th General Hospital during 1944 may be taken as representative. These cases represented 21 percent of all compound fractures and 24 percent of all compound fractures of the extremities admitted during this period. When fractures of the bones of the hand and foot are excluded from the calculations, the proportion rises to 37 percent. Fractures of the bones of the leg also represented 4.6 percent of all battle injuries treated at the 6th General Hospital from July through December 1944.
The most detailed information on the causes of compound fractures of the tibia and fibula was available from the 654 cases studied in disposition-board proceedings. Details were available for 506 battle injuries and for 116 injuries classified as nonbattle, as follows:
High-explosive shell fragments from artillery, mortars, mines, or grenades accounted for 345 of the 506 battle injuries (68.2 percent). Small-arms fire accounted for the remaining 161 cases.
The 116 nonbattle injuries constituted 18.6 percent of the total series (622 cases) in which this information was available. The largest group of fractures, 71 (61.2 percent),were caused by vehicular accidents. Falls accounted for 17 cases (14.7percent), injuries from falling objects for 13 (11.2 percent), and airplane crashes during training for 11 (9.5 percent). Explosions accounted for 3cases and a railroad accident for the remaining case.
Information as to the site of the fracture was available in 1,855 of the 2,137 cases analyzed in this chapter. The tibia alone was fractured in 819 instances (44.1 percent), the fibula alone in 523 (28.2 percent), and both bones in 513 (27.7 percent).
Information as to the presence or absence of associated nerve injuries was complete in 481 of the 498 cases from the 21st and 6th General Hospitals. In this group, there were13 injuries of the tibial nerve and 47 of the peroneal nerve, a combined total of 60 injuries (12.5 percent). This percentage is to be compared with7.7 percent in combined injuries in compound fractures of the femur (p.141)and 41.6 percent in compound fractures of the humerus (p.128).
WOUNDMANAGEMENT
Detailed data are not available on the preoperative management of patients with compound fractures of the bones of the leg in the general hospitals of the Mediterranean theater. It is known, however, that they were usually received in these fixed hospitals by the fifth or sixth day after wounding unless concurrent injuries required a longer stay in forward hospitals. They had usually received one or more transfusions of whole blood in forward areas, but additional transfusions were usually required, in the amount of 1,000 to 2,000
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cc., before hematocrit readings reached the minimum level (40) regarded as safe for surgery.
In the absence of specially unfavorable circumstances, the reparative operation could usually be undertaken well before the 10th day after wounding. In 100 consecutive cases treated at the 33d General Hospital, the average was 6 days. In 297 cases studied in disposition-board proceedings, the average was 8.5 days.
Management of the wound in compound fractures of the tibia and fibula presented certain special problems. The first had to do with bone fragments. Completely detached fragments of cortical bone were frequently found free in the large marrow cavity of the tibia. Because they were potential sequestra, their removal was imperative. Sharp, projecting ledges of bone were removed by rongeur.
The second problem had to do with wound closure. Loss of tissue was frequent. Even when the skin edges could be brought together without tension, healing was often prejudiced by dead space, which was usually present and which often could not be obliterated or effectively drained. In the early days of the reparative-surgery program, wound closure was often made more difficult by the use, in forward hospitals, of longitudinal incisions, with a long transverse axis, through the center of the combat wound. The crucial type of defect which resulted was almost impossible to close satisfactorily. Eventually, surgeons in forward hospitals recognized this difficulty and thereafter converted such wounds into a modified Z by the use of proximal and distal Incisions made from opposite corners. Closure was greatly simplified when such an incision was used at initial wound surgery.
It required discriminating judgment in many cases to decide to close the wound, perhaps with the aid of relaxing incisions or the advancement of flaps (figs. 36 and 40), or to leave it partially or completely open, in the expectation that the defect would heal by granulation (fig.42). The importance of covering all denuded cortical bone, and preferably the entire fracture site, with soft parts was well recognized and was a major objective of wound closure in compound fractures, hut deliberate acceptance of the closed plaster technique, with healing by granulation, was sometimes the wiser choice when there was extensive loss of soft tissue or when dead space was present that could not be obliterated.
Even if closure was considered safe, drainage was always necessary in wound of the leg because some residual dead space was invariably present and deep abscess formation was always a possibility if drains were not used. It was found best to provide drainage by soft rubber tissue or fine-mesh gauze and to allow the drain to emerge from the residual dead space through the sutured wounds. Attempts at dependent drainage through the posterior compartment of the leg were seldom successful, and the trauma of the incision or erosion from the drainage material introduced the risk of damage to regional vessels and nerves. When the compounding fractures were anterior, as they
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usually were, the solution of the problem was to keep the patient in the prone position for a week or 10 days after wound closure. This position effectively prevented puddling of blood and wound exudate in the bony defect.
When the decision was made to leave the wound partially or completely open, the defect was loosely filled with dry, fine-mesh gauze, and the patient was nursed in the prone position for a week or 10 days.
Still another contingency that had to be considered in injuries of the leg was how to manage a wound that had required extensive revision at the first operation of reparative surgery. In such cases, the best plan was to leave the wound open for 5 to 7 days after operation, to take advantage of the good drainage provided by the wide-open incision. In some hospitals, this plan was routine in fractures of the tibia and fibula managed by internal fixation. When delayed closure was undertaken at the appropriate time, which might be 14 days or more after wounding, it was usually possible to close the skin edges without tension by the use of relaxing incisions or by shifting of flaps of skin. The newly created skin defects were usually covered with split-thickness skin grafts at the same operation.
FRACTURE MANAGEMENT
Fractures of the Tibia or the Fibula
As has already been stated, fractures of either the tibia or the fibula seldom introduced problems of management, particularly when the injury was in the fibula. Even when it was in the tibia, plaster immobilization usually met the needs of the situation. The majority of United States orthopedic surgeons entered upon military duty with the expectation of managing all fractures of the tibia and fibula, whether alone or in combination, chiefly by plaster. Reports from the Spanish Civil War and reports of British surgeons of their experiences earlier in the war supported this point of view.
All plaster casts on the leg were so applied as to hold the knee and ankle joints in physiologic position. The arches of the foot were well molded. Unless muscle or nerve injury required support of the toes, the plaster was trimmed back to the metatarsal heads, so that full flexion of the toes would be possible. A wire or plaster loop incorporated in the cast protected the foot from the pressure of bedclothing and other trauma.
Fractures of the fibula . - The management of fractures of the fibula was simple unless the external malleolus was destroyed. In many such cases, only molding in plaster was possible. Bone loss in the shaft was seldom of significance. Immobilization in plaster was provided for several weeks but was not necessarily maintained until bony union was complete. The early removal of the cast permitted muscle and joint exercises during the final stages of fracture healing and played an important part in reducing the period of disability.
Compound fractures of the fibula were among the few compound battle fractures that allowed the return of soldiers to full duty status in a theater of
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operations. In 155 fractures of the fibula treated at the 45th General Hospital, about 40 percent of the soldiers were returned to their original duty status.
Fractures of the tibia . - Fractures of the tibia in the middle or the upper third were usually managed by plaster immobilization, to maintain alignment. The intact fibula acted as a strut to secure the normal length.
Fractures of the lower third of the tibia offered more difficulties. The two-pin plaster technique of external skeletal fixation was occasionally employed to insure full length and to avoid a yarns deformity of the foot. This complication usually occurred only in fractures in this location.
Internal fixation was employed in a few fractures of the upper third of the tibia with spread of the condyles or with forward displacement of a fragment to which the patellar tendon was attached. It was also used in a few fractures of the tibia at other levels. This technique was used in 1.5 percent of 158 fractures of the tibia treated at the 33d General Hospital, in 4.3 percent of 277 cases treated at the 45th General Hospital, and in 4.7 percent of 277 cases studied from disposition-board proceedings.
When bone loss had created a segmental defect in the tibia, the decision had to be made whether (1) to osteotomize and shorten the intact fibula but order to secure contact of the tibial fragments or (2) to leave the fibula intact in he expectation that the bony defect in the tibia could be repaired by grafting at reconstructive surgery (fig. 60). In a number of cases, the fibula was shortened. A number of other cases were observed in which it was thought that it would have been well to use this technique, since the shortening of the extremity would not have exceeded an inch. Another advantage of this technique was that deliberate shortening of the extremity sometimes permitted better approximation of the soft tissues. On the other hand, reports from Zone of Interior hospitals indicated that a high proportion of bone-grafting operations for segmental defects of the tibia were successful. In cases in which shortening would have exceeded an inch, it was therefore the general policy to permit the fibula to remain intact in expectation of later bone grafting.
Fractures of the Tibia and Fibula
Manipulative reduction with plaster immobilization was sufficient for the management of many fractures of both bones of the leg. If the fractures were severely comminuted, this often meant the acceptance of about a centimeter of shortening. The method presented one definite pitfall--late angulation within the cast, which could occur after edema had disappeared, atrophy of muscle and fatty tissue had ensued, and the cast had ceased to be a snug fit.
Fractures of both the tibia and fibula with segmental defects resulting from loss of bone at wounding or surgery provided a major problem. Unless shortening would be excessive, it was usually desirable to achieve contact of the bony fragments. When, however, the defect exceeded an inch or at the most an inch arid a half, it was usually preferable to allow it to persist, in an effort to maintain tibial length. Damage to soft parts, which was usually
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severe, further complicated the issue. The difficulties of wound management, the persisting dead space created by the bony defect, the prejudicial effect of the dead space on wound healing, and the limitation of function to be expected in an extremity that had been so severely damaged, all had to be weighed in the decision whether to shorten the extremity, maintain length mechanically, or, in the occasional case, amputate the limb. When, as just noted, information reached the theater that bridging bone grafts were proving very successful in the Zone of Interior, the scales were usually weighted in favor of preservation of length in the borderline cases in which amputation did not appear to he indicated, and the technique most applicable to the particular case was selected.
Techniques of fracture management. - In addition to plaster alone, four other methods of fracture management were employed in the Mediterranean theater in compound fractures of the tibia and fibula (tables 11 and 12):
1. Skeletal traction in a cast was employed effectively in a number of hospitals. The usual plaster immobilization was supplemented by traction obtained by means of a wire or pin inserted in the os calcis and incorporated
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into the cast (figs. 61 and 62). When traction was maintained for about 6 weeks, the risk of late angulation, which has just been mentioned, was greatly reduced. Stability frequently developed during this period, and apposition
TABLE 11. - Fracture management in 622 compound fractures of tibia and tibia and fibula 1
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169
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was well maintained. Traction supplement of the plaster technique should probably have been employed more frequently than it was. In a number of instances observed in the Zone of Interior in the spring of 1945, late angulation had occurred in both bones of the leg when only plaster immobilization was used. Roentgenograms made shortly before evacuation had showed the fractures to be well reduced, and the angulation had apparently occurred in the 3 to 4 weeks occupied by transfer over water and to the Zone of Interior hospital after landing. In some instances, the angulation had become fixed, and manual correction was not possible.
2. Two-pin stabilization in plaster involved merely the addition of pins to the plaster technique. This method was enthusiastically employed at one hospital in the theater but had a very limited use in other hospitals. It was chiefly employed in fractures with segmental defects in which it was desired that almost full length be maintained. The majority of surgeons preferred not to employ this technique in the absence of very specific indications. They did not regard it as effective in maintaining reduction, and they realized the hazards of persistent distraction, breakage of pins, and infection, which were associated with it.
3. External skeletal fixation, of which the two-pin plaster technique is really a modification, was steadily gaining in favor in the closing days of the war as an acceptable method of managing severely comminuted fractures of the tibia and fibula, including those with bone loss (p.207). In several hospitals, the half pins were inserted in the major fragments as the first step of fracture management at the reparative operation. Then, while the fracture site was exposed, reduction was accomplished under direct vision, and the stabilizing bars were locked to maintain it. Finally, a long leg plaster cast, in which the apparatus was incorporated, was applied. The cast held the foot incorrect position and increased the stability of the reduction.
4. It had been hoped, when the program of reparative surgery was introduced in the Mediterranean theater in the spring of 1944, that the problems of management of fractures of both bones of the leg would be solved in large measure by the use of internal fixation. This hope was only partly realized (figs. 63, 64, 65, 32, and 36). In the majority of injuries, comminution was too severe to make the technique feasible, while periosteal stripping in a region of poorly vascularized soft tissue continued to be hazardous, in spite of penicillin protection and refinements of surgical technique. Fractures in which coverage of denuded bone was difficult were usually unsuitable for management by this technique. In spite of these objections, the judicious application of plates, screws, or wire sutures in selected cases, particularly those in which it was possible to cover exposed bone and metal by healthy soft parts, resulted in improved and often stabilized reductions.
Wires sutures permitted major fragments to be held in approximation and insured some degree of apposition. Fixation by this method and by screws was considered less hazardous than plating, but plating was not infrequently utilized, in spite of the added risk, to obtain the benefit of better stabilization.
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The elective choice of internal fixation by plating was justified in this case because of (1) the difficulties ordinarily experienced in fractures of the lower third of the tibia and (2) the availability of soft parts to cover the denuded boric. The end result was excellent. (The case was managed at the 21st General Hospital by Maj. Newton C. Mead, MC, and Capt. Francis R. Crouch, MC.)
Toward the end of the war, it began to be recognized that it was a better plan to stage the procedures: Wound healing was accomplished as promptly as possible, and then, if adequate reduction had not been attained, plating was carried out through a surgical incision. A certain number of fractures, however, continued to present such combined problems of fracture reduction and wound
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This case clearly illustrates the hazards of plating of the tibia. The advantages offered by this technique when it is used before wound healing has occurred do not justify the risks entailed. In this case, wound healing did not occur and there was massive sequestration of the bone which had been denuded at operation.
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management that early plating through the compounding wound seemed justified, in spite of the risk involved.
Internal fixation of the fibula (figs. 66 and 67) was employed in several hospitals when a transverse or oblique fracture of that bone was associated with a comminuted fracture of the tibia. Plating, in effect, converted the combined fractures into a fracture of only the tibia; the stabilized fibula acted as a strut, maintaining tibial length and holding the tibial fragments in adequate reduction. Both metal and bone were easily covered by soft tissue, and wound healing was seldom a problem. Plating was usually accomplished through a separate surgical incision. After operation, the limb was put up in a long leg plaster cast.
This technique was used in 9 of 179 fractures of both bones of the leg treated at the 45th General Hospital. In 4 cases, the indication was a large segmental defect of the tibia, for which it was expected that a bridging bone graft would later be employed. In the other 5 cases, adequate reduction of the tibia was not possible by other methods. The fixation in 7 of the 9 cases was accomplished through the compounding wound.
The surgeons at this particular hospital believed that the simplicity and minimal hazard of this technique, combined with the feasibility of early transportability to the Zone of Interior with no fear of loss of reduction, made plating of the fibula the method of choice for combined fractures of the tibia and fibula whenever the contour of the fibular fracture permitted its use. Other surgeons, with somewhat less enthusiasm, accepted the concept that this technique had a limited application in the management of fractures of both bones of the leg.
EVALUATION OF RESULTS
Evaluation of the results of reparative surgery of compound fractures of the bones of the leg was necessarily limited to observation of the status of healing of the wounds and of reduction of fractures at the time of disposition. A soldier with a compound fracture of the fibula could be returned to duty in a fair proportion of cases. A soldier with a compound fracture of the tibia was unlikely to be of further military usefulness and was usually a candidate for early transfer to the Zone of Interior. Transfer was effected as soon as reparative management of the wound had been completed and it was reasonably certain that reduction would not be lost in transit. It was sometimes effected earlier than was desirable because heavy influxes of casualties demanded bed space in the theater.
The consensus throughout the theater was that on the whole, because of the handicaps attendant upon the management of these fractures (p. 160), the results were inferior to those accomplished in compound fractures of the femur and of the bones of the upper extremity. It was generally agreed, however, that they were far superior to the results which had been accomplished before
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As this case is viewed in retrospect, the severe trauma to the right foot and leg might well have been considered a justification for amputation in all echelons. Perhaps the fact that the trauma was bilateral was regarded by the surgeon as a contraindication. Since traction was not possible, the choice of internal fixation probably seemed justified. On the other hand, plating of the tibia is always hazardous because of the necessary periosteal stripping and the resulting denudation of bone, for coverage of which highly vascularized soft parts are not available in this area. The ever-present possibility of massive sequestration such as occurred in this case would seem to indicate that non plating methods are preferable in such injuries.
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the introduction of the reparative-surgery program. Necrotizing wound infection had become infrequent. Fracture reduction was improved. Complete wound healing was obtained in a large number of cases. In other cases, in which healing was incomplete, the size of the defects left to heal by granulation had been greatly reduced.
A high incidence of sequestration was considered almost inevitable in comminuted fractures of the tibia. When it occurred, sinuses formed and wound healing was not accomplished. Removal of the sequestra was recognized as a function of reconstructive surgery in the Zone of Interior. It was performed only on special indications, and in correspondingly few cases, in the Mediterranean theater. It was generally believed that, in most of these cases, satisfactory healing of the wounds would occur after removal of dead bone, provided that sufficient healthy soft tissue was available in the area.
In the 279 fractures of the tibia or the tibia and fibula which were treated at the 21st General Hospital, the tibia was fractured in 191 cases and the tibia and fibula in 88. The proximal third of the bone was involved in 81 cases and the distal third in 55; the knee joint was involved in 53 of the former group and the ankle joint in 12 of the latter. One hundred and ninety of the wounds were clinically clean on admission. In the remaining 69 cases in which this information was available, the wound contained necrotic tissue, and there was a heavy exudate.
Details of wound management were available in 270 cases in this series. Complete suture without drainage was carried out in 81 cases, partial suture or suture with drainage in143 cases, and suture with skin graft in 7 cases. Thirty wounds were left open. Amputation was necessary in 9 cases, in 1 instance
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because of a knee-joint infection and clostridial myositis complicating a severe fracture of the upper end of the tibia. In the remaining cases, the amputation was performed for circulatory causes.
Methods of fracture management could be ascertained in 264 cases, including 9 cases in which the fracture was incomplete and immobilization was not required. The remaining cases were treated by plaster-cast immobilization in 206, in 22 of which both bones were fractured; by cast traction in 23 cases, in all of which both bones were fractured; and by internal fixation in 26 (14 by screws, 9 by wire, and 3 by both techniques).
The status of the wound when the patients were evacuated was unknown in 100 cases in this series, because of the tactical necessity for speedy evacuation. In 40 of the remaining 170 cases (23.5 percent), the wounds were completely healed. In another 49 cases (28.8 percent), the wounds were healing, and there was no opening to the bone. In 59 cases (34.7 percent), in all of which the closed plaster technique had been used, the fracture site was exposed, but the wound was clean and healing appeared to be in progress. In the other 22 cases, the wound was not healed, and both bone and soft tissue were frankly infected.
Results accomplished overseas were also studied in a series of fractures of the tibia (132) and of the tibia and the fibula (80) treated at the 33d General Hospital. These 212 fractures were classified into three groups (table 13) on the basis of severity of damage to the soft tissue and bone, as follows:
Group A.- Extensive damage to soft tissue, and, usually, severe comminution of bone. In many cases there had been loss of soft tissue or of bone at wounding.
Group B.- Moderate soft-tissue damage, severe comminution of bone.
Group C. - Slight damage to soft tissues, little or no comminution of bone.
Results were classified as successful or unsuccessful from the standpoint of wound management and fracture management. Wound management was
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regarded as successful when the wound was either completely healed or completely healed except for small areas of healthy granulation tissue, with the fracture site well sealed off. Management was regarded as unsuccessful when there was an open, draining wound or a sinus leading to the fracture site. These criteria were exacting, since in highly comminuted battle fractures sinuses usually led only to sequestras forming from fragments of bone partially denuded at wounding. Leaving these fragments in situ also introduced this possibility. Wound healing had not been achieved in these cases, however, and they were considered instances of unsuccessful wound management.
Fracture management was considered successful when the fragments were held in adequate apposition, length, and alinement for the special bone injury. It was considered unsuccessful when reduction was inadequate.
By these criteria (tables 14, 15, and 16), wound healing was considered successful in 167 of these 212 compound fractures of the tibia and fibula. Fracture management was successful in 207 cases. When the criteria of success are combined, 166cases were successful from the standpoint of wound healing and fracture management, and only 4 were unsuccessful from both aspects.
Early in the reparative-surgical program, the depths of the wound, including the fracture site, were not routinely exposed, and there is no doubt that totally detached fragments of bone and tags of dead tissue were left in situ. As experience increased, it was increasingly appreciated that the entire wound must be freed of dead tissue. The improved wound healing in the cases in which
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additional debridement was carried out (89 percent, against 49 percent in the cases not completely explored) furnished substantiating evidence of this fundamental principle of reparative surgery.
TABLE 15. - Results in relation to severity of injury and technique of fracture management in 132 compound fractures of the tibia and 80 of the tibia and fibula1
TABLE 16. - Combined results of wound and fracture management in relation to severity of injury in 132 compound fractures of the tibia and 80 of the tibia and fibula1
Part IV. Compound Fractures of the Foot
All hospitals in the Mediterranean Theater of Operations had frequent admissions for compound fractures of the bones of the foot. At first glance, this fact might seem to violate the axiom that the proportion of injuries in any given area of the body bears a general relation to the proportion of body surface which the area represents. Although the foot constitutes a relatively small portion of the lower limb and an absolutely small part of the total body surface, admissions for compound fractures of the bones of the foot made up from 18
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to 20 percent of all compound fractures managed in general hospitals. At the 45th General Hospital, for instance, during 1944, the 565 compound fractures of the bones of the foot represented 19.3 percent of all compound fractures treated during that year. The os calcis was injured in 101 cases, the tarsals in 146, the metatarsals in 224, and the bones of the toes in 94. The explanation of the large numbers of fractures of the foot was chiefly the extensive and extremely effective use of land mines by German troops.
On the surface, it would not seem that compound fractures of bones of the foot would be of great significance. They are not inherently lethal, it is true, but they account for an enormous amount of disability, even when they are of minor severity, and, when they are extensive, they may permanently destroy a soldiers military usefulness. At the best, a man with a compound fracture of a bone of the foot, unless only a smaller toe was involved, could not be expected to return to duty within the theater holding period of 90 to 120 days. As a result, most patients with such injuries had to be evacuated to the Zone of Interior. It is perfectly fair to say that if an enemy could succeed in producing compound fractures of bones of the foot in most of their opponents, a very large expenditure of medical service would be required for their management and only an insignificant number of the soldiers could return to fight again.
Of the compound fractures which affected only a single toe, a fair proportion were the result of self-inflicted gunshot wounds. The battle-incurred injuries varied all the way from relatively simple fractures to completely disorganized fractures of the tarsus, with massive soft-tissue compounding wounds. Injuries of this type were most often caused by land mines.
WOUNDMANAGEMENT
Initial surgery in wounds of the foot was conducted according to the general principles of debridement as far as the regional anatomy permitted. Usually, all that could be done was to remove large foreign bodies and obviously dead tissue.
The anatomy of the foot, unfortunately, also militated against all but the most limited application of the program of reparative surgery, for a number of reasons: Some degree of tension is normal in the skin of the foot, particularly on the plantar surface. For this reason, the swelling which ordinarily occurs in the tissues after wounding and initial surgery is of more significance in the foot than in most other areas. Finally, the soft tissues of the foot possess generally inferior qualities of healing, even when there has been no great loss of tissue, and in many of these injuries the loss had been considerable.
As a result of these considerations, delayed primary closure of wounds of the foot, even when tissue loss had been small, was usually limited to occasional wounds of the dorsal surface. It was seldom possible to close wounds on the plantar surface. The best that could be done, in most cases, was to place a few sutures in the angles of the wound, cover exposed cortical bones and tendons, and accept healing by granulation.
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The fact that most wounds could not be closed did not, of course, contraindicate the routine performance of other steps of the reparative operation. Grossly displaced and rotated fragments of bone could often be replaced manually in their normal position at this time.
The wounds were dressed with fine-mesh gauze, preferably impregnated with Vaseline or some water-soluble ointment, to promote drainage from the depths of the wound. Dry gauze, which was preferred in other locations, was less satisfactory when it was used in wounds of the foot.
FRACTURE MANAGEMENT
Manipulation under full vision, as just noted, was a simple and effective method of management of many fractures of the foot. It was usually effective in fractures of bones of the small toes, with immobilization maintained by dressings. It was also sometimes useful in bones of the great toe, but fractures in this area required special management because this toe is essential for locomotion, and residual disability is highly undesirable.
Banjo traction was the preferred method of management when the proximal phalanx of the great toe was comminuted and fragments were overriding or when there was significant displacement of a major fragment, particularly a fragment which included a portion of an articular surface. A small Kirschner wire was introduced into the distal phalanx of the toe from the dorsal to the plantar surface, passing through the toenail. A boot cast extending to the metatarsal heads was then applied to hold the foot at 900 in neutral version. A heavy loop of wire was incorporated in the cast, and traction was accomplished by rubber bands extending from it to the Kirschner wire. This simple method permitted access to compounding wounds for dressings and at the same time minimized the deformity caused by the fracture.
Fractures of the metatarsal bones had to be prevented from uniting in dorsal angulation. If this were permitted, the metatarsal heads would be excessively prominent in the ball of the foot, and callus formation and pain on walking would be inevitable. Healing of all metatarsals in full length and in as nearly perfect alinement as possible was necessary for the heads of these bones to continue to serve as points of weight bearing. These results could be accomplished in most fractures of the metatarsals by simple manipulative molding and immobilization in a boot cast. If any significant degree of shortening was present after manipulation or if it was impossible to maintain proper alinement, banjo traction was instituted through one or more of the toes by the technique just described.
Fractures of the tarsus could be managed only by manipulative molding and immobilization in a boot cast. In this type of injury, the healing of the compounding wound was of greater concern than the management of the fracture, and the reduction of the fracture had to be conducted with this consideration in mind.
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Compound fractures of the tarsus, especially when the os calcis was involved, were a source of prolonged disability. Functional results were seldom optimal and were often actually poor. Although conservatism was ordinarily practiced, many orthopedic surgeons, when they reviewed their experience, wondered whether this had been the wisest course. They could recall many cases of extensive bony disorganization and persistent infection, with continuing destruction of bone or loss of weight-bearing skin on the plantar surface of the heel, in which conservative measures had been employed but in which amputation might have been the wiser course. In some of these cases, amputation was eventually performed in the Zone of Interior but only after the soldiers had been hospitalized for months and even years.
The same course of events was sometimes observed in fractures of the astragalus. Early amputation in this type of case would have lessened the period of disability and saved considerable hospitalization and medical effort which, in the end, achieved no results at all. It should be emphasized, of course, that amputation was never carried out in a case in which the vascular supply to the distal portion of the foot appeared adequate and in which there was a reasonable chance of preserving a functioning, weight-bearing extremity.
POSTOPERATIVE MANAGEMENT
Postoperative management in compound fractures of the bones of the foot treated in plaster after reparative surgery required bed rest, with the injured extremity elevated, for at least 7 to 10 days, to reduce edema of the foot and toes, prevent infection, and promote wound healing. When this plan was followed, the edema originally present subsided promptly, often to such a degree that a new plaster boot had to be applied.
Since the majority of these casualties were of no immediate military usefulness, they were usually evacuated to the Zone of Interior as soon as possible after reparative surgery. This was, as a rule, within 2 to 3 weeks after wounding. A snug boot cast was adequate for transportation splinting.
