CHAPTER X
Noncombat Orthopedic Lesions
In addition to wounds involving the bones and joints, patients in the hospitals of the Mediterranean Theater of Operations presented, almost from the day it came into existence as the North African Theater of Operations, two other groups of orthopedic lesions.2
The first of these lesions was the simple type of fracture which resulted from the many kinds of trauma to which a soldier in an overseas theater was subjected behind the fighting lines. These injuries were sustained, for the most part, in the performance of such tasks as are commonly a part of noncombat. activities A considerable number were sustained during athletic contests and other recreational activities.
This type of fracture needs no extended discussion. Most of them were treated by simple manipulation and plaster immobilization, supplemented, occasionally, by simple forms of traction. Open reduction and internal fixation were performed on the same indications as in civilian practice. The attitude was conservative, and these special techniques were not resorted to unless adequate reduction had not been accomplished by simpler measures.
The second group of noncombat incurred lesions comprised the orthopedic disabilities ordinarily seen in civilian practice, including painful feet, painful backs, painful and unstable knees, recurrent dislocations of the shoulder, and old fractures of the carpal scaphoid bone. Some of these conditions were known to exist before the soldiers were inducted. They sometimes caused only minimal disability during the training period in the Zone of Interior but produced such disability under conditions of combat that the soldiers frequently reported on sick call and had to be hospitalized for investigation, evaluation, and treatment. In some cases, the disability was of such long standing and so evident that one wondered how the patients had ever been classified for overseas duty. These lesions were of military importance because of the disability which they caused, their chronic and recurrent character, and the two serious consequences to which they gave rise in an active theater of combat; namely, loss of manpower and utilization of hospital-bed space and of other medical facilities.
Early in the North African experience, it was not at all unusual for soldiers hospitalized with these complaints to state that they had suffered considerable
1The material in this chapter is largely based on a survey made by Maj. Newton C. Mead, MC, 12th General Hospital, after V-E Day.
2The injuries described in this chapter were sometimes produced during combat, as the result of falls and other accidents, but they were not produced by missiles, and for convenience of reference they are therefore described as noncombat lesions.
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difficulty from them during training but that appropriate therapy had permitted them to continue on duty. Sometimes a soldier would state that he had duly reported his trouble when he was given his final physical examination before embarking for overseas, and that the existence of the condition had been verified, but that the examining officer had said that he would be reclassified overseas for limited duty. Many of these men were never of combat usefulness Some of them were of limited usefulness even on limited duty A few were promptly returned to the United States, as being completely unfit for any sort of duty in an overseas theater There are no supporting statistical data for any of these statements, but they are substantiated by the observations of many of the orthopedic surgeons who served in the theater.
The early confusion in respect to these noncombat. orthopedic conditions was probably unavoidable. As the war progressed, the situation was gradually rectified and in the last year only a small percentage of the soldiers who reached the Mediterranean theater had conditions of sufficient seriousness to warrant classification to limited duty. If a policy of similar strictness had been in effect throughout the war and if these disabilities had been diagnosed and properly evaluated in the Zone of Interior, time, effort, and expense would have been saved, and badly needed hospital-bed space would have been conserved overseas.
GENERAL PRINCIPLES OF MANAGEMENT
Soldiers with the noncombat type of orthopedic lesions were more closely studied in fixed hospitals. When the difficulties became apparent in forward areas, every effort was made to screen out those whose complaints were trivial and functional and to return them promptly to duty Under the stress of a heavy combat load, however, this was not always possible, for these complaints frequently required a great deal of time for investigation and evaluation. As a result, the majority of the patients had to be transferred back to fixed hospitals This was unfortunate. Experience in all fields throughout the war clearly indicated that the farther to the rear soldiers were evacuated, the more difficult it was to return them to combat duty.
As this statement suggests, the psychogenic factor played an important part in these complaints and greatly increased the problems of management and disposition. This group of patients did not consist of malingerers in the ordinary sense of the term. These men honestly regarded their disabilities as sufficiently serious to prohibit their participation in heavy duty and in combat. Liaison between orthopedic and neuropsychiatric medical officers was obviously called for and proved very profitable, though it was not until the winter of 1945 that concrete steps were taken to stop the practice of sending numbers of these soldiers from forward areas to fixed hospitals. At this time, as part of the neuropsychiatric program in the theater, a reinforced field hospital platoon was designated and set up under time supervision of Maj. (later Lt. Col) Calvin S. Drayer, MC, consultant in neuropsychiatry,
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Office of the Surgeon, Fifth U.S. Army, close to the division area, to receive patients with chronic or vague complaints directly from clearing stations. The professional staff of this field hospital platoon consisted of various specialists, among them an orthopedic surgeon. All were men of judgment and experience. When soldiers complaining of orthopedic conditions were admitted to this platoon, they were quickly but thoroughly studied and screened When observation seemed to establish or made it seem likely that there was ground for the soldier`s complaints, he was evacuated to a fixed hospital in the rear for further investigation and possibly for treatment. Otherwise, he was promptly sent back to the line. This plan of management made it possible to return a large number of soldiers to combat status without their ever leaving the forward area
At the fixed hospital, the emphasis was always upon rapid evaluation of the complaints of these patients, with an equally prompt decision as to their disposition. In civilian practice, the emphasis in such conditions is upon precise diagnosis and time institution of therapy. Only later is any prognosis made as to the duration of temporary disability or the extent of permanent disability In overseas hospitals, the first consideration was whether the complaints had a physical basis and, if so, whether it was of sufficient seriousness to prevent the soldier`s immediate return to a duty status If the answer was ‘‘No," the surgeon`s first duty was to discuss his condition with the patient and to make it clear to him that his disability was not sufficient to prevent him from performing his military duties. The question at issue was whether he could perform them adequately. If it was thought that he could, he was promptly returned to combat duty.
If a clear-cut decision could not be arrived at promptly, a detailed routine of investigation was begun, including roentgenologic examination and laboratory studies While it was in progress, physical therapy was often instituted, in an effort to relieve symptoms and shorten the period of hospitalization When the diagnostic routine was completed, the patient was again evaluated, and disposition was accomplished, the preference being given to duty status whenever it was felt that he could assume the necessary duties and could continue to perform them. Patients who could not be returned to duty at once were kept in the hospital and were treated as intensively as possible Reevaluation was carried out after the lapse of 10 days to 2 weeks, and final disposition was then accomplished A soldier who could not be rehabilitated within this period was unlikely to be of further combat usefulness
The essential factor in this routine of evaluation, treatment, and disposition was the promptness with which it was carried out. The whole military experience showed that, in such conditions as these, prolonged hospitalization and treatment were seldom more effective in salvaging a soldier for duty than were shorter periods. The more prolonged the hospitalization, in fact, the more difficult it was to return soldiers to duty status, whether the condition was acute, chronic, on recurrent.
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The soldier who really needed treatment was given the benefit of all the standard treatment appropriate to his condition, but he was disposed of just as promptly as good orthopedic practices permitted The first and paramount mission of the Medical Corps is to maintain the fighting strength of the Army This objective required the salvage of all possible manpower, together within the most efficient possible use of all hospital and other medical facilities, including the time of medical officers. Undoubtedly, in an occasional instance, some injustice was done, and soldiers were returned to active duty too soon. This worked no individual hardship, however, for those who had real complaints promptly reported to sick call again. The general policy was considered highly effective It provided full medical care for those who really needed it, while at the same time it reduced the days lost from duty for soldiers who had mild forms of orthopedic lesions and who really needed no hospitalization amid no treatment beyond explanation and reassurance.
THE MANAGEMENT OF PAINFUL BACKS AND FEET
Lesions of the back and the feet were the two noncombat connected orthopedic complaints most commonly encountered in overseas theaters They accounted for a considerable loss of manpower but need no extended discussion because, in spite of their importance, no new techniques were developed for their management and no special studies were made from which conclusions concerning them could be drawn
Painful Backs
When a soldier complaining of back pain was admitted to a general or station hospital, the routine was (1) to take a careful history, with particular reference to the time and circumstances of the first appearance of the disability; (2) to make a physical examination; and (3) to obtain anteroposterior, lateral, and oblique roentgenograms of the lumbar and sacral spine In many cases in which there was organic reason for the complaint, the chief diagnostic evidence was roentgenologic Mild arthritic changes were not considered disabling in themselves Moderate or extensive changes were considered confirmatory of the clinical complaints, and treatment was promptly instituted. If the symptoms were not promptly relieved, possible transfer to limited-duty status was considered Congenital anomalies, other than spondylolisthesis or evidence of extensive structural weakness, were not considered disabling in themselves. Bone tumors and destructive lesions were practically always regarded as justification for evacuation to the Zone of Interior for continued hospitalization and definitive treatment A clinical syndrome suggesting rupture of the intervertebral disk was a special problem, which is discussed in the neurosurgical volume of this series.
Treatment for painful backs was usually limited to bed rest on a hard bed, with movement minimized by the use of a board between the mattress and
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the springs, and physical therapy consisting of infrared heat and massage Simple braces and supporting canvas belts were sometimes made in the hospital braceshops. They were useful for soldiers who had been on limited duty or who were being assigned to it, but. these devices were never effective in returning a soldier with a painful back to combat duty.
In the majority of chronic complaints referable to the back, maximum symptomatic improvement was usually obtained in about 2 weeks, and with few exceptions it was possible to determine by this time whether disposition should be to combat duty or to a limited-duty status In acute back strains, a longer period of treatment was often justified, but maximum symptomatic improvement was usually obtained by the end of the third or fourth week, and disposition could be made with assurance by that time.
Painful Feet
Painful feet were more of a problem than painful backs Soldiers with symptomatic flat feet who were admitted to clinics or hospitals raised questions of disposition rather than treatment. Such measures as rest and physical therapy were of no value. Arch supports did not reach the Mediterranean theater until early in 1944 They provided some relief for soldiers on duty in rear areas but appeared to be of little value in returning to combat duty soldiers who complained of their feet There were numerous complaints about these supports, the most frequent being that they were too high in the longitudinal arch and often caused pain from excessive pressure. It was frequently possible to remedy these defects in the braceshops of general hospitals, but the general impression was that the use of arch supports was of limited value in the management of painful feet in a theater of operations
Surgical intervention for hallux valgus was seldom undertaken overseas. The operation only occasionally made possible the return of a patient to combat duty, and after the first months of the war it became the rule to assign patients with this condition to limited duty if they proved unfit for combat and to make the disposition without surgery
Operation on a single hammertoe on an otherwise normal or almost normal foot was frequently carried out by standard techniques In most such cases, the soldier could be returned to full duty. Operation was seldom undertaken for hammertoes associated with a flat metatarsal arch and with dorsiflexion of all the toes. Experience promptly showed that surgery seldom permitted full-duty disposition and that the wisest plan was to assign the soldier to limited duty without surgery.
March fractures accounted for a certain proportion of painful feet observed overseas, though most such fractures occurred during training in the Zone of Interior. This subject is discussed in detail elsewhere in this series It might be said here that while weight bearing was not permitted if it was painful, there was an increasing tendency overseas to omit prolonged immobilization from the routine of treatment In some instances, a plaster boot was worn for a few weeks, but many times only a metatarsal pad was applied
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SURVEYS OF MANAGEMENT OF NONCOMBAT ORTHOPEDIC LESIONS
Surveys were carried out in the Mediterranean theater for three special types of injuries; namely, recurrent disabilities of the knee, including injuries of the semilunar cartilage and loose bodies in the joint (osteochondritis dissecans); recurrent dislocations of the shoulder; and simple fractures of the carpal scaphoid bone. The purpose of each of these investigations was the same--to determine what success had been achieved in restoring to a useful duty status the patients who had been subjected to surgery. The cost of treatment to the Army, in terms of utilization of hospital days, was investigated in each survey.
An attempt was made to follow up patients who had received surgical treatment for meniscus injuries, in order to determine, at least by inference, how they had stood up under the duties to which they were assigned Results in other lesions were evaluated simply on the basis of hospital disposition. The classification and disposition of patients employed in the Mediterranean theater in 1944 and 1945 were as follows:
Category A covered soldiers whose physical condition was considered as qualifying them to perform full military duty, without any restrictions. Those who required a preliminary period of conditioning, up to 6 weeks, before being returned to full-duty assignments, were temporarily classified as A2.
Category B covered soldiers who were capable of limited service, according to the degree and manner specified by the hospital disposition board. Thus classification was frequently invalidated by failure of the units to which they were assigned to observe the specifications. The subcategory B temporary covered soldiers who were expected to prove eligible, after a certain period of conditioning, for reclassification to Category A. Only disposition boards in general hospitals were authorized to place officers in class B.
Category C covered soldiers who could not be restored to any duty status within the holding period permitted in the theater. These patients were evacuated to the Zone of Interior Disposition to category C was authorized only in general hospitals or in station hospitals acting in the capacity of general hospitals
Soldiers who were classified to full duty in the Army had to be able to perform full duty. In the very nature of ground combat, there could be no relief from certain strenuous duties and no halfway performance of them. In the Army Air Forces, the situation, for obvious reasons, was rather different, and disposition in hospitals devoted exclusively or almost exclusively to Army Air Forces personnel could be carried out by somewhat different criteria. For one thing, patients returned to duty within the Air Forces were quartered in relatively comfortable barracks, easily accessible to the hospital, in sharp contrast to the foxholes and pup tents which were usually the lot of infantrymen. The situation was roughly similar to that of a civilian industrial community. Hospitals supporting the Army Air Forces were not usually in the direct chain of evacuation from the front lines and were therefore not constantly crowded within battle casualties, as were the other hospitals included in
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these surveys. Their work, for this reason, could be conducted somewhat along the lines of a civilian hospital.
There were also other differences. The Army Air Forces had its own flight surgeons, whose responsibilities were entirely toward its own personnel These surgeons had opportunities to become acquainted with the men, they were familiar with their duties, and they could control and supervise their activities during periods of rehabilitation. Because they were in a position to judge what duty a patient just released from the hospital was capable of assuming, disposition of Army Air Forces personnel was often made to class A duty, within the tacit understanding that there would be a period of conditioning and rehabilitation under the flight surgeon`s supervision before full duty was actually attempted This arrangement eliminated the period of reconditioning at a replacement center which ground troops often had to undergo and which was always unpopular Furthermore, there was never any necessity in the Army Air Forces for heavy marching or for ground operations over unfavorable terrain Finally, although precise evaluation is impossible, the morale factor undoubtedly played an important part in the generally better results secured in elective surgery in the Army Air Forces
In 1944, the Army Air Forces discontinued class B duty and placed personnel returning to duty in either class A or class C. This was a feasible plan in that branch, whose duties, while exacting and hazardous, were very different from the duties of ground troops Many patients who were placed in class A in the Army Air Forces would have been placed by practical necessity in class B had they belonged to other branches of the service
INTERNAL DERANGEMENTS OF THE KNEE
1943 Survey
Early un the North African campaign, the management of internal derangements of the knee joint in a theater of operations was recognized by certain orthopedic surgeons as a problem which needed investigation An investigation of a series of operations performed before 15 July 1943 was therefore undertaken (by Maj Oscar P. Hampton, Jr, MC) in 2 general and 6 station hospitals in the Mediterranean Base section. Special attention was paid to the followup, which was concluded as of 1 November 1943. Whenever possible, the patients were traced to their current assignment
This investigation covered 150 arthrotomies of time knee joint, 140 undertaken for lesions of the semilunar cartilages and 10 on the indication of osteochondritis dissecans The medial cartilage was removed in 120 cases, the lateral cartilage in 12, and both cartilages in 4. In four cases, although the joint was opened, neither cartilage was removed. These 150 patients spent an average of 72 days in the hospital At the time the survey was concluded, five were still hospitalized, the average period of hospitalization to that date being 95 days
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The results of the remaining 145 arthrotomies were as follows:
Returned to full duty after spending an average of 53 days in the hospital, 67 patients (46 percent)
Returned to limited duty after spending an average of 89 days in the hospital, 56 patients (39 percent).
Evacuated to the Zone of Interior after spending an average of 83 days in the hospital, 22 patients (15 percent)
Of the 84 combat troops included in the 150 cases, 28 were returned to full duty and 42 to limited duty, 12 were evacuated to the Zone of Interior, and 2 were still hospitalized at the conclusion of the survey
These figures require further analysis They show, first of all, that, after the expenditure of an average of 72 days of hospitalization per patient, there was less than an even chance of restoring the soldier to combat duty or, if he had been on limited duty, of making him fit for combat duty They show, next, that 2 of every 3 patients who had been combat troops could not be returned to their former status
Finally, the hospital-stay days require analysis. The average period of hospitalization for the whole series, 72 days, is low because it includes a number of extremely early dispositions One combat soldier, for instance, was returned to his infantry division on the eighth postoperative day, and 10 others were returned in less than 30 days Obviously, these dispositions cannot be accepted at their face value; any duty disposition made within less than 6 or 8 weeks after arthrotomy must have necessitated some restriction of duty. In a number of the hospitals surveyed, other patients were observed whose disposition had been effected within unusually short periods and who had had to be hospitalized for reclassification
In the light of these facts, it was concluded that arthrotomy for a torn semilunar cartilage in an overseas theater of operations was often of very doubtful value If a soldier had a disability of such seriousness that he could not perform combat duties, it was probably more sensible to downgrade him to limited duty, without operation, than to spend the time and effort and utilize the hospital-bed space required to restore him to full duty, since the chances of success were no more than 50 percent and since the chances of his being able to perform full duty further reduced the percentage.
Establishment of Theater Policy
Circular Letter No. 48, Office of the Surgeon, North African Theater of Operations, published 18 November 1943, 3 took full cognizance of these facts Its substance was as follows:
1. Operations for repair or reconstruction of the collateral or cruciate ligaments of the knee or for recurrent dislocation of the patella were forbidden
3See appendix, pp. 312-316
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2. Excision of a semilunar cartilage or of joint mice was permitted, but only in selected cases, in which there had been careful evaluation of the patient`s age; the findings on roentgenologic examination; the relative stability of the joint; and, most important of all, the soldier`s mental outlook
3. Operation was not to be performed for primary injuries of the semilunar cartilage unless the knee was locked and could not be unlocked either by gentle manipulation or by skin traction for 5 or 6 days In all other cases, treatment was to be limited to pressure support, rest, graduated to protected weight bearing and then full weight bearing, and carefully supervised quadriceps exercises for 2 to 10 weeks. These soldiers were to be returned to duty as soon as symptomatic relief was obtained.
4. Arthrotomy was to be performed only for (1) persistently locked knees and (2) unlocked knees if the disability made it impossible for the soldiers to perform noncombat duty. The latter indication was to be employed only in exceptional cases.
5. Soldiers with recurrent disability in which the knee was not locked or in which it could be unlocked by conservative management were to be returned to duty. If, however, the total disability in any calendar year exceeded 90 days, they were to be returned to the Zone of Interior.
6. Operations for the removal of a cartilage from each knee or for the removal of both cartilages from one knee were to be performed only on the written recommendation of a disposition board in a general hospital.
7. Elective arthrotomy was to be performed only on the orthopedic services of general hospitals. The patient was to be held, for a minimum of 6 weeks in the hospital in which the operation was performed, to permit the operating surgeon to supervise the regimen of postoperative exercises and graded motion which were essential to good results If prevailing evacuation policies did not permit holding for this length of time, the operation had to be performed in a hospital farther to the rear. After 6 weeks in a general hospital, the patient was to be transferred to a convalescent hospital for further supervision. Full instructions for the continuation of corrective exercises were to be sent with him.
The implications of these policies were perfectly clear. If a soldier with an injured meniscus or other knee disability could perform any type of duty in his present condition, he was to be placed in the appropriate classification and returned to duty. If he could not perform even limited duty satisfactorily because of frequency of recurrence of the difficulty or persistent locking of the knee, he was to be considered a possible candidate for surgery unless there were contraindications to operation. If these existed, he was to be returned to the Zone of Interior. Among these contraindications were arthritic changes of any considerable degree, definite cruciate relaxation, and age (usually over 30 years) Operation was not to be undertaken if the soldier showed any signs of hypochondriac tendencies or emotional instability. In short, all cases for surgery were to be selected on an individual basis, and no elective surgery on the knee was to be done routinely.
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1944 Survey
In order to secure additional statistical data concerning the management of knee disabilities, the Surgeon, Mediterranean Theater of Operations, directed all general and station hospitals in the theater to submit specified information for 1944 for inclusion in Essential Technical Medical Data for March l945 4 Similar requests were made of the 6 general and 8 station hospitals which were formerly in the Mediterranean theater but which had been sent to the European theater after the invasion of southern France. Hospitals which did not submit the data as directed were visited by Maj Newton C. Mead, MC, on the order of the Surgeon, Mediterranean Theater of Operations, in the summer of 1945, after the fighting had ended, in order to secure the required statistics.
A direct followup of these patients would not have been practical, but an indirect followup was possible. The Central Postal Directory Service supplied their current Army or civilian addresses, with the dates of transfer, and also supplied information concerning the dates of transfer to other theaters or of evacuation to the Zone of Interior. If the soldier had been sent to the Zone of Interior, it was frequently possible to determine whether he had been evacuated from a hospital, sent home on furlough, or assigned to new duty. These data permitted reasonable assumptions as to the type of duty performed since operation and, in many cases, based on time length of time spent on each assignment, permitted assumptions as to the efficiency of his performance.
The reports of time Adjutant General`s Office on theater strength and on the number of weekly admissions for injuries provided background material against which the importance of injuries of the meniscus could be assessed.
Material from the 26th General Hospital (129 cases) was analyzed separately. This hospital supported the Army Air Forces, and such hospitals, as already pointed out, occupied a somewhat special position.
Essential data. – In the 14 general and 22 station hospitals of the Mediterranean theater which were surveyed by the plan just described, there were 1,527 admissions for injuries of the meniscus during 1944. Elimination of duplicate admissions, of cases in which the records were too fragmentary for use, and of the 129 Army Air Forces cases reduced the number to 960 cases. Six hundred and eighty-four of these nine hundred amid sixty patients were treated conservatively in the theater or returned to the Zone of Interior for surgery, and 276 were submitted to arthrotomy in the theater.
The 684 patients treated conservatively spent 18,588 days in the hospital, an average of 27.2 days per soldier. Their disposition was as follows:
Discharged to category A (full military duty), after spending a total of 5,961 days, and an average of 22 days, in the hospital, 271 patients (40 percent).
Discharged to category B (limited duty), after spending a total of 9,922 days, and an average of 30.72 days, in the hospital, 323 patients (47 percent).
4The data could not be secured early enough for publication in the March report and were analyzed personally later, after all the material became available.
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Classified to category C (evacuation to the Zone of Interior), after spending a total of 2,705 days, and an average of 30 days, in the hospital, 90 patients (13 percent).
The 276 patients treated by arthrotomy were classified as follows on their discharge:
To category A, after spending an average of 57.2 hospital days, and an average of 46.15 postoperative days, in the hospital, 132 patients (48 percent)
To category B, after spending an average of 74.61 hospital days, and an average of 60.15 postoperative days, in the hospital, 120 patients (43 percent)
To category C and returned to the Zone of Interior, after spending an average of 86.71 hospital days, and an average of 69.79 postoperative days, in the hospital, 24 patients (9 percent).
The proportion of patients returned to category A duty after arthrotomy was substantially the same in both 1943 (46 percent) and 1944 (48 percent.) The difference in those returned to category B duty in the 2 years was also not great (39 percent in 1943 and 43 percent in 1944). What is more significant is that these percentages do not differ very greatly from the percentages of patients returned to category A duty (40 percent) and category B duty (47 percent) in 1944 without operation. To express it differently, even the very careful selection of cases practiced in 1944 did not materially improve the chances of returning a soldier to useful duty in the theater after arthrotomy, while it took at least twice as long to accomplish by surgical measures substantially the same results as could be achieved without surgery.
The reduction in hospital-stay days, including postoperative-stay days, in 1944 as compared with 1943, undoubtedly reflected a better selection of cases for surgery. The averages were often considerably immersed by unsuccessful attempts at conservative therapy, which in some instances lasted as long as 90 days. It is not entirely accurate to charge this time against surgical cases, but the error, such as it is, cannot be avoided. A more or less prolonged trial of conservative therapy will usually be necessary in the management of a condition so difficult to evaluate as the recurring meniscus syndrome. The decrease in hospital-stay days in 1944 was largely due to the elimination from the surgical series of patients within atrophic quadriceps muscles, relaxed collateral ligaments, and a tendency to psychoneurosis and emotional instability. These are the patients who always remain in the hospital for long periods of time after operation.
It is unfortunate that the basis of comparison and the estimation of results in these two series must be classes of disposition, but in the 1943 series no figures on actual duty performance could be secured for comparison. Furthermore, the classification to duty at the time of discharge from the hospital did not necessarily indicate the type of duty to which the soldier would be assigned when he left the replacement depot or conditioning camp.
When the 1944 survey was undertaken, there was a general feeling in the theater that the performance of the patients returned to duty--and particularly to full duty--was probably less good than the discharge classifications would
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seem to imply. The attempt at followup studies in the 1944 survey was intended to settle this question by the indirect evidence of the length of time the soldier remained in the particular duty to which he had been assigned.
This information was available in 269 of the 276 cases in which arthrotomy was performed. The length of time followup ranged from less than 3 months to 9 months. Duty of less than 3 months was not regarded as evidence of satisfactory performance. On these criteria, when the investigation was concluded, 109 of the 132 troops assigned to full duty (82.6 percent) were still performing their duties satisfactorily, as were 105 of the 120 assigned to limited duty (87.5 percent). If these figures can be accepted at their face value, the results of arthrotomy in selected cases in 1944 were reasonably satisfactory
Results of arthrotomy in the 26th General Hospital. – The 26th General Hospital, as already noted, was surveyed separately because of its predominantly air personnel. The orthopedic section of this hospital made the diagnosis of injury of the semilunar cartilage 224 times in 1944. One hundred and nineteen patients were hospitalized, of whom 65 were treated conservatively and 54 by surgery. Fifty-two of the surgical histories were sufficiently detailed for analysis
The 65 patients treated conservatively spent an average of 15.74 days in the hospital, as compared with an average of 27.2 days for the 684 patients treated conservatively in other branches of the service. A total of 95 percent were discharged to full or limited duty (chiefly full duty) as compared with a total of 87 percent (chiefly limited duty) in ground troops.
The 52 arthrotomized patients spent an average of 42 days in the hospital and an average of 29 postoperative days, against 64 days and 52 days, respectively, for ground troops. Ninety-eight percent were discharged to full or limited duty (chiefly full duty) against 91 percent for ground troops. At the end of the survey, 76 percent of those discharged to duty were known to be performing their duties, against 71 percent for ground troops. The probable reasons for better results in elective surgery in Army Air Forces patients have already been discussed (p. 277).
Previously arthrotomized soldiers. Seventy patients who had previously been subjected to arthrotomy were admitted to hospitals in the Mediterranean theater during 1944. It had been expected that a great deal of useful information could be obtained from this group, but the expectation was not realized. The surgery had been performed in overseas hospitals in only 16 cases, and only in these cases was it possible to learn the details of the previous operations If, however, this small group is representative, it suggests that arthrotomy in an overseas theater is an operation of doubtful value, for only 5 of the 16 could be returned to duty after their period of hospitalization. The other 11 were sent back to the Zone of Interior, in 8 instances specifically because of unstable joints or severe synovitis.
In 19 other cases, the soldiers had demonstrated their ability to perform useful duty after surgery, at least for a certain period of time. Most of them had done full duty, for an average of 15 months. The results of surgery,
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however, were not permanent. When they were discharged from the hospital on their second admissions in 1944, only 4 of the 19 could be reassigned to full duty, and 7 had to be returned to the Zone of Interior. Moreover, of time 12 assigned to some duty in the theater, only 9 were still assigned to it at the time of the followup investigation in 1945
Comment. – Although the statistical data in this survey were disappointing, they were sufficient to indicate trends and to substantiate, in large part, clinical impressions. The important considerations of the study were as follows:
1. Time frequency of these knee injuries was greater than had been realized Statistics furnished by time Adjutant General`s Office, Mediterranean Theater of Operations, indicated that on any given day in the theater 4,811 patients were hospitalized as the result of nonbattle injuries and that injuries of the meniscus were responsible for approximately 2.81 percent of these admissions These figures took no account of the large number of patients with this type of injury who were under treatment while on a duty status in the orthopedic clinics throughout the theater. The inclusion of these figures would have increased the proportion of meniscus injuries, though by how much is not known.
2. Many of the difficulties were the result of old athletic injuries. A surprising number were blamed on obstacle courses in basic training. A good many of the more recent injuries were caused by falling or by twisting the knee on night problems or on patrols on rough or mountainous terrain Some injuries were traced back to precipitate motions while under fire and in this sense were combat. incurred. Drunkenness was an influential factor in a few cases
3. Accurate diagnosis was often difficult because the history, sometimes deliberately and sometimes unconsciously, was colored by the soldier`s desire to use the knee injury as a means of avoiding combat dangers. The symptoms of a trick knee were sufficiently well known to occasional soldiers for them to be able to recite histories which, although false, were extremely convincing. The surgeon had to keep an open mind, so that his experiences with actual malingerers and within patients who exaggerated their complaints would not lead him, unconsciously, into considering all soldiers in this unfavorable light.
4. The diagnostic problems raised by the unreliability of many histories were increased by the meager objective evidence which these patients so often presented. One of the most useful objective signs was atrophy of the quadriceps; this process tends to occur rapidly after any knee injury, and its absence always led to suspicion of the seriousness of the soldier`s complaints.
5. Although roentgenograms were made routinely, they were usually were negative. They were chiefly useful in ruling out chip fractures and osteochondritis dissecans.
6 Generally speaking, a patient who presented himself with a locked knee which could not be unlocked by a few days of traction became an automatic candidate for surgery. He was totally disabled, and he could become of military usefulness only when the acute condition was relieved. Manipulative reduction under anesthesia was substituted for arthrotomy if there was any
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contraindication to the joint operation. If the roentgenograms revealed osteoarthritis, manipulative reduction was usually used.
The patients whose knees were either unlocked on admission or could be readily unlocked with traction sometimes told a story of recurrent locking. The problem in these cases was not one of diagnosis but one of expediency.
The decision to perform operation or withhold it had to be based on the possibility of the individual soldier`s future usefulness in the theater and the length of time it would take in the hospital and in rehabilitation for him to achieve a duty status. Statistics for the theater indicated that even in carefully selected cases, return to full military duty could be accomplished in less than half of all arthrotomized patients. Of the surgical cases surveyed in 1945, 82.6 percent of the 132 troops assigned to full duty were successfully performing their duties from 3 to 9 months after operation. Only 16 of the 109, however, 14.7 percent, were serving with infantry units, in which the need was greatest and combat was most arduous and most dangerous
Routine classification for temporary limited duty for all arthrotomy cases, with special care in assignment to duty, might have been a better solution than the attempt, so soon after surgery, to distinguish between soldiers fit for full duty and those fit only for limited service. This plan would have been effective, however, only if each case could have been carefully reviewed within a minimum of 90 days by a board of medical officers well versed in knee-joint surgery. Such a policy would have resulted in shortened hospitalization and more satisfactory final disposition of these patients Without a specially qualified disposition board, it would not have been effective, and the system employed probably gave about as good results as could have been expected.
7. The prognosis for arthrotomy for knee injuries was much less favorable in overseas hospitals than civilian experience might suggest One reason was that the patients could not receive the close personal attention from the surgeon which is so desirable in such operations. A postoperative routine of quadriceps exercises, for instance, often had to depend for its success on such attention as overworked ward personnel could give to it; when battle casualties were numerous, attention to such refinements was necessarily scant. The chief difference between military and civilian practice was that some soldiers regarded the hospital as a haven from the dangers of battle, and their cooperation in rehabilitation exercises was a good deal less than enthusiastic.
The comparison between a football player with a knee injury and a soldier within the same type of injury, although often made, was never sound. Because athletes can return to violent activity on the football field within 6 to 8 weeks after menisectomy, it did not follow that soldiers could return to combat duty within a similar period of time. The circumstances are widely different. The injured athlete, outside of the game, is in the hands of a trainer and has access to heat lamps, massage, and other forms of therapy. When he goes on the field, his knee is well strapped. He remains in the game for only brief periods at first and may be removed on the first indication of trouble. Even at its
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roughest, a football game is divided into alternate periods of action and rest, and at the most only an hour is spent in actual play.
The lot of an infantryman is very different. He must carry heavy packs and equipment many miles over rough ground or mountainous terrain, often in darkness, often in rain, snow, or mud. He cannot, like the football player, leave the game He must continue until his mission is accomplished, even if his knee swells and is painful. When he has an opportunity to rest, it is likely to be in a wet foxhole, often in cold and freezing weather. The commanding officer of a combat unit cannot always, like a football coach, consider his men first and the outcome of combat next He must utilize every man at his disposal A man unable to keep up with his comrades is a liability.
The chief fallacy of the comparison concerns morale. The football player, anxious to retain his place on the team, cooperates in every effort at rehabilitation. The infantryman has only his sense of duty to urge him back to combat Every instinct of self-preservation makes him call attention to any symptom from his knee. It requires a man of strong character to return to combat and to stay in it in spite of a knee which swells and becomes painful when it is overtaxed This is why such stress was put upon a favorable mental attitude as an absolute prerequisite to surgery of the knee joint in any theater of operations.
Technical considerations. – Techniques of menisectomy were practically the same in all hospitals in the Mediterranean. Tourniquets were used universally. A straight, short incision medial or lateral to the patella was also used universally; sometimes it was curved into a J or a reverse J. Retractors were employed, of such shapes as to minimize intra-articular trauma.
An attempt was always made to remove as much of the cartilage as possible through the anterior incision A separate posterior incision was sometimes made to insure that it had been entirely removed. The trend to total removal of the cartilage through two incisions became somewhat more marked as the war progressed. When the cartilage was entirely in the intercondylar notch or when it could be placed in it after lateral dissection, total removal was effected, for all practical purposes, through an anterior incision only. If a half inch or so was left in situ, no difficulties need be expected When, however, the cartilage could not be displaced into the notch, it was best to make a separate incision posteriorly to remove the remaining inch or inch and a half. The majority of surgeons excised the fat pad only if it was swollen and appeared chronically inflamed. Routine removal was not practiced because postoperative effusions, which required aspiration, seemed somewhat more frequent when the pad was removed
One hospital which used sulfanilamide powder in the joint in about half of its cases discontinued the practice which postoperative synovial thickening was found to be more frequent than in the cases in which the sulfa drug was omitted. One or two hospitals used a posterior plaster slab for a week, but pressure dressings alone were most often employed.
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Preoperative and postoperative quadriceps exercises were always stressed. One or two hospitals permitted weight bearing on the second or third postoperative day and encouraged rapid return to complete ambulation. The majority of surgeons preferred to delay weight bearing until 7 to 10 days after operation and to keep the patient on crutches for the next 2 or 3 weeks. Whatever the practice, care was always taken to see that the ability to extend the knee completely was not lost.
JOINT MICE (OSTEOCHONDRITIS DISSECANS)
Loose bodies in the joint and osteochondritis dissecans are conveniently discussed together. They are related clinically and the terms were often used interchangeably on the histories examined in Mediterranean-theater hospitals. It must not be inferred, of course, that all loose bodies observed were the result of osteochondritis dissecans. The term is technically reserved for those cases in which a definite defect of the articular surface is demonstrable by roentgenograms or at operation. The defect may contain an avascular osteocartilaginous body, or the affected nodule may have been extruded into the joint cavity.
Osteocartilaginous loose bodies were not seen frequently enough in Mediterranean-theater hospitals to be regarded as a common cause of disability. They were, however, encountered often enough to warrant the adoption of a policy for their management.
Data sufficient for evaluation of the usual methods of treatment in this condition were secured from the 12th, 33d, and 45th General Hospitals. A total of 29 arthrotomies was performed for joint mice in these 3 hospitals over the same period in which about 84,500 patients were admitted for all causes. Of the 29 operations, 22 were on the knee, 4 on the elbow, and 3 on the ankle joint.
Avascular nodules were removed from craters in the femoral condyle in 4 of the 22 arthrotomies on the knee joint; the crater was then curetted, and overhanging articular cartilage was removed. Two patients were discharged to limited duty, and the other two were evacuated to the Zone of Interior. Ten of the remaining patients, who presented defects of the patella or who required no treatment of the crater, were discharged to full duty, and five others with the same conditions were discharged to limited duty. The disposition of three other patients in this category is unknown.
Three of the four patients operated on for loose bodies in the elbow joint were returned to full duty. The disposition of the fourth case is unknown. All three patients subjected to arthrotomy of the ankle joint were classified to limited duty.
Statistical conclusions would not be warranted in so small a number of cases, but discussions with many orthopedic surgeons in the Mediterranean theater permit certain generalizations. Disposition to appropriate duty without arthrotomy was recommended when the loose body was not producing
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symptoms and did not change its position on repeated roentgenologic examination. This policy avoided the loss of service time and conserved hospital space and medical effort If the symptoms were troublesome, the policy depended upon the joint affected In a non-weight-bearing joint such as the elbow, which was otherwise adequate, the results of surgery were likely to be good and return to duty reasonably prompt If a weight-bearing articular surface was affected, especially if the defect was large, it was unlikely that the results would be good enough and return to duty prompt enough to justify operation in an overseas theater. In any event, surgery for joint mice amid osteochondritis dissecans was permitted only by qualified orthopedic surgeons, only in general hospitals, and only after complete investigation of the patient as well as his orthopedic status.
RECURRENT DISLOCATIONS OF THE SHOULDER
The lack of uniformity in the management of recurrent dislocations of the shoulder in the hospitals of the North African theater early in the war was officially eliminated in November 1943 when Circular Letter No. 48 was issued from the Office of the Surgeon, North African Theater of Operations. A previous history of recurrent dislocation of the shoulder was not to be accepted per se if it rested on the soldier`s testimony. Instead, diagnosis was to be made only if a history of one or more episodes, preferably with supporting roentgenologic evidence, appeared on the Army medical record. Operation was to be undertaken only with the written approval of the disposition board of a general hospital following demonstration that the disability was such as to prevent noncombat duty and then only when the soldier`s age and mental attitude offered reasonable prospect of military rehabilitation.
Guided by these general instructions, an experienced surgeon was permitted to formulate his own policies of management and select such surgical techniques as he preferred.
Survey of cases. – In an effort to determine the effectiveness of this policy, a survey of the cases observed in the theater in 1944 was carried out in 1945, by the plan already described for derangements of the knee joint. The survey covered the experiences of 16 general and 25 station hospitals. Five other hospitals were not surveyed, for one reason or another, but it was not thought that the small number of patients missed wound in any way alter the value of the investigation. Data were not available from all hospitals for all items desired.
In all, there were 314 admissions for this cause during 1944, 71 of which were duplicate admissions, which reduced the number of cases to 243. Thirty-eight of the 243 patients were treated by surgery and 205 by conservative measures. Operation would have been justified in almost all of these patients in civilian life, and the fact that only 15 percent were submitted to surgery indicates an extremely conservative attitude toward surgery for recurrent dislocations of the shoulder in a theater of operations.
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The 205 patients treated without operation on whom information as to disposition was available spent a total of 3,566 days in the hospital, which is all average of 17.4 days. Disposition was as follows:
Discharged to full duty, after spending a total of 1,224 days, and an average of 13.02 days, in the hospital, 94 patients (46 percent).
Discharged to limited duty, after spending a total of 1,736 days, and an average of 21.17 days, in the hospital, 82 patients (40 percent).
Classified to category C, after spending a total of 606 days, and an average of 209 days, in the hospital, 29 patients (14 percent).
The 30 (of 38) patients treated surgically on whom information as to disposition is available spent a total of 1,874 days in the hospital, which is an average of 62.47 days. Disposition was as follows:
Discharged to full duty after spending a total of 515 days, and an average of 51.5 days, in the hospital, 10 patients.
Discharged to limited duty after spending a total of 1,359 days, and an average of 67.95 days, in the hospital, 20 patients.
There were no category C dispositions in this group. If the original category A and B dispositions could have been maintained, on which matter there is no information, these are reasonably satisfactory results.
One hundred and twenty of the 205 patients not operated on were discharged from general hospitals and 85 from station hospitals. The proportionate distribution of the various types of disposition showed considerable differences in the two types of installation. In the 16 general hospitals included in the survey, 30 percent (36) of 120 patients were classified as category A, 50 percent (60) as category B, and 20 percent (24) as category C. In the 25 station hospitals, the respective proportions were 68 percent (58) category A, 26 percent (22) category B, and 6 percent (5) category C. Both the total-and the average-stay days were also materially fewer in the station hospitals.
At first glance, it is hard to see why the results in the station hospitals should be, apparently, so much more favorable than in the general hospitals. Superiority of treatment does not explain it, for the same conservative measures, chiefly rest and physical therapy, were used in both. Analysis of the preliminary figures seems to furnish the explanation, which is that considerable number of the patients discharged from the general hospitals had been transferred to them from station hospitals, chiefly, it would seem, because they presented problems of management and disposition. These patients required a longer time for investigation and in general represented a less favorable group of cases. They therefore, it is reasonable to assume, not only increased the average period of hospitalization in general hospitals but also required a greater percentage of category B and C dispositions in those institutions. It also seems probable that the attitude toward disposition was more conservative in general hospitals and the criteria for category A disposition somewhat stricter, than in station hospitals. Disposition in noncombat injuries of all sorts was always a matter of judgment, not of rules, and neither documentary minor statistical data are available to confirm or disprove this reasoning.
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It should be borne in mind, in interpreting these statistics, that most admissions to station hospitals were noncombat troops and that admissions to general hospitals were combat troops plus transfers from station hospitals. Station hospitals would therefore be expected to make more category A dispositions.
Comment. – The relative frequency with which recurrent dislocation of the shoulder was encountered in the Mediterranean Theater of Operations was frankly surprising to some orthopedic surgeons, who regarded the number of cases as disproportionately great in comparison with civilian experience. As a matter of fact, the actual number of cases observed was considerably greater in 1944 than the 243 upon which this discussion is based. This number makes no allowance for the soldiers treated on a duty status in dispensaries and outpatient clinics. What proportion of the total cases is represented by the 243 cases treated in hospitals it is not possible to say. It is clear, however, that these soldiers furnished a serious medicomilitary problem. Their disability made them an actual loss to their organizations and also required the utilization of medical personnel and hospital facilities, sometimes for long periods of time.
Before the management of any case of recurrent dislocation of time shoulder was decided upon, it had to be evaluated individually, in the light of the following considerations:
1. It had to be established that the lesion was a true dislocation. It was not uncommon to find that what a patient called a dislocation was simply a relaxation of the joint, associated with frequent subluxations and a general feeling of instability. An occasional soldier could produce, at will, luxation of sufficient extent to be demonstrated to the medical examiner. Some, who were malingerers at heart, could furnish a glib history of numerous previous recurrences. A careful series of questions and a careful physical examination usually settled the matter, but many a medical examiner, in these circumstances, was glad to be able to fall back on the instructions in North African Theater of Operations Circular Letter No. 48, that there must be a definite Medical Department record of a previous dislocation or a supporting roentgenogram before the diagnosis was made or concurred in.
2. The degree of disability caused by the lesion had to be determined. Intelligent management and disposition were impossible without such an evaluation. Dislocation of the shoulder was seldom completely disabling except for a brief period following the actual luxation. The type of dislocation followed by partial disability for a few days or even a few weeks was the variety most often seen in Army orthopedic clinics. It rendered the soldier unfit for combat infantry duty, as well as for certain other types of duty, but still permitted him to handle many useful assignments without danger of serious or permanent injury to himself.
In some cases, the dislocation recurred frequently, sometimes every few weeks. There was no pain between the episodes, and no disabling muscle atrophy occurred. Fear of recurrence, however, materially reduced the soldier`s efficiency and in a sense made him chronically disabled; he tried not
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to abduct his arm because he was afraid of producing a recurrence. This type of lesion was amenable to surgery; it was fear rather than the lesion per se which disabled the patient. On the other hand, surgery promised very little from the standpoint of returning him to useful duty if muscle atrophy or painful tendinitis was part of the clinical picture. In such cases, it was best to defer disposition as long as possible and permit the soldier to continue in his current assignment. A patient in this condition was practically never found in frontline service, and the outcome of operation sometimes resulted in his further downgrading.
3. When a case suitable for surgery was encountered, two points had to be settled before operation was recommended. The first was whether the prognosis with surgery was good for some form of duty in the theater. If it was not, operation was not justified overseas, and the correct policy was either to continue the soldier in his current assignment, if he were capable of performing his duties, or to return him to the Zone of Interior for surgery. The second point was related to the first. What was the man`s mental attitude? This consideration always had at least as much to do with the decision to undertake surgery as did the physical lesion, and in some instances it had more to do with it
4. The final consideration was the essentiality of the soldier. Key personnel were sometimes operated on overseas, in disregard of ordinarily accepted criteria, because they were regarded as useful or essential. Nonessential men were left in their current status or, if surgery was clearly indicated, were returned to the Zone of Interior for treatment.
FRACTURES OF THE CARPAL SCAPHOID BONE
The results of time methods used in fractures of the carpal scaphoid bone during the North African campaign were not conclusive, and considerable doubt was felt as to the soundness of the techniques employed and the criteria of disposition. Circular Letter No 48, Office of the Surgeon, North African Theater of Operations, 1943, offered guidance in the management of this injury as follows:
Greater care mast be exercised in making a precise and prompt diagnosis of carpal fractures and dislocations, since early reduction is essential for a satisfactory result. Surgical treatment of an old, unrecognized fracture of the scaphoid will not rehabilitate a soldier. If his disability is complete, he should be transferred to the Zone of Interior.
The exact method of treatment was left to the decision of the surgeon who encountered the case, and disposition was according to the judgment of time disposition board of each hospital.
Survey of cases. – In an effort to determine the effectiveness of the methods employed in the management of fractures of the carpal scaphoid bone, a survey of the cases observed in the theater in 1944 was carried out in 1945 along the general line of the plan described for derangements of the knee joint
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Because of the nature of this injury, the circumstances of this survey and of the surveys already described were not entirely similar. As in the other investigations, no account was taken of patients not hospitalized for their injuries, which means that the number of carpal scaphoid fractures analyzed does not nearly indicate the total number of cases observed. This injury was often treated in outpatient clinics, without hospitalization. At the 182d General Hospital, for instance, there were no admissions for this cause during 1944, but 50 carpal scaphoid fractures were treated in the outpatient clinic Unfortunately, the records for outpatient clinics were generally so fragmentary as to make their use in this investigation worthless.
Patients with fractures of the carpal scaphoid bone, particularly in station hospitals, were often discharged to duty or to quarters status after the fracture had been reduced and they had adjusted themselves to their casts, the remainder of their treatment being conducted in outpatient orthopedic clinics. As a result, the figures collected for hospital-stay days do not meanly reflect the length of the required for return to duty or other disposition They merely show the length of the hospital facilities were utilized in the care of carpal scaphoid fractures and do not indicate the length of time the men affected were unable to perform useful duties for their organizations.
The information analyzed includes data from the hospitals transferred to the European theater after the invasion of southern France. These hospitals, however, were not asked to supply the number of carpal scaphoid fractures in the hospital 1 March 1945, as, obviously, no such patients were from the Mediterranean theater. On this date, there were 58 patients with carpal scaphoid fractures in the general and station hospitals in the Mediterranean theater. Admissions for noncombat injuries during the week ending 1 March 1945 had numbered 3,335. This means that fractures of the carpal scaphoid bone accounted for 1.73 percent of all such admissions.
During 1944, 16 general and 23 station hospitals in the Mediterranean theater reported the admission of 291 soldiers with fractures of the carpal scaphoid bone The number of cases available for analysis is reduced to 180 by the elimination of 92 duplicate admissions and of 19 other cases in which the records were too incomplete to be used. Disposition of these patients was as follows:
Returned to full duty, after average hospitalization periods of 44.89 days, 128 patients (71 percent).
Returned to limited duty, after average hospitalization periods of 79.21 days, 27 patients (15 percent).
Classified to category C, after average hospitalization periods of 49.28 days, 25 patients (14 percent).
Since the average time for the healing of carpal scaphoid fractures is 3 to 4 months, no clinical significance can be read into the figures for hospitalization. Most of the category A and B dispositions must have been made with the hand and forearm still in plaster, the patients being assigned to light duties within their outfits. Whether the dispositions made when they were
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discharged from the hospital prevailed when the casts were removed it is not possible to say.
Methods of management. – Although no theaterwide policies of management were established, orthopedic surgeons all tended to use the same general principles in carpal scaphoid fractures. Both military and civilian experience indicated that one routine was required for recent or fresh fractures and another for old fractures. The prognosis of fresh fractures was good if early, efficient immobilization was instituted and was continued until union had occurred, assuming, of course, that the fragments were in good position. The prognosis was less good, and was often poor, if adequate treatment was not begun within the first few days after the injury or if immobilization was inadequate or was not continued until healing occurred. If the blood supply of the fragments, as demonstrated by roentgenograms, remained adequate, healing could be expected under proper management in 3 to 4 months. If one or more of the fragments was avascular, healing was likely to be delayed and was frequently unsatisfactory.
The following principals, based on these concepts, were followed by many surgeons in the theater. If they had been universally adopted, most of the poor results observed in these injuries would have been avoided.
All sprains of the wrist were examined roentgenologically, within the idea of demonstrating or eliminating possible fractures of the carpal scaphoid bone. This was an essential precaution. In the orthopedic clinic of the 182d General Hospital, all nine of the old carpal scaphoid fractures which had to be treated for nonunion had been regarded as sprains when they were sustained and had not been correctly immobilized. The situation was entirely different in 41 fresh injuries, which were recognized as soon as they occurred and when promptly and properly immobilized. Healing was complete in every instance within 12 weeks, and the fracture line had usually disappeared entirely by this time. A smaller series from the 46th General Hospital also pointed to the role of the missed fracture in poor results In this hospital, disposition-board records showed that 6 on 7 nonunions of carpal scaphoid fractures occurred in cases in which early care had not been given, while the course of 12 promptly treated fractures was uncomplicated and satisfactory.
If a fracture was not demonstrable in time roentgenograms but it still seemed likely that the bone had been broken, the wrist and thumb were put up in a plaster cast. The cast was removed cautiously at the end of 2 weeks, and additional roentgenograms were made. A new cast was applied if a fracture was visualized on these films.
If a fracture was visible in tine first roentgenograms, a plaster cast was at once applied. It included the forearm and hand, with the thumb encased to the distal joint. The wrist was in dorsiflexion and radial deviation, and the thumb was abducted and in the position of semiapposition. The cast extended only to the distal palmar crease and allowed free finger motion, which made it practical for the patient to use his hand for light, simple work. He was told
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that correct immobilization would determine the end result and was instructed to report to the clinic as soon as the cast became loose or soft.
The cast was removed between 6 and 8 weeks after it was applied, and additional roentgenograms were made. At this time, it was possible to determine the vascularity or avascularity of the fragments and to arrive at some decision as to disposition If calcification seemed to be proceeding and union to be occurring, the prognosis was considered good, and the patient was retained in the theater of operations for further treatment. If the relative density of one or more fragments indicated avascularity, the prognosis was not considered good The healing process in such a case was likely to be prolonged, possibly requiring many months, and unless treatment could be continued in an outpatient dispensary disposition to the Zone of Interior was recommended. Continued use of overseas hospital facilities was not regarded as justified under these circumstances.
Complete, sound healing of a carpal scaphoid fracture could be assumed only when the fracture line had completely disappeared. Immobilization was necessary until there was roentgenologic proof that this had occurred.
Old carpal scaphoid fractures, which had been unrecognized or had been treated improperly, were likely to show nonunion: avascular necrosis; and traumatic arthritis, within instability of varying degrees. Some soldiers with lesions of this kind could perform combat duty. Others suffered from so much pain and weakness that they were more or less disabled and were often unfit even for limited duties.
The procedures employed to correct the consequences of neglected carpal scaphoid fractures included drilling, bone grafting, excision of the fragments, or prolonged immobilization. All gave uncertain results and treatment was likely to be time consuming. Such methods were therefore not indicated in a theater of operations unless the particular officer or enlisted man was performing essential duties and the prognosis in the case was particularly favorable.
Careful evaluation and correct disposition of patients provided the answer to the problem of old carpal scaphoid fractures A period of observation, during which rest and physical therapy were employed, might promise enough improvement to justify assignment to limited service or even to full duty. If treatment was likely to be prolonged, however, it was not logical to institute it overseas If the soldier`s disability prevented his performing even limited service in the theater, the better plan was prompt evacuation to the Zone of Interior.
Ninety-five records of old carpal scaphoid fractures were available from analysis in the 1944 survey Less than half of the soldiers (40) could be returned to full duty, after spending an average of 23.23 days in the hospital and unknown periods of the in further treatment in outpatient clinics. The remaining patients were almost equally distributed between categories B and C. The hospital-stay days in the category C group averaged 31.54 days and in the B group 19.41 days. There was no economy of military manpower and medical facilities in these results.
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Principles of disposition. – In carpal scaphoid fractures, as in other noncombat injuries in which the symptoms were chiefly subjective, the mental attitude of the patient was of primary importance in determining his disposition. Exaggeration of minor difficulties was often suspected but was extremely difficult to prove. The soldier who persisted in his complaints was usually, therefore, successful, at least eventually, in his attempts to avoid duty. Frequently he had to be given the benefit of the doubt. The disposition board had the major responsibility of conserving manpower for combat, but it had an equally important responsibility in limiting the duties of soldiers to work which they could reasonably be expected to perform successfully and perform without injury to themselves.
