War Surgery and Medicine
FIRST WORLD WAR
FIRST WORLD WAR
THE treatment of fractures during the First World War underwent considerable development as regards both wound treatment and splintage. The development of wound treatment of fractures is naturally just part of general wound treatment, which has been already described in another chapter.
The only special aspect is the treatment of the actual bone itself. It was the custom to remove any loose portion of bone, which would naturally be without blood supply, and in the presence of infection would become a sequestrum. Sequestration was common, and till the dead bone was satisfactorily removed final healing could not take place. In the treatment of chronic bone infection, and after the removal of sequestrae, BIPP paste was often used. The removal of all loose bone, often too rigorously carried out, led to many severe cases of non-union. Secondary suture of wounds complicated by fractures was not often undertaken, but it was done in cases of late removal of sequestrae.
The association of joint injury and subsequent infection led to serious toxaemia, and amputation was often found necessary. Dependent spreading abscesses in the back of the thigh were frequently encountered, and drainage was resorted to freely in these cases and for any gross infection. Long-continued infection was common in the first part of the war, but during the last year of the war the picture became much more cheerful, and in the majority of cases sepsis was well controlled by the Carrel-Dakin treatment, toxaemia was uncommon, and the wounds healed much more quickly.
At the beginning of the First World War splinting was so unsatisfactory that the majority of men with fracture of the femur died. The splints used were archaic and provided no proper stability to the limb. Long Liston splints were generally applied to fractures of the femur. When the Thomas splint was introduced the whole picture changed, and the mortality in cases of fracture of the femur fell dramatically from 70 to 30 per cent. The splint was thereafter used as a routine for all fractures of the long bones of the lower limb, and also for all injuries of the knee joint. Attachments page 279 were made, such as the iron foot-piece, to allow suspension of the foot and support for the splint, and an extra movable leg-piece to permit movement at the knee joint. Special wooden foot-pieces for glueing to the soles of the feet were used as a means of extension and accurate fixation of the position of the foot. Extension was obtained by glue bandage, by strapping to the limb, or else by the foot-piece described. Rubber slings were made out of the inner tubes of tires and fixed by strong bulldog clips to the sides of the splint.
The Thomas splints were suspended by cord to Balkan beams, and special fracture wards had framework put up to fulfil the same function. Fixed extension was usual, the foot of the bed being raised, but weight extension was also used.
Fractures of the leg were treated in the same way, the glued foot-piece being more often used for extension. Injuries of the knee joint were also treated in the Thomas splint with some extension. Hip-joint cases were treated in Balkan frames.
In the upper limb the straight-arm Thomas was used for severe cases, with extension to the end of the splints, also slung up by cords. A Jones splint, bent at a right angle at the elbow, was used for fractures of the lower part of the humerus, the elbow, and the forearm. Abduction splints were utilised as an ambulatory splint for fractures of the shoulder and humerus, as well as for muscular and nerve injuries.
The Carrel-Dakin treatment, with the constantly soaked dressings and frequent changes required, was facilitated by the use of the Thomas splint with its narrow iron bars. The utilisation of cords and pulleys enabled the patient to move in bed, and made nursing much less onerous. The results obtained towards the end of the war were generally excellent as regards length and alignment of the limbs and healing of the wounds.
There remained the question of sequestration and chronic osteomyelitis and the stiffness and wasting of the limb. Stiffness in the joints of the limbs after prolonged treatment and fixation was frequently seen, especially in the earlier years of the war. Much attention was directed to the functional rehabilitation of the limb in the later stages of the war, and physiotherapeutic treatment was assiduously applied, as was re-education of muscular and joint movements. Sir Robert Jones made a great contribution to the treatment of these injuries, and Sinclair, in France in his special unit, made important contributions to the treatment of leg fractures, and demonstrated what excellent results could be obtained. It was Sinclair who introduced the method of extension by glue and the wooden foot-piece.page 280
The French surgeons utilised free drainage of fracture and joint injuries by means of rubber tubes, and carried out rigid plaster immobilisation for long periods.
The improvements carried out in the war persisted into the peace, and army methods were used in civilian work. For the treatment of chronic osteomyelitis the Winnett Orr technique began to be used with success.
Winnett Orr described his treatment as embodying early reduction, rigid immobilisation, drainage, rest, and absence of dressings. His technique consisted of reduction of the fracture on a traction table; débridement, followed by swabbing the wound with iodine in alcohol; packing of the wound with vaselined gauze from the depths to the periphery, with dry dressings on top; putting the limb in a plaster cast incorporating a traction pin; no dressings for four to eight weeks; and changing the plaster on the operating table with full aseptic precautions when the odour became unbearable.
He maintained that no plaster cast caused constriction if properly applied, and that frequent dressings caused infection. With adequate surgery, complete rest, and no dressings the patient's own defences were usually adequate. He reported a series of 268 compound fractures, of which 259 had healed. There were three deaths but 90 per cent good results. The technique depended on a fracture table being available. The good results can be ascribed to the complete rest and to the prevention of cross infection.