War Surgery and Medicine
TREATMENT OF INDIVIDUAL FRACTURES
TREATMENT OF INDIVIDUAL FRACTURES
Fracture of the Humerus
Plaster was generally used for the splinting of fractures of the humerus in the forward areas, and at the Base. Kramer wire was frequently used in the forward areas as a temporary splint till operation was performed. The most common method of application of plaster, the U splint, was by means of a slab starting on top of the shoulder and carried down on the outer aspect of the arm to the elbow, then round to the inner aspect of the arm to the lower border of the axilla. This was moulded to the arm and then fixed by circular plaster bandages. A pad was placed in the axilla and then the arm was fixed to the chest by circular plaster bandages around the arm and the body, also supporting the forearm but leaving the hand free. At first there was no plaster round the body and the forearm was held up by a sling. This did not give enough stability during evacuation, and the fixation to the chest materially improved the comfort of the patient. Better fixation was obtained by an abduction arm spica, but this was impossible to apply properly at the original operation, and, if markedly abducted, created difficulties during transit in an ambulance. If the abduction plaster was applied the day after operation, with the patient sitting up, a satisfactory plaster could be put on. Abduction was, however, only of particular value in fractures at or near the shoulder joint, especially when joint fixation was feared, and the simple U plaster, slightly abducted, was generally more practicable. For fractures at the lower end of the humerus a slab was usually carried along the forearm to the wrist, the elbow being fixed at a right angle, with the forearm in mid position. At the Base, plaster was generally continued and abduction plasters were more commonly employed. With the development of delayed primary suture, these fractures gave very little trouble.
In England there were two schools in regard to treatment, the one utilising plaster splint and fixation till union took place, the other using only the simplest form of splinting with a sling and encouraging free and early movement. It was held that movement page 287 encouraged union and preserved and encouraged function. Both schools agreed that early and free movement of the wrist and hand was to be encouraged.
Fractures of the Radius and Ulna
These were treated in plaster splints in the mid position of pronation and supination, the arm being in a sling and the hand free for movement. In simple fracture early excision of a dislocated head of the radius was practised if replacement was not possible. Plating of simple fracture of the radius was also carried out frequently at the end of the war.
Fracture at the Hip
The treatment of these fractures was very difficult under war conditions, especially when there were extensive wounds in the buttock region, a not uncommon complication. A plaster spica was the only method of obtaining fixation and stability, but there were many difficulties associated with it.
In the forward areas it was difficult to apply without the help of a special orthopaedic table. An unsatisfactory spica contributed to the discomfort often experienced during transportation, and to the common development of plaster sores. Careful padding and the use of felt round the pelvis helped a good deal, but the presence of wounds under the plaster added to the difficulties. These cases were shifted as little as possible, and the New Zealand cases were retained overseas till full stability was reached. Sepsis was a very serious complication, and involvement of the hip joint always meant a dangerous illness. Penicillin was given to these patients from the beginning, as soon as supplies permitted, and continued till the fear of sepsis was over. It was also of great value in the treatment of established infection. Good drainage of the hip joint was established by chiselling the great trochanter from the femur.
Fracture of the Femur
At the beginning of the war the Thomas splint was used with the usual slings and extension. In the field the limb was often placed in the splint without removal of clothes or boots, and extension applied by a clove hitch over the boot or by a clip into the heel of the boot.
If any marked extension was applied this was found to cause sores across the dorsum of the foot. This was relieved by loosening the laces and placing a pad under the tongue of the boot, but it was soon realised that at that level all that was required was sufficient extension to steady the limb in the splint and then no page 288 injury would be caused. If time and conditions allowed, the boot was removed and elastoplast extension applied to the leg after it had been shaved.
At the forward operating centre careful wound excision was carried out, with free incision to relieve tension and transverse division of the fascia if necessary, and the usual application of sulphanilamide and dressings with vaseline gauze inserted in the wound to keep the wound open. Then the Thomas splint was applied with elastoplast extension to the limb and the ring well padded at the outer aspect to fit the limb, as normally the Thomas splint had rings much too large for proper fixation. The usual foot-piece and stretcher bars were adjusted and the 1914–18 technique completed. The desert, however, provided special difficulties, and evacuation over its rough surfaces was a trying ordeal for the patient in the ordinary Thomas splint. Plaster was then suggested as an addition to provide more stability, and this led to the development of what was called the Tobruk splint. The original Tobruk splint consisted of the application of a plaster splint for the limb from the upper part of the thigh to the toes, extension having been applied to the limb beforehand. The limb in plaster was then put into a Thomas splint. The extension was fixed to the end of the splint, and then circular plaster bandages were used round the splint and limb to fix the plastered limb securely in the splint and a pad put on the outer aspect of the ring. By this means there was very adequate stability and the patients travelled with greatly increased comfort over the desert. Instead of the complete plaster splint round the limb, which necessitated some disturbance and time, simpler methods were tried. At first the limb was fixed in a Thomas splint in the usual manner and then circular plaster bandages passed round the splint and limb as extra fixation. These bandages were apt to cut into the thigh above the page 289 knee, and the leg below the knee, and if the extension became loose there was little fixation.
Then a posterior slab was used beneath the slings from the ring to the ankle, and then circular plaster applied after padding firmly between the limb and the splint, all along the front of the limb, with thick padding of wool or gamgee, also placing rings of felt round the ankle and a pad inside the ring. After the circular plaster bandages were applied the full length of the limb to the ankle, the plaster was moulded round the bars of the splint and between the limb and splint so as to provide adequate fixation. Care was taken to apply only sufficient extension to stabilise the limb in satisfactory position. Real extension caused the ring to ride over the tuber ischii during transit, with the occasional production of sores. The Thomas splint was slightly bent at the knee and the usual foot-pieces attached. This was the method used by our New Zealand forward surgeons throughout the war, and it proved very satisfactory as well as being easily and rapidly applied.1
At the Base the Thomas splint was still utilised for treatment, with slight flexion at the knee. Weight extension was generally used, but fixed extension was also employed. The extension was obtained by Steinmann pins and sometimes by Kirschner wire inserted into the upper end of the tibia. The weight employed was calculated at two to two and a half pounds per stone body weight for four to six weeks, but generally the weight was adjusted according to the measured length of the limb and the X-ray. A weight of 15 lb. was generally satisfactory after the initial stage.
The Braun splint was also used by some surgeons, especially for supracondylar fractures, but the great majority of surgeons preferred the Thomas splint for all cases, bending it more when treating supracondylar cases.
Fractures of both femora were treated by two Thomas splints, sometimes joined together at the rings. Treatment by a double plaster spica for fractures below the level of the trochanter had the serious disadvantage of allowing the development of both angulation and shortening.
Fractures of the Patella
Fractures of the patella were of special importance because of the danger of infection in the knee joint and of the stiffness that was apt to develop in the joint following the prolonged fixation that was necessary for the healing of the fracture. If the fracture page 290 were simple in nature the danger was slight, but if severe comminution was present the danger was real. Forward surgeons treated the fractures of the patella conservatively at first but later excised the patella in any severe fracture, bringing the capsule together laterally. This facilitated early movement and resulted in surprisingly little disturbance to the knee.
Fractures of the Leg
The closed plaster treatment was employed from the beginning of the war, the plaster extending well up the thigh and enclosing the foot except the toes. The plaster was extended beyond the toes along the sole as a protection, but on the dorsum the toes were left quite free so that toe movements were permitted, and these were strongly encouraged.
With wound excision and vaseline gauze dressings there was normally no replacement of dressings till called for by the softening or serious fouling of the plaster or by complications such as serious infection. At first non-padded plasters were used, but it was found that this often led to danger of interference with the circulation of the limb. Transport caused increase of swelling and in the change of medical units detection was necessarily difficult. Padded plasters were then used and also split as an extra safeguard before the patient was evacuated. The splitting was facilitated by the introduction of a long vaselined rubber tube along the front of the leg, outside the padding, before the application of the plaster. The tube was then removed, leaving a raised arch along which the plaster could be rapidly cut up later. This remained the routine treatment throughout the war. At the Base, at first, healing was allowed to take place under the plaster. In many cases, however, it was found that the wound became unhealthy and healing was sluggish. Packing under the plaster had been noticed to dam up secretion. Windows were then left in the plasters and local applications of antiseptics made, or Thomas and Braun splints used, to allow of more satisfactory local treatment. Skin grafting was often undertaken when the wound became healthy. Closed plaster treatment was still used for the majority of the cases of fracture of the leg unassociated with definite infection, and in these cases gave satisfactory results. When penicillin became freely available, delayed primary suture was carried out when possible and parenteral penicillin utilised. There was difficulty, however, in suturing the leg wounds because of tension and frequently the skin could not be approximated. Bristow pointed out that a foot fixed in varus was a disaster and that the ankle must be splinted at a right angle.
Fracture of the Os Calcis
Severe injuries to the foot were very commonly seen as the result of mine injuries, either sustained in a vehicle or on the ground. These injuries were often so severe that amputation was inevitable, but lesser injuries were present, often not associated with an open wound. Fracture of the os calcis was common, the heel being split off and drawn up by the tendo Achilles, or else the bone split and spread out laterally. The first step in the treatment of these injuries was manipulation to bring the heel down, or moulding the fractured bone together laterally. Kirschner wires and pins were inserted into the heel to pull it down into position, and plaster was utilised to fix it in the improved position. It was found very difficult to get much improvement, and the fixation in plaster tended to delay the return of functional activity. As regards fixation, this occurred to excess in any case. So frequent were the disappointments resulting from attempts to get improved position that primary correction alone was attempted, and no splint used. Free movement was encouraged so as to preserve the functional activity of the foot and ankle, but weight bearing was delayed till stability was obtained. Much improved results were then obtained and surprisingly good function eventually was obtained in seriously damaged feet. Astragalectomy was sometimes carried out at the earlier period in an attempt to get better position, but this was later given up and condemned by the senior orthopaedic surgeons. The good functional results obtained, often in spite of misshapen feet, justified the preservation of the foot in the forward areas in many of the severe mine injuries. The conservative attitude triumphed in this as in many other directions.
Fracture of the Carpal Scaphoid
Fractures of the carpal scaphoid frequently occurred during the war and gave rise to considerable difficulty, both as regards treatment and disposal. Pre-enlistment fractures often led to disability during service; their treatment was unsatisfactory and the patients were generally graded down for work at the Base or sent back to New Zealand. Arrangements were made quite early in the war for the treatment and control of all these cases to be put under the charge of the orthopaedic surgeons, both whilst in hospital and also as out-patients.
The fracture was caused by falling on the hand, most commonly at football, and by backfiring when starting up motor engines. The early symptoms were generally not severe, and often the possibility of fracture was quite overlooked and the diagnosis made of slight sprain. Local tenderness could be located over the scaphoid.page 292
Immediate X-ray very often disclosed no sign of fracture, which would only show up three or more weeks later. It was therefore imperative that any patient suspected of having a fracture should be treated by immobilisation for three weeks on suspicion till a further X-ray was taken. A true sprain of the wrist rarely occurred, and this made the investigation of possible fracture all the more necessary.
It was found essential to apply plaster splints as soon as the diagnosis of a recent fracture was made, and to continue the splint for a minimum period of three months, and frequently longer. It was necessary to rigidly control the wrist joint and the metacarpo-phalangeal joints by extending the plaster half-way along the first phalanx. The period of immobilisation was determined by X-ray examination.
In cases diagnosed and treated shortly after the original injury the results of immobilisation were satisfactory, though many cases required very prolonged fixation. In later cases the results were not as good, though immobilisation was persisted in for long periods. The treatment of pre-war long-standing cases was still more difficult, though immobilisation following the possible further injury on service was sometimes successful if active bone was present. In some cases treatment involved drilling of the bone, in others bone grafting, and, in some cases, removal of the proximal fragment or the whole of the scaphoid. The results were not satisfactory in the large majority of the cases. Ankylosis of the wrist was at times done when serious arthritis was present, associated with marked pain.
From the army standpoint operation was not justified by the results, and grading or discharge from the army was preferred. Conservative treatment; owing to its prolonged nature, also led to marked interference with military service and led to down-grading for varying periods. It was very difficult to evaluate the degree of disability in these cases. Many cases were seen with long-standing non-union but with function unimpaired even when the man had been employed in hard manual work. In only about a third of the cases was the diagnosis made within a month of injury. Arthritis was present in a proportion of the cases, but serious arthritic changes were uncommon. It was difficult to exclude the psychological element, and difficult to ignore symptoms if X-rays disclosed an un-united fracture; but there could be little doubt that in a very large number of the cases the disability was very slight, and was either not present or ignored by many men with well-marked fracture. The results of later treatment were given by Dr D. Macdonald Wilson in a survey of Pensions cases in 1949. He considered that the best results were undoubtedly obtained when page 293 union had occurred. In 56 cases with union 41 had no disability, and only 2 had as much as 25 per cent. In 73 cases with nonunion and no further treatment, only 11 had no disability, the majority having a disability of 20 to 25 per cent and 9 of 30 per cent or more. There were 15 cases which had had excision of proximal fragments, the average disability being 20 per cent and 2 with no disability. Seventeen cases had had total excision and in 7 there was no disability and in 5, 25 per cent. Four cases with arthrodesis had a 30 per cent disability.
These results give a more optimistic outlook on the cases operated on than was formed during the war, especially in the cases of total excision of the scaphoid. The cases associated with arthritis had no higher degree of disability than those without arthritis, which seems to show that in the greater number of these cases the degree of arthritis is slight, and maybe depends largely on radiological appearances of little moment functionally.
Early and prolonged treatment of recent fracture was established as the best treatment, and grading down or discharge from the army proved necessary in the great majority of the cases, either of old or recent fractures.
In the 2 NZEF arrangements were made from the beginning to attach a qualified orthopaedic surgeon to each of the three base hospitals. These were available to take charge of the treatment of the more serious and important fractures, to advise general surgeons on orthopaedic problems, and to run an out-patients department for orthopaedic cases when conditions made this desirable. The supply of orthopaedic surgeons from New Zealand was, however, not sufficient to allow of replacements for those evacuated to New Zealand because of sickness, or for those promoted to executive positions in medical units, and in Italy orthopaedic surgeons were not available for each of the hospitals.
There were no full orthopaedic units or centres such as were set up by the RAMC, but there were all the essentials in the matter of staff and equipment, including physiotherapeutists, vocational training staff, and nursing sisters trained in the work.
In the forward areas all the fracture work was carried out by general surgeons-some with experience of orthopaedic work. There was no rigid classification of the cases to be placed under the control of the orthopaedic surgeons, but in effect all cases necessitating specialised treatment, such as fractured femurs, came under their charge. As regards civil cases, the semilunar cartilage operations were all undertaken by the orthopaedic surgeons. The page 294 segregation of the orthopaedic cases by the RAMC into orthopaedic centres attached to a few of the base hospitals worked efficiently, and allowed large numbers of patients to be treated with the minimum of specialised staff. It meant more administrative planning in the evacuation of patients and more difficulty in the treatment of the orthopaedic cases still remaining in those base hospitals without an orthopaedic surgeon on the staff.
A surgeon with some orthopaedic experience was attached to the staff of the HS Maunganuz. (In New Zealand the fracture cases were sent to the four main hospitals where orthopaedic surgeons and departments were available.)
By the end of the war in Europe there was a wonderful improvement in the treatment of war fractures compared with the treatment given at the beginning of the Second World War. There was only 4′6 per cent mortality in 2364 cases of fracture of the femur in the North-West European campaign.
This improvement can be ascribed to the increasing knowledge and experience of the war surgeons, as the surgical treatment of these cases remained the cardinal factor and, if we read surgical history aright, will always do so. The adequate surgical cleansing of the wound with removal of all devitalised tissue, the prevention of wound contamination, and the complete suturing of the wound by delayed primary suture about the fourth day, proved remarkably successful. The provision of adequate fixation and rest by means of the application of splints, plaster or otherwise, was a valuable aid.
With regard to splintage, plaster retained its place as a comfortable and efficient means of primary splinting and for transport. Its incorporation with the Thomas splint made an excellent method of transporting fractured femurs. The splinting of hip-joint cases remained a great difficulty and the plaster spica, although in many ways undesirable, remained the most satisfactory method both for transport and for hospital treatment.
With regard to the arm fractures, what we may call the partly abducted arm plaster was generally employed for fracture of the shoulder and humerus.
For transport the binding of the splinted arm to the trunk by means of plaster bandaging was the best technique devised but was still not quite satisfactory. At the Base treatment varied from the ordinary abduction plaster to much more simple splinting combined with free movement.
For the forearm simple plaster splints were generally used.page 295
The Thomas splint remained superior in the treatment of fracture of the femur and for knee-joint injuries. Braun splints were sometimes used for supracondylar fractures. The Steinmann pin continued to be the popular method of extension, which was carried out either by weight or fixed extension. Padded plaster splints, split before transportation, remained the routine treatment of fractures of the leg, and proved very suitable when delayed primary suture was carried out. In septic cases the Thomas splint was often employed as in the First World War. The cardinal end-result desired in the upper limbs was functional use of the hand, and every effort was concentrated on that. As far as the lower limb was concerned stability was all-important, the limb's primary function being to support the body both at rest and in locomotion.
1 A full description is given in the appendix to this chapter.