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War Surgery and Medicine

Appendix — PRESENTATION OF ROEHAMPTON IDEAS AT THE END OF THE WAR

Appendix
PRESENTATION OF ROEHAMPTON IDEAS AT THE END OF THE WAR

The surgeons at the Ministry of Pensions Hospital, Roehampton, formulated the following conclusions as a result of their experience of limb fitting after many thousands of amputations:

1.

End-bearing stumps did not last. The majority of the pensioners of the First World War with Syme and transcondylar amputations had required re-amputation at a higher level.

2.

The shorter the stump, the less risk there was of circulatory dis-turbances and ulceration. The end of a long stump was cold and blue in winter, suffered from chilblains, and frequently ulcerated.

3.

The stump must be long enough to remain within the socket during movement when the joint was bent to a right angle, and to contain the insertion of the controlling muscles.

4.

A conical stump was desirable.

Mr G. Perkins stressed that unless a surgeon could guarantee a primary stump that would satisfy the requirements of the limb fitting surgeon he should plan to perform two amputations, a preliminary or provisional amputation followed at a later date by a definitive or final amputation. The provisional amputation would be preferred in the presence of infection and should be performed as low as possible. In recent infections, and especially in battle casualties, no sutures should be inserted.

The final amputation was not performed until the risk of infection was minimal. This meant waiting till the oedema and tenderness of the stump had disappeared and until there was a healing edge all round the ulcer.

There were four sites of election, two in the leg and two in the arm:

  • Below Knee: A five-and-a-half-inch stump, measured from the level of the knee joint. The shortest stump that could be fitted with a below-knee prosthesis was about two inches.

  • Above Knee: An eleven-inch stump, measured from the top of the trochanter. A stump shorter than nine inches was deficient in adductor power, and the artificial limb could not be allowed free abduction-adduction movement at the hip; this was a serious drawback, because the amputee could not walk without a limp unless he was able to balance his trunk over the artificial limb by unrestricted movement at the hip.

    When the stump was too short for an above-knee limb (i.e., less than six inches long) a tilting table would be necessary; even then it was better to leave a four-inch stump if -possible, around which the socket of the limb could be moulded.

  • Below Elbow: The ideal stump was seven inches long, measured from the tip of the olecranon. Amputations through the wrist joint were not satisfactory, as it was impossible to fit a socket which would allow rotation of the arm. With a shorter stump the appliances could be brought nearer the elbow and better controlled. The stump, however, must be long enough to get a good purchase on the socket of the limb, and for this reason it should not be less than four inches in length.

  • Above Elbow. The ideal stump was eight inches long, measured from the tip of the acromion process. This ensured that the bone was page 319 sectioned through the narrow part of the shaft and gave a conical stump. A length of at least six inches was needed to retain the stump in the socket.

The operative technique was almost the same for all four recommended amputations. The flaps should be antero-posterior, of equal length and semicircular in shape. This gave a terminal transverse scar, which was not subjected to pressure, and which would not be pulled upwards between the two bones in below-knee and in below-elbow amputations. The semicircular flaps gave the stump a conical shape, which was essential when fitting the modern limb. The skin and deep fascia were reflected together to prevent the skin from becoming adherent to the deeper tissues. The muscles were cut transversely, half an inch below the site of the proposed bone section. The muscles must on no account be sutured over the bone, as this left a bulky mass of soft tissue which was difficult to fit into the conical socket. The nerves should be cut at the same level as the muscles, and afterwards left undisturbed. The bone was sawed through flush with the retracted muscles, except in below-knee amputations, where the sharp anterior angle of the tibia should be levelled and the fibula cut one inch shorter than the tibia. Haemostasis must be as complete as possible, for a haemotoma was the most frequent cause of sepsis. The deep fascia should be sutured carefully, and the skin edges finally brought together, care being taken that there was no tension on the suture line.

After Treatment

The stump must be converted into a conical shape. This was achieved by firm bandaging by crepe bandages applied several times a day, the greatest pressure being applied to the end of the stump. The muscles controlling the stump must be strengthened by exercising them against a weight and pulley. This applied particularly to the adductor and extensor muscles of the hip in above-knee amputations. Early movement of the stump should be encouraged, special care being taken to avoid flexion deformity of the knee and a flexion-abduction deformity of the hip. Massage was deprecated.

Finally, the patient must be instructed to use the stump, in order to restore co-ordination movement. The simplest method was to make the patient play with a large, soft, indiarubber ball which he could propel with his stump, whatever the level of the amputation.

When the prosthesis had been supplied, the patient must be taught to walk, or, in the upper limb, the correct use of the scapular muscles. The proper training of the amputee in the use of his artificial limb was still too frequently neglected.

It was usually possible to fit an artificial leg in three months from the healing of the wound, and an artificial arm in six weeks. Shrinkage might not be complete at this time, but it was better to obtain a new socket when full shrinkage had occurred than to delay the fitting of the limb.

The views of the Roehampton limb-fitting surgeons as expressed by Dr Kelham agreed with those of Mr Perkins. In addition, he stated that weight bearing in the lower limbs was taken:

Above Knee: On Tuber Ischii.

Below Knee:

(a)
(i)

Inner head of tibia.

(ii)

Shaft tibia beneath anterior tibial tubercle.

(iii)

Shaft of fibula beneath the head.

(b)

Tuber Ischii (with or without stump bearing).

page 320

Upper Limbs: It was claimed that, if the artificial limbs were applied early, with adequate training and early commencement of suitable occupation by the amputee the limbs were quite satisfactory.

Pylons were held to be unnecessary, the same results being most easily obtained by crepe bandaging.

Other Amputations

Syme: Not approved, though the stumps were sometimes satisfactory. Combined end and tioial bearing could be provided.

Foot Amputation: Could be fitted with limbs, but were generally unsatisfactory.

Care of Stumps
1.

Careful washing daily, with good soda-free soap. Scar not rubbed. Spirit applied, followed by talc powder on the scar.

2.

Stump socks and crepe bandages washed regularly. A clean sock worn every day, next to the skin.

3.

Leave off limb when stump was bruised, cut, or septic.

4.

Neuromata were best left alone.

5.

Bursae occasionally needed excision.

6.

Chronic ulcers might call for excision or re-amputation.

7.

Chronically infected skin areas might sometimes require excision.

8.

Adjustment of buckets was often necessary before the stump had become stabilised.

Experience in USA and Canada at the End of the War

A conference was held at the end of the war in Canada at which representatives of both the United States and Canada were present, as well as British surgeons from Roehampton. A very marked difference of opinion was shown. The Americans and Canadians were in favour of guillotine operations for primary amputations in the field and of end-bearing stumps such as the Syme and the Stokes Gritti as the final amputation. Some observations made by Mr Perkins, the senior Roehampton surgeon, were as follows:

1.

Provisional amputations should save as much as possible of the limb. British surgeons prefer to fashion flaps and leave them open for secondary suture. The Americans favour the guillotine amputation with early skin traction.

2.

Final amputations should be done only by surgeons experienced in such work.

3.

Many, but not all, of the Canadians and Americans favour endbearing stumps-Syme and Stokes Gritti or supracondylar amputations. The British prefer the five-and-a-half-inch tibial and eleven-inch femoral stumps.

Perkins noted that circulatory troubles in long stumps did not seem to be as common in Eastern America as they were in Britain.

His conclusions were:

1.

British limbs are better made, have better mechanism, and are better fitted than Canadian and American limbs.

2.

In spite of seeing some successful Syme and Stokes Gritti cases, he still believed that the standard British methods were better.

Mr Perkins thought that some of the difference in opinion was due to the climatic conditions in Britain, predisposing to circulatory disturbance, page 321 whereas in the eastern part of Canada he had been told that chilblains and other troubles were uncommon, as were circulatory changes in stumps. The main difference in opinion related to the Syme amputation, which the Americans considered the ideal for the lower limb, whereas the Roehampton surgeons had found that the cases done in the First World War had proved quite unsatisfactory later, and as a result they preferred an amputation at the site of election in the leg. Again, the Stokes Gritti was not liked by the British Army surgeons. A Syme amputation could only rarely be done in war injuries, so that the matter was of mere academic interest. The Stokes Gritti could also normally be considered only as a secondary amputation.

A statistical survey of amputation cases evacuated from 2 NZEF in the Middle East from 1942 to 1945 shows that there were 273 major amputations of the lower limbs caused by battle wounds and 18 by accidental injury. Associated with these cases were no fewer than 90 fractures of the long bones and 16 major vascular injuries. There were very few complications during treatment. The most common missiles involved were shells, mines, and mortars. The largest numbers occurred in 1944 in Italy.

There were many fewer arm amputations in the same period (1942–45), 66 due to battle wounds and 13 to accidental injuries. Again there were few complications, but 5 of the cases were associated with gas gangrene. The shell was much the commonest missile involved in the arm cases.

A comparison of the wounds serious enough to cause invaliding from 1 NZEF in France in 1916–18 and from 2 NZEF in 1940–45 reveals that the most significant feature was the increased number of amputations of the lower limb in the Second World War. In a total of 7591 wounded invalided from 1 NZEF in France there were 193 major amputations of the lower limb and 156 of the upper limb, whereas in a total of only 4609 wounded invalided from 2 NZEF, there were 307 major amputations of the lower limb and 80 of the upper.

The marked increase in gross wounds of the lower limb involving amputation was undoubtedly due to the extensive use of mines as a defensive measure by the enemy. A survey has been made of the kinds of missile causing the wounds. In a series of 228 amputations of the lower limb in 2 NZEF no fewer than 66, or 29 per cent, were definitely noted as due to mine injuries. In a similar series of 45 amputations of the arm only 3, or 6 per cent, were recorded as due to mine injuries. (The only other group showing a marked relative increase in 2 NZEF compared with 1 NZEF was that of injuries to the eye, and this was also due mainly to mine explosions.)

The War Pensions Department records the following applications up till March 1952 for pensions from amputees of all three services:

Overseas Service New Zealand Service Total
Upper limb 131 7 138
Lower limb 344 11 355
Fingers 225 30 255
Toes 57 15 72
page 322
2 NZEF—AMPUTATIONS OF Leg INVALIDED TO New Zealand
complications
Gas gangrene in stump 2
Infective arthritis, other hip 1
Septic arthritis, knee 1
Osteomyelitis, stump (PW) 1
Suppurative arthritis, knee (PW) 1
Septicaemia(PW) 1
Uraemia 1
associated injuries
Fracture femur 18
Fracture tibia and fibula 38
Fracture tarsus 23
Fracture tibia 9
Fracture fibula 1
Fracture leg undefined 1
Vascular injury
Ligature ext iliac 1
Ligature femoral artery 6
Ligature popliteal 9
missiles causing
Shell 78
Mine 63
Bomb 25
Mortar 20
Gunshot 16
Grenade 8
Bomb, anti-personnel 3
Bomb, aerial 2
Schu mine 3
Spandau 1
Crush injury 1
Booby trap 1
Machine-gun 1
Accidental 1
Undefined 4
——
228
2 NZEFAmputations of Arm Invalided to New Zealand
complications
Gas gangrene in stump 2
Infective arthritis, other hip 1
Septic arthritis, knee 1
Osteomyelitis, stump (PW) 1
Suppurative arthritis, knee (PW) 1
Septicaemia(PW) 1
Uraemia 1
associated injuries
Fracture femur 18
Fracture tibia and fibula 38
Fracture tarsus 23
Fracture tibia 9
Fracture fibula 1
Fracture leg undefined 1
Vascular injury
Ligature ext iliac 1
Ligature femoral artery 6
Ligature popliteal 9
missiles causing
Shell 78
Mine 63
Bomb 25
Mortar 20
Gunshot 16
Grenade 8
Bomb, anti-personnel 3
Bomb, aerial 2
Schu mine 3
Spandau 1
Crush injury 1
Booby trap 1
Machine-gun 1
Accidental 1
Undefined 4
——
228
DATE OF MEDICAL BOARDING
PW 12
1941 8
1942 52
1943 31
1944 108
1945 37
?PW 3
——
251
Amputations of Arm Invalided to New Zealand
BC AI
Amputation at shoulder 4
Amputation at upper arm 38
Amputation at elbow 1
Amputation at forearm 12 7
Amputation at wrist 1 1
Amputation arm, undefined 10 5
—— ——
66 13
associated conditions
Gas gangrene 5
Staphylococcal septicaemia 1
Ligature axillary artery 1
Ligature brachial vessels 1
Median nerve injury 1
Fracture humerus 1
missiles causing
Shell 28
Bomb 8
Gunshot 5
Mine 3
Machine 1
date of medical boarding
PW 5
1941 5
1942 21
1943 6
1944 15
1945 2
——
54
Amputations of Hand And Fingers Invalided to New Zealand
BC AI
Amputation hand 7 1
Amputation through hand 3
Amputation thumb and index 3
Amputation thumb 7
Amputation fingers 56 10
76 11
missiles causing
Shell 39
Gunshot 6
Bomb 4
Mortar 3
Machine-gun 3
Mine 2
Grenade 1
Tank hatch 1
Phosphorus burn 1
date of medical boarding
1942 23
1943 5
1944 27
1945 9
——
64