War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
At the beginning of the Second World War Great Britain was in the fortunate position of still having available the orthopaedic surgeons who had laid the foundations of the work during the previous World War. They not only had vast experience of these cases, but had been able to watch and evaluate their results over the years. It was possible, therefore, to lay down early in the war detailed information concerning the diagnosis and treatment of neive injuries for the information of the younger generation of neurologists and surgeons.
The methods advised were similar to those used in the First World War. Primary suture was not advised in war wounds because of the fear of infection, and suture was delayed till at least six weeks after healing of the wound. When it was uncertain whether the nerve had been actually divided, exploration was advised only after careful evaluation of the signs of loss of nerve function. Full opportunity was given for spontaneous recovery to take place. Exploration was generally delayed for five to six months, but it was realised that any delay longer than a year made recovery problematical.
Interest was also focused on the problem in the neurological centres, which began to carry out researches in the physiology and pathology of nerve injury and repair. Oxford was particularly active in this direction. It was shown that shortly after injury page 171 the nerve was friable and the sheath in an unsatisfactory condition for suture. Then the Schwann cells regenerated and within about ten days the sheath became thicker and stronger and suture was much facilitated. It was found that, in keeping with these changes, suture of the nerve at the time of injury gave worse results than suture two or three weeks later. This observation seems to have been accepted by others. Studies of later changes showed that the axons sprouted strongly and rapidly from the proximal end of the severed nerve, but that after several months there was not such a strong action. The distal end of the nerve underwent degeneration throughout its course, with loss of the axon cylinders and steady and progressive shrinkage of the nerve, with resultant constriction of the channels through which the regenerating axon cylinders would have to make their way. The nerve ending in the muscle plates would, in the meantime, be degenerating, and the muscle fibres themselves losing their structure and becoming fibrous tissue. It was only logical, if these observations were correct, to assume that the earlier operative repair of severed nerves was carried out the better the chance of recovery of function. It was also certain that if repair were too long delayed, the recovery of function would be impossible.
Opinions on Operation
Conflicting opinions arose somewhat similar to those held in the First World War—the conflict of the ultra-conservative and the radical. Gradually the conservative view, deprecating early operation and maintaining that better results were obtained by non-operative treatment, lost ground. Strong support, however, was given to this view by Foerster of Germany, who, in a series of 3079 cases, had 1320 complete and 660 partial recoveries without operative treatment. Another German report stated that delay in operation was adopted after noting the favourable results in cases from the Russian front which had not been seen for long periods after wounding. Brigadier Cairns, consultant neurologist to the British Army, had stated that a high percentage of nerve injuries recovered spontaneously.
The more radical group noted the degenerative changes in the limb, and, for that reason, wished to operate early, and start the recovery of the nerve so as to allow of the return of nerve function before muscle function was completely lost by atrophy and fibrosis, and the joints probably stiffened.
Seddon, Nuffield professor of orthopaedic surgery at Oxford, definitely aligned himself and his team in favour of radical exploration of nerve injuries associated with war wounds. He page 172 explored all cases showing signs of complete division, except when an intact nerve had been noted at the original operation. In his opinion half of the cases of nerve injury were associated with division of the nerve, and exploration alone decided the matter, unless one was prepared to wait a long time for the possible signs of recovery. He asserted that he would explore even if there were an even chance that the nerve was not divided, and declared that the results proved the wisdom of doing so. The harmful effects of delay on the nerve, the muscle, and the joints were amply demonstrated.
Optimum Time of Operation
The time of operation depended first of all on the condition of the wound and also on the presence of associated injuries, especially fractvires. Primary suture was not carried out because of the risk of infection. Although theoretically at the end of the war it would have been possible to suture the nerve safely in a clean wound, this was not attempted and the operation was postponed till the wound had been soundly healed for two to three weeks. This generally meant that nerve suture could be carried out in straightforward cases about six weeks after the injury. As the ideal time for suture had been determined and agreed upon as two to three weeks, suture at six weeks in war wounds was as near the ideal as possible. By that time the nerve had become stabilised and reparative changes had commenced, and the perineurium had become firm and suture was easy.
Maximum Delay with Successful Operation
The period of delay in operation after which recovery was possible had not been clearly laid down, some putting it at eighteen months, some at three or four years. Brigadier Cairns had had success following suture up to two and a half years after injury. Our experience would definitely lead us to place the figure near the lower limit.
Seddon stated that, as far as motor recovery in the median nerve was concerned, nine months was the period of critical delay for intermediate and high lesions. For all lesions there was a definite deterioration in results, relative to the delay in suture, after the optimum period of two to three weeks following injury.
The Determination of the Nature of the Nerve Injury
The diagnosis of nerve division often caused great difficulty and the tests available did not permit at an early period of a distinction between anatomic and physiological nerve block. The signs of page 173 nerve division were loss of motor and sensory function, wasting of the muscles supplied by the nerve, loss of tendon reflexes, and alteration in the response to electrical stimulation. This latter consisted in lack of response to faradic current and sluggish reaction to galvanism, the so-called reaction of degeneration. More elaborate methods of electrical stimulation and electro-myography were utilised in special clinics. The loss of sweating in the anaesthetic areas was used as a test. Tinel's sign of sensation on tapping over the nerve below the lesion was utilised and was thought of benefit by some but not by others.
The more simple determination of nerve injury of the different main nerves available for rapid clinical use was: in the median nerve the loss of the opponeus action of bringing the thumb across the palm, in the ulnar the loss of grip between the thumb and the index, in the radial the loss of extension of the thumb, in the peroneal the loss of extension of the hallux, and in the internal popliteal the loss of flexion of the hallux. A definite diagnosis could be made only by the return of function, proving that no gross injury to the nerve had taken place, or by exploration of the nerve. Most surgeons of experience agreed that early operation was essential for diagnosis in any doubtful case.
Reasons for Exploration
Exploration was carried out when the nerve was known to have been divided. It was also carried out when signs of complete loss of function were present and no signs of recovery had taken place in five to six months.
The opinion of leading neurosurgeons finally was that operation should be undertaken early in all cases showing loss of function, because in over half these cases suture was necessary and the time lost by watching for functional return would seriously jeopardise the chances of recovery. Exploration was also carried out for a partial lesion of the nerve and sometimes to place the nerve in a healthier bed. Re-exploration was also undertaken in cases showing no signs of recovery.
The question of what was to be done when a nerve was found divided in the wound naturally arose. There were some who definitely favoured immediate suture, but they were in a small minority because of the natural objections concerned with possible infection. Professor Platts, of Manchester, in 1940 considered that suture should be done in six weeks after the wound had healed and the mobility of the limb restored. Cairns in 1942 recommended immediate suture if possible, but generally waited five to six months page 174 before exploring. With the improvement in the results of wound treatment, partly associated with the introduction of penicillin, our outlook had somewhat altered, but the evidence already adduced of the improved condition of the nerve two weeks after injury seemed to point to the necessity for delay, even if infection could be ruled out. Seddon definitely stated that in clean wounds, such as those produced by a sharp instrument, when primary suture of the wound was carried out, he would not suture the nerve at the time but would deliberately leave this for an operation two to three weeks later. It was found of advantage, however, to draw the ends of the nerve together by a simple stitch in the sheath, so as to make the later exploration easier. If the ends could not be brought together, then lightly fixing them to adjacent muscle was of value.
The subsequent exploration and suture of the divided nerve was undertaken by the same technique as that developed during the First World War: the same free exposure, the same liberal freeing of both ends of the nerve, the same suture of the sheath, and the same utilisation of flexion at the joints to relieve tension.
The decision as to whether to resect and suture the nerve at the operation itself still remained a question of the experience and judgment of the surgeon. Electrical stimulation of the nerve to test its conductivity during operation was utilised by Bristow and others. Often the decision was easy as there had been obvious gross division and separation of the ends of the nerve, with the formation of a mass of nerve scar tissue in between. When the nerve was anatomically intact, except for some thickening at the site of the injury, the decision rested mainly on the feeling of induration in the nerve. On cutting out the thickened and hardened area the presence of scar tissue and the absence of nerve fibres could be demonstrated. Seddon came to utilise what he called a -trial incision as the most valuable diagnostic aid at his command, and he resected the nerve if more than half the nerve was involved by scar tissue.
There was no change in technique except the introduction of fibrin clot as a method of suture in relation to the smaller nerves and in nerve grafting. Seddon stated that the utilisation of plasma rendered the repair by cable grafts easy and satisfactory. The use of a tourniquet was considered inadvisable, certainly as far as the arm was concerned, and probably also for the lower limb, as ischaemic changes were so much to be dreaded in association with nerve injuries.
At times only a portion of the nerve was divided and it was possible to separate the two portions and suture the damaged part, leaving the rest intact.page 175
Removal of Bone
This was sometimes done in order to shorten the limb and so render possible suture of the nerve when the ends of the divided nerve could not be approximated without undue tension. The humerus was the bone usually involved.
In many cases of late exploration the nerve was found to be imbedded in scar tissue, the nerve itself not being seriously injured. Careful dissection of the nerve with removal of the surrounding scar and the formation of a new bed, preferably of muscle, for the freed nerve was carried out. In suitable cases the results of this treatment were very satisfactory, and often quite a rapid recovery of function took place. Bristow, however, considered that the removal of the nerve from a bed of scar tissue made little difference to its recovery.
During the 1914–18 War nerve grafting was tried as a means of bridging gaps in nerves which could not be repaired by the usual technique of nerve suture. Grafts of many kinds were tried, but with no success. During the 1939–45 War the consensus of opinion was that nerve grafts for the main nerves were generally completely useless. Spurling reported that there had never been a successful large nerve graft in the American Army. Bristow had never seen any useful function restored. Seddon recorded some satisfactory results in autogenous nerve grafting, using cable grafts from small cutaneous nerves, the employment of plasma instead of suturing having added much to the ease and the success of the technique. He employed a pedicle nerve graft in repairing the sciatic nerve. There were no successes in homogenous grafting.
As in the First World War, tendon transplants gave very good results in musculo-spiral paralysis so that it was performed in cases where suture was difficult or had been a failure. The transplantation of the palmaris into the thumb was of some use in median paralysis. In peroneal paralysis the results were not generally of permanent value.
The treatment of nerve injuries, apart from operative repair, changed to a certain extent. The accentuation placed on splinting and galvanic stimulation of paralysed muscle had gone. Stress was page 176 now laid particularly on the preservation of the general nourishment of the limb, and especially of the supple movements of all the joints. There was common agreement that active and passive joint and muscle movements should be regularly carried out. Heat and massage were also used. Splints, especially plaster splints, were found at the early stage of the war to lead to atrophied stiff limbs, and many surgeons on that account advised the complete discarding of all splints. However, removable splints, if properly designed and intelligently used, were still valuable in preventing overstretching of the paralysed muscle, in retaining the position of optimum function, and in the prevention of deformities. Splints of the elastic type were favoured as they allowed of functional use of the limb, and could be readily removed for physiotherapeutic treatment.
Highet, a New Zealander working in England, stated that in the application of splints the following conditions should be observed:
No paralysed muscle should be subjected to stretching.
All joints should have as full movement as was compatible with (1).
No pressure should be allowed on an anaesthetic area, and there should be no interference with circulation.
The patient should be able to do occupational or ordinary work.
The splints should be removed twice daily for half an hour for physiotherapy and every joint put through a full range of movement.
He described the following splints:
For median nerve palsy cases: Elastic splint to hold the thumb in palmar abduction and opposition with a broad wrist strap and a band round the thumb.
For ulnar cases: Knuckle-duster type of splint holding the fingers in slight flexion at the metacarpo-phalangeal joints.
For radial cases: An elastic extension splint with bands to each finger, the finger never being immobilised.
For circumflex and brachial plexus cases: The usual abduction splint but movement allowed at the elbow and rotation at the shoulder.
For sciatic cases: Side-irons with toe-lifting spring and a mobile ankle.
Electrical stimulation of muscle was not utilised to the same extent as in the First World War, many considering it of little use, and some that it was distinctly harmful in many cases. Experiments carried out at Oxford showed that daily galvanic treatment was most page 177 beneficial in the treatment of small muscles but of little use in the large muscles. Eventually, however, it was agreed that galvanic stimulation was of definite use in preserving the muscle volume. Many considered that the manipulation of the limbs through all the normal movements of the joints was of much more importance, and that this was the main factor in the preservation of the nutrition and potential function of the limb. The main difficulty in treatment was due to the very long period of recovery, necessitating continuous daily treatments for eighteen months or more. This meant attachment to a physiotherapeutic department for that time. In cases where the recovery was very problematical it often appeared advisable to adopt some less tedious course, such as tendon transplantation in the case of an injured radial nerve.
Signs of Recovery
These normally occur in some degree in about six months, but success is possible up to two and a half years. Sensation is the first to recover, the tactile sense first and pain later. The reaction of degeneration is then lost and there is an arrest of atrophy and a return of tone. Faradic response then appears and finally muscular power. The return of muscle function is the most reliable sign of recovery. Tinel's sign was held to be useful by some observers and unreliable by others. In unaided recovery touch and pain return together and all the muscles may regain power at the same time. Trick movements have to be guarded against and also the overlap of sensory areas from other nerves.
This was said to be very common by some observers, particularly the Germans, and one writer quotes as high a percentage as 50. In the larger series a figure of about 10–12 per cent is given. In quite a considerable number of cases there is only a temporary disturbance with a rapid and complete recovery. (After the second Libyan campaign the DMS 2 NZEF ordered all cases of nerve injury to be evacuated to New Zealand by hospital ship. A considerable proportion of these completely recovered on the journey to New Zealand.) Slower recovery took place in the majority of the cases and often the recovery was incomplete.
Recovery after Suture
It had been known before the war that the later the suture the worse the recovery, and this was entirely substantiated during the Second World War. It was found that the results became worse when suture was delayed for ninety days and that after six months the results were poor. Recovery of some function after two and page 178 a half years was reported by Cairns. In general, all results of suture were relatively bad in that normal function never returned. The return of sensation was much more satisfactory than muscular recovery. The muscles underwent degeneration with the destruction of the terminal motor bundles and became fibrosed. The smaller muscles were particularly affected. Injuries of the median and ulnar above the elbow, and of the sciatic high up, were particularly unfavourable.
Recovery of Different Nerves
The radial nerve often showed good recovery with only slight disability. The ulnar showed fair sensory recovery, but the intrinsic muscles generally atrophied and became useless; the disability, however, was slight. The median nerve gave somewhat similar results, the intrinsics again degenerating; sensory loss was a serious disability, the main muscular disability being due to the loss of opponens action. The sciatic nerve results were not good nor were those of the external popliteal branch. The internal popliteal and post-tibial gave better results.
Delay in Operation
In the first three to four years of the war there was considerable delay in the treatment of nerve injuries. This was largely due to the closed plaster treatment obscuring the nerve lesion and to the very long time taken to obtain healing, especially in fracture cases. There was considerable wound sepsis in the earlier periods, and there can be little doubt that suture of divided nerves was very seriously delayed. There are many reports of contractions and atrophied limbs, stiff and immobile joints, and withered, paralysed muscles. Our New Zealand cases were all evacuated to New Zealand in plaster splints and it is likely that operative treatment was delayed, and what results we have support this view. The introduction of delayed primary suture and penicillin brought about a radical change in the situation and enabled early suture to be undertaken.
Function in Nerve Paralysis
The loss of nerve function is a very serious disablement. So much so that the loss of all nerve function, such as the loss of all three nerves in the arm, makes that limb worse than useless. The loss of ulnar and median function gives rise to a useless anaesthetic hand. The loss of the radial and median leads to severe crippling, but the loss of radial alone is not serious, as tendon transplantation is generally successful. Complete sciatic disability page 179 is greater than that of loss of the limb as the limb cannot tolerate weight bearing on the anaesthetic foot. The loss of main nerves often determines the question of amputation.
Serious complications arose in the limbs as a result of injury to the nerves, apart from the loss of power and sensation. Reference has already been made to the marked atrophy, and also to the deformities which had to be guarded against. More serious changes arose as a result of interference with sensation, and trophic sores readily developed. Injuries such as burns can be suffered in limbs devoid of sensation. Trophic ulcers were especially liable to occur in sciatic nerve injuries involving the internal popliteal nerve. These were so severe and intractable that amputation through the thigh might be called for. Irritative symptoms also arose, sometimes by pressure on, and foreign bodies in, the nerve trunks. Causalgia, a condition of severe pain, generally associated with partial lesions of main sensory nerves, also arose, though fortunately this condition was noted much less frequently during the Second World War than it was in the First World War.
Causalgia was first described by Weir Mitchell during the American Civil War, and our knowledge of the condition is not very much greater than it was then. There were two types, one a true causalgia and the other more transient and milder. The milder condition arose shortly after the injury and persisted for some weeks and then completely cleared up. This was frequently noted in our cases. The more severe true causalgia arose later and was an infinitely more severe condition. The pain was burning in nature and continuous. It was increased by any movement, by touch, and also by heat or cold. There was a loss of epicritic sensation, especially light touch. Moisture definitely gave some relief, and the patient applied wet cloths to the part. The skin became dry, smooth, and red. It was a truly lamentable condition. No local treatment except rest and the application of moisture gave any relief. Various operative measures were carried out in an attempt to cure this condition. The nerve was freed from any scar. It was cut across and resutured, or cut across without suture. The nerve was injected with alcohol. The nerve roots were divided. Finally sympathectomy was adopted as the most certain and efficient form of treatment when temporary sympathetic block had demonstrated its efficacy. Seddon stated that upper thoracic sympathetic ganglionectomy had proved the most page 180 reliable form of treatment. This procedure had been very successful in the majority of cases, but did not give full relief. Pain was relieved, though some discomfort remained. A somewhat similar condition was present in amputation stumps, and again sympa-thectomy had proved the best form of treatment. However, there were cases which had resisted any form of radical surgery of the limbs and spinal roots, and the division of tracks in the brain had been carried out with some success. Milder forms of irritation were relieved by local operation at the site of nerve injury if spontaneous cure did not take place in a reasonable time.
Closed Injuries of Nerves
Traction Injuries: These injuries, as a rule, caused widespread damage to the nerve involved, often extending for a distance of several inches. In some cases where the damage was limited spontaneous recovery occurred, but this did not happen in the severe cases for which, in addition, operative treatment was useless.
Injuries associated with Fractures: Fractures of the long bones were a frequent complication of nerve injury, and led to delayed treatment. These were most commonly seen in association with fracture of the humerus. It was realised that repair of the nerve was of more importance than that of the fracture, but that nerve repair could not be undertaken till wound healing had taken place. In the earlier part of the war that meant very considerable and hopeless delay in many cases. An attempt to plate the fractures at the same time as the suture of the nerve was not successful, as in 40 per cent of the cases the plates had to be removed. Fortunately in the majority of cases the damage was slight and early recovery took place. Exploration was required only where recovery did not occur in the expected time.
The severe destruction of the function of a limb caused by ischaemia is well known. This is especially shown in regard to the loss of function of the nerves. Not only is there serious disturbance, but all the nerves in the limb are usually affected. There is associated with this profound atrophy and fibrosis in the muscles, and stiffness and contraction in the joints, a condition for which no treatment is of much avail. The diagnosis of the condition is made on the basis of the combination of disability of nerve, muscle and joint, and the involvement of more than one nerve.
The condition may arise following destruction of the main vascular supply to the limb by severing of the main artery, or it may be brought about by constriction of limbs by tight bandages page 181 or splints. The danger was realised early in the war in association with the treatment of wounds by the closed plaster technique. Very soon direction had to be given to cut up plasters in the forward areas to relieve any tension, and also to prohibit bandaging under a plaster splint.
The utilisation of non-padded splints was prohibited, in spite of some resistance by civilian orthopaedic surgeons who had been so long accustomed to use these splints in their treatment of simple fractures, and who could not easily readjust their ideas to war conditions.
Cases can be vouched for in which amputation had to be carried out in consequence of gangrene resulting from tight plaster splints, and a severe ischaemic condition of the limb is only slightly less destructive than an amputation. In severe ischaemia there is present not only gross interference with nerve function, but a functional destruction of muscle which is converted into fibrous tissue. There is also serious joint disturbance with marked rigidity, and unless early and efficient treatment is instituted marked deformities arise. There is little to be done in treatment except the prevention of deformity and the preservation by physiotherapy of what muscle may remain.
Treatment in 2 NZEF
In the 2 NZEF there was little scope for treatment of nerve injuries as cases were evacuated promptly to New Zealand, so promptly that at times transient paralysis recovered on the voyage home. In the first years of the war the majority of the severe wounds were either unhealed, or quite recently healed, at the time of evacuation by hospital ship. Physiotherapeutic treatment was also difficult to carry out as so many of these wounds were enclosed in plaster splints in addition to the dressings.
This arrangement delegated the prolonged treatment of nerve injuries, including their operative repair, to the civil hospitals in New Zealand, where the orthopaedic surgeons were called upon to deal with the problem. There were relatively few cases operated on overseas, though when satisfactory conditions arose there was no hesitation in dealing with them by surgical means. One operation on a lesion of the median nerve above the elbow demonstrated the division between a motor and sensory portion of the nerve at that level. The sensory portion had been completely severed and the motor portion was quite intact. Suture was readily carried out without any interference with the intact motor portion. The nerve might well have been left alone to recover spontaneously, as all the motor functions were normal, but it was page 182 felt that the sensory function of the nerve was all-important and with complete loss of sensation exploration was advisable, a very fortunate decision. Later in the war, as wound healing became more rapid and certain and sepsis became rare, more opportunity arose to explore the nerves.
Surgeons in the 2 NZEF were very concerned as to the period of time that would necessarily elapse before the patient evacuated to New Zealand would be operated on. The break between the army and the civil hospital would provide difficulties in keeping an accurate check on the men, especially if they were sent to their homes away from orthopaedic centres. As general opinion gradually veered round to the necessity for early operation, it was felt that the patients had a worse chance under these conditions than they had in the First World War, when they were operated on in England and sent to New Zealand later. The prolonged plaster treatment carried out in the early stages of the war increased the difficulties.
Treatment in New Zealand
The operative and late treatment of peripheral nerve lesions was undertaken by the civil hospitals in New Zealand. There were no military orthopaedic hospitals such as were set up at the end of the 1914–18 War at Trentham and at the Chalmers Annexe of the Christchurch hospital. At that time there were no orthopaedic departments in the public hospitals, and no orthopaedic surgeons in New Zealand and no physiotherapists. As a result of experience gained in the First World War, departments were set up in the main hospitals in New Zealand. At Wellington a physiotherapist trained in the Army was appointed to the public hospital and afterwards became an orthopaedic surgeon. In Christchurch and Auckland the same thing happened, and in Dunedin an orthopaedic surgeon with war experience was appointed to the staff.
The special orthopaedic centres at the end of the 1914–18 War were able to do work which the public hospitals at the time could not have done, having neither the staff nor the equipment. During the Second World War conditions were quite different. Special orthopaedic and physiotherapeutic departments were available in all four main centres well able to deal with the work, though some of it was largely new to civil surgeons. The soldier patient on landing in New Zealand at once became a civilian as far as medical treatment was concerned and lost his identity as a soldier. The treatment given was in conformity with that already described and it was carried out by the orthopaedic surgeons in the main centres.page 183
The treatment demanded by these cases, either with or without operation, was prolonged physiotherapy, and continuous observation and social help. For this it was necessary to ensure attachment to a special centre where physiotherapists and specialist personnel were available. Special provision for employment and occupational training were also required in many cases. In New Zealand all treatment was given in the civilian hospitals and occupational training was arranged by the Rehabilitation Department.
The results of nerve suture in the Second World War are difficult to evaluate. Many surgeons have reported their opinions as to results, and generally it can be stated that many results following nerve suture are good, but, as Bristow said, none are perfect.
The results were followed up carefully in the special neurological and orthopaedic centres, especially in the United Kingdom. They showed that the factors affecting the prognosis were:
The level of the lesion.
The delay between injury and operation.
The extent of the gap after resection.
Progressive improvement took place till beyond the third year. The results of high division were much worse than low divisions of the nerve. Satisfactory results could not be expected if the gap was more than 7 centimetres.
Seddon summed up the position as follows:
As a practical summary of the value of nerve repair, it may be said that, provided the interval between injury and operation does not exceed a year, and that end-to-end suture is not employed where the gap in a nerve is more than 7 cms., a worthwhile result is obtained in most cases of radial, median, and internal popliteal nerve injury. Repair of the lateral popliteal component of the sciatic nerve is rarely successful (that is, enabling the patient to dispense with a toe-raising spring) unless the lesion is situated distally and the gap after resection of the stumps is less than 5 cms. Repair of the ulnar nerve is hardly worth attempting if the lesion is proximal to the elbow; and successful repair of the brachial plexus is limited to lesions of the upper trunk, cervical 5 and 6.
In a small series of cases investigated in New Zealand in 1949 the results were poor. In practically all the cases the joint function was good but the general functional activity of the limb was poor. The average pension granted was 53 per cent, including the nerve injury and associated injuries. When more than one nerve was page 184 involved the average was 65 per cent, and when associated with fracture of the humerus 57 per cent. When only one nerve was involved the average pension was 48 per cent.
Late Results: Pensions Survey in New Zealand
In 1951 Dr. D. Macdonald Wilson made a survey of results of peripheral nerve injuries occurring in New Zealand servicemen in the Second World War. There were 416 gunshot wounds, which caused 473 nerve injuries, and 29 accidental injuries producing 37 nerve injuries. Very few cases had been operated on overseas, and operation on the nerve was not carried out, except in one or two cases, till the wound was satisfactorily healed. Associated fractures had led to marked delay in nerve repair.
The operative procedures employed in New Zealand were simple, and practically no attempts were made to use artificial materials or grafts of other nerves to bridge gaps. Nerves were operated upon for suture, for excision of neuromata before suture, for freeing of adhesions, transplantation to shorten their course and so allow approximation of divided ends, and for the relief of pressure.
Details concerning the individual nerves injured, and the results of treatment, are given below. In the results of treatment the nerves were classified into three categories: those with complete restoration of function; those with sufficient restoration to give the patient useful function, but with restoration of either or both motor and sensory power not complete; those with no restoration of function of the nerve, or in which the return of function was so slight that there was no practical benefit to the patient.
Many of the cases where restoration of function occurred had no operation to the nerve, and it is evident there was no solution of continuity of the nerve by the missile causing wounding and that temporary loss of function was due to concussion of the nerve with spontaneous recovery.
Evaluation of Results shown by Survey
Of the actual sutures of nerves performed in the series the results are very disappointing. In all, 83 sutures were carried out, and in 63 cases no improvement was shown. The good results are set out below:
Ulnar: Good functional results in 3 cases of accidental injury and in 6 cases of gunshot wounds.
Median: Complete recovery in 1 partial suture for accidental injury and 2 good functional results in gunshot wounds.
Radial: Two complete recoveries (GSW) and 5 good functional results. Sixteen of the radial cases had tendon transplantation carried out, 13 of them after unsuccessful suture.
There is no improvement following suture of the sciatic nerve, 1 good recovery in suture of the popliteal nerve, but no successes in operation on the peroneal or tibial nerves.
Nine cases of accidental injury had suture performed, with 1 complete recovery and 3 good functional recoveries. Seventy-four cases of gunshot wounds had suture performed, with 2 complete recoveries and 14 good functional recoveries. Of the 20 cases recovering some useful function, 16 were either ulnar or radial injuries. Five of them were operated on on the day of injury, 13 within nine months, and two (both ulnar injuries) after a year. In the 63 unsuccessful cases 41 were operated on under fourteen months and probably 15 of these under six months.
In spite of the fact that the large majority of the sutures were carried out within the optimum period, the results were very poor.
From the results it would appear that nerve injuries should in future either be kept in the theatre of operations overseas for operative treatment or be segregated immediately after arrival in New Zealand in special centres under the control of experienced neurosurgeons.page 186
Recommendations for the Future
At the primary operation in the forward areas nerve suture should not be performed, but a simple approximating stitch, if necessary, introduced.
When it is known that the nerve has been divided, suture should be performed as early as the condition of the wound will admit, but not earlier than two to three weeks following injury.
When signs of recovery do not appear within a period of five to six months exploration should be undertaken in any case where satisfactory results are deemed possible, recognising the hopeless prognosis in certain types of injury.
At operation free exposure is essential. Simple suture of the nerve sheaths following excision of the area of fibrosis is the routine operative procedure, and freedom from tension is essential.
The use of splints should be strictly limited and the function of the limb preserved by regular movements of the limb and electrical stimulation of the muscles both before and after operation, and when no operation is performed.
The cases should be segregated at the earliest possible moment under the care of physiotherapists and surgeons with experience in neurosurgery, and this segregation is imperative when the patients are evacuated to New Zealand.
Rehabilitation is a major question in the treatment of these disabilities, and special provision should be made for employment and occupational training.
Battle Casualties Invalided FROM 2 NZEF, 1940–45
|Battle Casualty||Accidental Injury|
|Median and ulnar||21||1|
|Median and another||16|
|Battle Casualty||Accidental Injury|
|Upper Limb||Lower Limb|
|1941||9 (PW)||1941||6 (PW)|
|Post-interosseous||17||Nerve injury: general||33|