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War Surgery and Medicine

Wound Treatment

Wound Treatment

The treatment of gunshot wounds associated with fractures of the long bones consisted essentially in the treatment of the wound, followed by the application of splints to ensure union of the bone in as near perfect length and alignment as possible. In the treatment of the wound the aim was the promotion of rapid healing without infection. This treatment depended on the character of the wound. If the wound consisted of a small puncture of the skin or two small punctures of a perforating wound, and there was no marked swelling of the limb, no operative treatment was required unless some complication was present or a large foreign body was definitely located. These cases, especially in the Desert period, generally healed without any difficulty. When there was any marked swelling, however, exploration was undertaken and the wound dealt with in the same way as an open wound. In the case of the open wound, operation was essential and wound excision undertaken so as to remove all devitalised tissue, especially muscle, as was done in the ordinary flesh wound. In dealing with fractures, very free exposure was essential to open up all nooks and crannies in the depth of the wound and also to relieve all possible tension. For this purpose transverse incision of the deep fascia was often carried out in addition to the usual longitudinal incisions. In perforating wounds the excision had to be carried out in respect of both wounds. In large wounds in the early period of the war extra incisions for dependent drainage were frequently made.

The main bone ends and fragments were generally moulded into satisfactory position. Foreign bodies were removed when found during the wound treatment or sometimes sought for when localised by prior X-ray examination.

The general treatment of the wound was similar to that of the ordinary flesh wound. The closed plaster treatment with local and parenteral sulphonamide, the latter given as a course of six grammes daily for six or seven days, was, at first carried out, and was undoubtedly of value, providing rest and preventing cross infection. Signs and symptoms of infection necessitated inspection of the page 283 wound, with change of plaster and dressing. From the end of 1943 penicillin gradually replaced the sulphonamides, both locally and parenterally. Unsuccessful attempts at primary suture were followed by the performance of delayed primary suture in suitable cases, with large doses of parenteral pencillin both before and after suture. Three-hourly injections were given for five days (a total of 500,000 units) for fractures of the upper extremity and a seven to ten-day course of 700,000–1,000,000 units for those of the lower limb.

In Italy in 1944 delayed primary suture of fractures of the femur, with a gap left for drainage, was tried at 3 NZ General Hospital shortly after the patient's admission, and dressings were left unchanged for three weeks. Parenteral penicillin was given following suture. Finally, in 1945, complete suture, if possible, was carried out twenty-four hours after arrival at the Base, parenteral penicillin having been given regularly in the forward areas, and a full course given afterwards. In a considerable proportion of cases tension prevented complete suture, and partial suture alone was possible, but closure of the deeper part of the wound was aimed at. In other cases when infection was present drainage was necessary, parenteral penicillin being given as a routine in all cases.

Delayed primary suture of arm fractures was carried out even before penicillin became available. During the Cassino battle period one of the New Zealand padres was admitted to 2 NZ General Hospital at Caserta with a severe comminuted fracture of the humerus. The wound was healthy, and it was decided to carry out suture shortly after arrival. Complete success was obtained and, as a result, closure of all similar cases was undertaken, at first without penicillin, utilising sulphathiazole-proflavine locally in some cases.

During the last year of the war in Italy delayed primary suture of all suitable fracture cases was carried out as a routine except when contra-indications such as established sepsis were present, penicillin being given in full dosage.

Secondary repair of wounds by suture or by skin grafting was carried out as soon as practicable, to prevent cross infection and to allow of rapid restoration of function. The closure of the deep part of the wound, ensuring cover for any exposed bone, was infinitely more important than the closure of the skin.

In the latter stages of the war flaps were often fashioned and fixed over any exposed part of bone to preserve the vitality of the bone, the surface of which would otherwise flake off as a sequestrum. A change was made in the dressings used later in the war, and plain gauze was substituted for vaseline gauze. The surgeons were of the opinion that this led to a healthier wound when exposed to delayed primary suture, and also facilitated drainage.

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