MEDICAL DEPARTMENT 
UNITED STATES ARMY 
IN WORLD WAR II MEDICAL DEPARTMENT, UNITED STATES i 
4RMY 
SURGERY IN WORLD WAR II 
ORTHOPEDIC SURGERY 
in the 
MEDITERRANEAN THEATER 
OF OPERATIONS 
Editor in Chief 
Colonel John Boyd Coates. Jr., MC 
Editor for Orthopedic Surgery 
Mather Cleveland, M. D. 
Associate Editor 
Elizabeth M. McFetridge, M. A. 
OFFICE OF THE SURGEON GENERAL 
DEPARTMENT OF THE ARMY 
WASHINGTON, D. C., 1957 SURGERY IN WORLD WAR II 
Prepared under the direction of 
Major General S. B. Hays 
The Surgeon General, United States Army 
Historical Unit, Army Medical Service 
Colonel John Boyd Coates, Jr., MC, Director 
Major I. H. Ahlfeld, MSC, Executive Officer 
Captain J. K. Arima, MSC, Special Projects Officer 
Donald O. Wagner, Ph. D., Chief, Historians Branch 
Willa B. Dial, Chief, Editorial Branch 
Josephine P. Kyle, Chief, Archives and Research Branch 
II azel G. Hine, Chief, Administrative Branch 
Michael E. DeBakey, M. D., Chairman 
Frank B. Berry, M. D. John B. Flick, M. D. 
Brian Blades, M. D. Frank Glenn, M. D. 
J. Barrett Brown, M. D. M. Elliott Randolph, M. D. 
Sterling Bunnell, M. D. Isidor S. Ravdin, M. D. 
Norton Canfield, M. D. Alfred R. Shands, Jr., M. D. 
B. Noland Carter, M. D. Howard E. Snyder, M. D. 
Edward D. Churchill, M. D. R. Glen Spurling, M. D. 
Mather Cleveland, M. D. Barnes Woodhall, M. D. 
Daniel C. Elkin, M. D. Robert M. Zollinger, M. D. 
Colonel Joseph R. Shaeffer, MC (ex officio) 
Colonel John Boyd Coates, Jr., MC (ex officio) 
Advisory Editorial Board ORTHOPEDIC SURGERY 
in the 
MEDITERRANEAN THEATER 
OF OPERATIONS 
by 
Oscar P. Hampton, Jr., M. D., F. A. C. S., Colonel, MC, USAR 
Assistant Professor of Clinical Orthopedic Surgery 
W ashington University School of Medicine, St. Louis, Mo. Foreword 
Orthopedic surgery in the Mediterranean (originally the North African) 
Theater of Operations developed by a process of evolution. One would almost 
be justified in saying that the surgery which was first performed was pioneer- 
ing in character. Certainly, one is justified in saying that the early endeavors 
culminated in superb treatment of combat-incurred injuries of the extremities. 
The Mediterranean theater thus served as a testing ground for the principles 
and techniques which were applied with such success in the later campaigns 
in this theater and by which these injuries were treated in the European 
Theater of Operations in 1944 and 1945. 
When United States Army troops invaded North Africa in the fall of 
1942, almost no medical officers with previous experience of combat-incurred 
injuries of the bones and joints were on active duty in the theater, and no 
official, definitive policies had been established for the management of these 
wounds. It was inevitable, therefore, that these combat-incurred injuries 
should be managed by the principles and techniques then employed in peace- 
time practice and that they should be managed, also, by individual variations 
of these principles and techniques. 
A brief experience showed that the methods employed, however satisfac- 
tory they might have been in the circumstances of peacetime practice, were 
not satisfactory in time of war for a variety of reasons; namely, (1) the logistic 
situation in North Africa; (2) the timelag, which was frequently quite pro- 
longed; and (3) the nature of most combat-incurred wounds, which were 
devastating to a degree entirely unknown in peacetime. 
The new policies of management, which were based on the staged treat- 
ment of battle-incurred wounds, were first applied to soft-tissue wounds. By 
the end of 1943, a year after the beginning of combat in this theater, the prac- 
tice was well established of managing this type of wound by initial and rep- 
arative surgery overseas, with reconstructive procedures reserved for Zone of 
Interior hospitals. By the spring of 1944, it had become accepted practice to 
use the same methods in the management of compound (open) fractures. 
Before the war ended, they were also applied to wounds of the joints. 
The most important consideration in the management of compound frac- 
tures and wounds of the joints was that of sound surgery. The sulfa drugs 
were useful until penicillin became available. Penicillin proved extremely 
valuable in the prevention and control of invasive infection. Both chemo- 
therapy and antibiotic therapy, however, were always regarded as adjunct 
measures. They were never considered as substitutes for indicated surgical 
procedures. VIII 
FOREWORD 
Dr. Hampton’s comprehensive coverage of orthopedic surgery in the 
Mediterranean theater during World War II is the result of careful planning. 
Through the foresight of Col. Edward D. Churchill, MC, chief consultant in 
surgery to the theater surgeon, surveys of special types of combat-incurred 
injuries and other lesions of the hones and joints were planned and carried out 
while the war was still in progress. The analyses of these surveys and the 
conclusions drawn from them add materially to the value of this record. 
It is fortunate that the subject of wartime orthopedic surgery is so 
thoroughly covered in this volume. The errors made early in the war in the 
management of combat-incurred injuries of the bones and joints are frankly 
recorded, as they should be, to prevent the making of the same errors in the 
event of another war. The validity of the principles of management which 
were established in the Mediterranean theater was proved in actual combat. 
They are still valid. These are the principles which must govern the manage- 
ment of mass casualties should total war ensue in the future. Details of 
management may change. Principles of management are permanent. 
The story that is told in this volume is a record of hard experience. It 
is a story that should be generally known. For this reason, I hope that this 
book will find its way into the libraries of medical schools and that the prin- 
ciples which it sets forth will be incorporated in the curricula of these schools. 
The medical students and young physicians who are our future medical officers 
will find the history of orthopedic surgery in the Mediterranean theater a 
helpful introduction to the management of combat-incurred injuries of the 
bones and joints. 
S. B. Hays, 
Major General, United States Army, 
The Surgeon General. Preface 
In World War II, as in all previous wars, wounds of the extremities, a 
great number of which involved the bones and joints, constituted the bulk of 
the surgical load. In the Mediterranean (previously the North African) 
Theater of Operations, of 111,125 wounded or injured in action it is estimated 
that 79,000, more than 71 percent of the total number, sustained wounds of the 
extremities. A significant proportion of these required orthopedic management. 
Incidentally, the number of wounds of the extremities in this theater approxi- 
mately equaled the total number of wounded or injured in action (79,526) in 
the entire Korean conflict. 
These figures are not surprising. In the Mediterranean theater, United 
States Army ground forces experienced the longest period of continuous ground 
combat which they had known since the War Between the States. With only 
very brief interludes, in the early and late summer of 1943, they were in con- 
stant contact with the enemy from 8 November 1942 until 2 May 1945. They 
fought from the shores of Casablanca across North Africa to Bizerte. After a 
short respite, they conquered Sicily. After another interlude, they invaded 
Italy and fought up to the Swiss border. 
The medical history of the Mediterranean theater parallels the tactical 
history. The steady flow of battle casualties through forward and fixed 
hospitals from November 1942 until May 1945 provided a concentrated 
experience in military surgery, unusual opportunities for the observation of 
results, and, on indications, changes in both concepts and methods. These 
changes are described in detail in the chapters of this volume. In brief, the 
management of compound skeletal injuries in the early days of this experience 
was based upon the concepts of plasma for shock, sulfonamide drugs for the 
prevention of infection, and the closed plaster method for the management of 
fractures and wounds. As the result of continuing observation of the results 
obtained in the theater, each of these concepts was discarded. 
Long before the fall of Rome on 5 June 1944, the prevailing concepts were 
that the most important preventive measure against wound infection was 
adequate debridement at initial wound surgery; that whole blood was crucial 
in the management of wounded men; that penicillin, used systemically, was an 
important measure in impending or established infection; and that wounds left 
open at initial surgery need not heal by granulation but, instead, that it was 
surgically feasible to perform delayed closure of clinically clean wounds over 
fractures, following which good results could be anticipated. 
The delayed primary closure of soft-tissue wounds by suture, including 
wounds associated with compound fractures, was not, of course, an entirely 
new concept. It had been practiced to some extent in World War I. In that PREFACE 
X 
war, however, the criterion of low bacterial count on repeated cultures of the 
wound before delayed closure was undertaken not only made the method 
impractical for general use but also, because of the repeated dressings neces- 
sary, was an invitation to secondary infection. In World War II, closure was 
predicated upon only a clean clinical appearance of the wound several 
after the initial surgery. The method was, therefore, more widely applicable. 
The lessons of World War I had, in large measure, to be learned again in 
World War II. Lives and limbs will be saved, and countless extended periods 
of morbidity will be avoided, if the lessons derived from the Mediterranean- 
theater experience with musculoskeletal injuries as set forth in this volume are 
put into practice without delay in any future war. 
Oscar P. Hamptox, Jr., M. D. Acknowledgments 
This reasonably complete and comprehensive record of the experience in 
orthopedic surgery in the Mediterranean Theater of Operations reflects the 
efforts of a number of medical officers who served in that theater during World 
War II. They include— 
Brig. Gen. (later Maj. Gen.) Albert W. Kenner, Brig. Gen. Frederick A. 
Blesse, and Maj. Gen. Morrison C. Stayer, who at various times served as 
theater surgeon and who had the overall responsibilities for the medical activities 
of the theater; and Col. (later Maj. Gen.) Joseph I. Martin, MC, Surgeon, 
Fifth U. S. Army. 
Col. Edward D. Churchill, MC, Chief Consultant in Surgery, Office of the 
Surgeon, Mediterranean Theater of Operations, who guided the transition 
which took place in the theater in the management of wounds of the soft tissues 
and then in the management of wounds involving the bones and joints, and 
which provided the pattern for the subsequent management of these injuries 
in all overseas theaters. 
Col. Frank B. Berry, MC, Chief, Surgical Service, 9th Evacuation Hospital, 
and later Consultant in Surgery, Office of the Surgeon, Seventh U. S. Army, 
whose observations on, and advice concerning, the problems of serious wounds 
of the extremities was invaluable. 
Col. Howard E. Snyder, MC, Consultant in Surgery, Office of the Surgeon, 
Fifth U. S. Army, who effectively taught the principles of good initial surgery 
in all the hospitals of that army. 
Maj. Champ Lyons, MC, Consultant in Wound Infection, Chemotherapy, 
and Penicillin Therapy, Office of the Surgeon, Mediterranean Theater of Oper- 
ations, who did so much to emphasize that penicillin therapy was merely an 
adjuvant to good wound surgery and should be used to obtain better surgical 
results. 
Appreciation is also expressed to the late Brig. Gen. Fred W. Rankin, 
Chief Consultant in Surgery, Office of the Surgeon General, and his assistants, 
Col. B. Noland Carter, MC, and Col. Michael E. DeBakey, MC. They were 
all most helpful in the followup survey on the results of delayed internal fixation 
of compound battle fractures in the Mediterranean theater and on other prob- 
lems of management of casualties with wounds of the bones and joints which 
were carried out in Zone of Interior hospitals. 
Acknowledgment is also made to the various surgeons and orthopedic sur- 
geons in the Mediterranean theater who made the special surveys upon which 
several of the chapters in this volume are based. 
Finally, acknowledgment is made to the chiefs of orthopedic surgery in the 
general and station hospitals in the communications zone in the theater and 
XI XII 
ACKNOWLEDGMENTS 
to the general and orthopedic surgeons in the forward hospitals, all of whom 
aided so materially in the development of the program of initial and reparative 
surgery for compound battle fractures which was in effect at the end of the war. 
A very substantial and indispensable contribution to this volume, in a 
field widely separated from that covered by the author and by the medical 
officers on whose work he has drawn for the content of the book, has been 
made by Melvin J. Hadden, HMC, USN, who, under the direction of Mr. 
Herman Van Cott, chief, Medical Illustration Service, Armed Forces Institute 
of Pathology, prepared the very excellent layouts for the illustrations and super- 
vised artwork and preparation of illustrations for printing. 
Appreciation is expressed to The C. V. Mosby Company for their coopera- 
tion in providing printing media for several illustrations appearing in this 
volume which also appeared in the book “Wounds of the Extremities in Military 
Surgery” by Oscar P. Hampton, Jr., M. D. Prologue 
The principle that underlies all surgical management of battle 
fractures and wounds of major joints was relearned in the field 
in North Africa and Italy. When Serjeant-Chirurgeon Richard 
Wiseman who attended Charles II in his wanderings on the 
continent of Europe in the 17th century wrote on the “Cure 
of Gun-shot Wounds,” he turned to a Latin version of Hip- 
pocrates. Omne quod contusion, necesse est ut putrescat, 
& in pus vertatur, it was written. “What is contused must 
necessarily putrefie, and be turned into matter.” This is the 
ancient principle that surgeons reared under the aseptic mantle 
spread by Lister must come to know when they are called upon 
to deal with the soiled and torn flesh of gunshot wounds. 
“But,” said the young surgeon, “I cannot take responsibility 
for opening a knee joint in a tent with a dirt floor!” “Why 
not,” is the reply, “when the joint already contains devitalized 
cartilage and mud from a foxhole?” 
A distorted version of Trueta’s teaching which omitted his 
emphasis on the careful excision of dead tissue was a false 
starting point, but facts disclosed by experience soon replaced 
unsound ideas. Skeletal pins fixed in plaster do not withstand 
transport. Packing the wound with vaseline gauze causes 
necrosis and macerated flesh. Splinting for transport is a 
different art from splinting for the maintenance of reduction. 
Unpadded plasters abrade the skin. An evil smell and gas 
bubbles do not necessarily spell clostridial myositis. These 
and many more detailed lessons emerged as the product of grim 
experience and came rapidly to the surgeons of the Mediter- 
ranean theater. They are set forth in this volume dealing with 
gunshot wounds of the extremities. 
Edward D. Churchill, M. D. 
XIII Contents 
Page 
FOREWORD VII 
PREFACE IX 
ACKNOWLEDGMENTS XI 
PROLOGUE XIII 
Chapter 
I Introduction 1 
II Administrative Considerations 3 
Evolution of the Consultant System 3 
Visits to Medical Installations 7 
Assignment of Personnel 12 
Facilities 14 
Hospital Administration 25 
Graphic Records 27 
Accumulation of Data 28 
III Splinting in the Combat Zone 29 
Classification of Military Splinting 29 
Emergency Splinting 31 
Transportation Splinting 39 
IV The Management of Compound Battle Fractures 53 
Part I. The Evolution of the Program of Staged Management 
Concepts and Practices Before World War II 53 
United States Experiences With the Closed Plaster Method 55 
Development of the Program of Reparative Surgery 58 
Application of the Reparative-Surgery Program to Compound Fractures- 61 
Part II. The Initial Surgery of Compound Fractures 
Surgical Timing 64 
First Aid 66 
Preparation for Initial Wound Surgery 67 
Appraisal of the Wound 71 
General Principles and Practices 72 
Technical Considerations 74 
Management of Bone Fragments 78 
Fracture Management 80 
Postoperative Regimen 80 
Evacuation 80 
Part III. The Reparative Surgery of Compound Fractures 
Preoperative Preparation 82 
Technical Considerations 83 
Postoperative Management 103 
Results 1 103 XVI 
CONTEXTS 
Chapter Page 
V Regional Compound Fractures 115 
Part I. Compound Fractures of the Humerus, Radius, and Ulna 
General Considerations 115 
Problems of Management 115 
General Principles of Management 116 
Compound Fractures of the Humerus 121 
Compound Fractures of the Radius and Ulna 133 
Conclusions 137 
Part II. Compound Fractures of the Femur 
General Considerations 137 
Survey of Results, Spring, 1944 139 
Source Material 140 
The Program of Reparative Surgery 141 
Technical Considerations 142 
Appraisal of Results 157 
Conclusions 159 
Part III. Compound Fractures of the Tibia and Fibula 
The Reparative-Surgery Program 160 
Analysis of Cases, 1944-45 161 
Wound Management 162 
Fracture Management 164 
Evaluation of Results 173 
Part TV. Compound Fractures of the Foot 
Wound Management 181 
Fracture Management 182 
Postoperative Management 183 
VI Delayed Internal Fixation of Compound Battle Fractures—A Followup Study 
in the Zone of Interior 185 
Technical Considerations 187 
Survey of Results 188 
Conclusions of the Survey 197 
Analysis of Unfavorable Results 200 
VII External Skeletal Fixation of Fractures in the Communications Zone 203 
Analysis of Cases 203 
VIII Wounds of Joints 211 
Historical Note 211 
General Considerations 213 
Wounds of the Knee Joint 215 
Wounds of the Hip Joint 237 
Wounds of the Smaller Joints 243 
IX Amputations 245 
Indications 246 
Technical Considerations 247 
Analysis of Cases 260 
X Noncombat Orthopedic Lesions 271 
General Principles of Management 272 
The Management of Painful Backs and Feet 274 
Surveys of Management of Noncombat Orthopedic Lesions 276 
Internal Derangements of the Knee 277 CONTEXTS 
XVII 
Chapter Page 
X Non combat Orthopedic Lesions—-Continued 
Joint Mice (Osteochondritis Dissecans) 280 
Recurrent Dislocations of the Shoulder 287 
Fractures of the Carpal Scaphoid Bone 290 
XI Disposition of Patients From Orthopedic Services of General Hospitals 295 
General Principles of Disposition 295 
A Sample Hospital Experience 297 
APPENDIX 299 
INDEX 345 
Tables 
Number 
1 Timing of splinting of compound battle fractures in relation to objectives and 
facilities 30 
2 Relationship of shock and blood loss in 67 battle casualties 69 
3 Blood replacement before and during initial surgery in 100 compound fractures. 70 
4 Results in relation to procedure and wound healing in 147 compound fractures 
of humerus 131 
5 Results in relation to technique and status of fracture in 147 compound fractures 
of humerus 131 
6 Results in relation to technique, wound healing, and status of fracture in 147 
compound fractures of humerus 132 
7 Location of Kirschner wire for skeletal traction in 613 compound fractures of 
femur 149 
8 Methods of fracture management in 1,063 compound fractures of femoral shaft. 157 
9 Techniques of internal fixation in 284 fractures of femoral shaft 157 
10 Appraisal of wound healing in 825 compound fractures of femoral shaft 158 
11 Fracture management in 622 compound fractures of tibia and tibia and fibula.. 167 
12 Fracture management in relation to level of tibial injury in 621 compound frac- 
tures of tibia and tibia and fibula 167 
13 Severity of injury in relation to location of fracture in 132 compound fractures 
of tibia and 80 of tibia and fibula 178 
14 Results in relation to severity of injury and technique of wound management in 
132 compound fractures of tibia and 80 of tibia and fibula 179 
15 Results in relation to severity of injury and technique of fracture management 
in 132 compound fractures of tibia and 80 of tibia and fibula 180 
16 Combined results of wound and fracture management in relation to severity of 
injury in 132 compound fractures of tibia and 80 of tibia and fibula 180 
17 Results of internal fixation on obligate indications in 135 compound fractures. _ 193 
18 Results of internal fixation on elective indications in 165 compound fractures 193 
19 Results of internal fixation in relation to indications in 67 compound fractures 
of humerus 193 
20 Results of internal fixation in relation to indications in 31 compound fractures 
of radius and ulna 194 
21 Results of internal fixation in relation to indications in 146 compound fractures 
of femur 194 
22 Results of internal fixation in relation to indications in 88 compound fractures 
of tibia and fibula 194 
396961 °—57 2 XVIII 
CONTEXTS 
Number Page 
23 Composite results of internal fixation in relation to technique and location of 
fracture in 332 compound fractures of long bones 195 
24 Results of internal fixation in 29 compound fractures with established wound 
infection 196 
25 Essential data on 14 fractures treated by external skeletal fixation 205 
26 Essential data on 27 fractures treated by external skeletal fixation 205 
27 Essential data on 25 fractures treated by external skeletal fixation 206 
28 Sites of amputation in 1,379 separate operations on United States Army troops. 263 
29 Sites of amputation in 1,389 separate operations on German prisoners of war 264 
30 Agents of wounding and causes of amputation in 1,271 United States Army 
troops 265 
31 Agents of wounding and causes of amputation in 1,332 German prisoners of war. 266 
32 Complicating injuries in 1,000 United States Army amputees 266 
33 Indications for amputation in 1,344 operations following wounds or injuries in 
United States Army troops 267 
34 Indications for 843 primary and 243 secondary amputations in United States 
Army troops 267 
35 Indications for 962 primary and 427 secondary amputations in German prisoners 
of war 268 
36 Combinations of levels in 85 multiple amputations in United States Army cas- 
ualties 269 
Illustrations 
Figure 
1 First aid in field 15 
2 Scenes at first-aid stations 16 
3 Scenes at collecting station 18 
4 Arrival of casualty at admission tent of clearing station 19 
5 Ambulance transportation of wounded 20 
6 Scenes in field hospital 21 
7 Scenes in evacuation hospital 22 
8 Evacuation hospital 23 
9 General hospital 24 
10 Improvised battlefield splinting for fracture of femur 33 
11 Emergency splinting for fractures of forearm and about elbow and wrist 35 
12 Emergency splinting for fracture of humerus 36 
13 Emergency splinting for fractures of lower third of leg and ankle 37 
14 Emergency splinting for injuries of thigh, knee joint, and leg 38 
15 Improvised techniques of splinting after initial wound surgery 42 
16 Modification of elephant-tusk splint for fractures about shoulder joint and elbow. 44 
17 Plaster Velpeau bandage for injuries of shoulder joint, arm, or elbow 45 
18 Shoulder spica for injuries about shoulder joint and of arm 46 
19 Transportation splinting of compound fracture of femur with hip spica 48 
20 Modified Tobruk splint 50 
21 Transportation splinting for fractures of lower extremities 52 
22 Staged surgery of wound of calf 60 
23 Staged surgery of wound of right arm 61 
24 Reparative surgery of wound of left axilla and shoulder 62 
25 Initial wound surgery of soft-part wound 75 
26 Staged surgery of wound of thigh 76 CONTEXTS 
XIX 
Figure Page 
27 Initial surgery of wound of thigh 77 
28 Appearance of wound at completion of initial surgery 78 
29 Correct excisional surgery in infected compound comminuted fractures of left 
tibia and right femur 85 
30 Management of compound comminuted fractures of femur and patella by de- 
layed internal fixation 88 
31 Reparative management of wound of thigh with associated compound fracture 
of femur 90 
32 Management of compound comminuted fractures of right tibia and fibula by 
delayed internal fixation .. 92 
33 Staged management of compound comminuted fracture of femur 94 
34 Management of compound comminuted fracture of femur by delayed internal 
fixation 95 
35 Staged surgery of bilateral compound fractures of shaft of femur 96 
36 Management of compound fractures of tibia and fibula by internal fixation 104 
37 Comminuted compound fracture of right humerus with radial-nerve paralysis 106 
38 Compound comminuted fracture of right humerus with loss of bone 108 
39 Staged management of associated humeral-radial fractures and nerve injury by 
shortening of bone 111 
40 Reparative management of fracture of tibia 112 
41 Management of compound comminuted fracture of femur by balanced-suspen- 
sion skeletal traction 113 
42 Management of compound fracture of right tibia by staged surgery and modified 
closed plaster technique 114 
43 Management by delayed internal fixation of compound comminuted fracture of 
humerus, with loss of bone and laceration of median and ulnar nerves . 118 
44 Management by delayed internal fixation of compound comminuted fracture of 
humerus with segmental loss of bone and laceration of radial nerve 120 
45 Splinting for paralysis of radial nerve 121 
46 Comminuted fracture dislocation of right shoulder, comminuted fractures of 
humerus and both bones of forearm, with injuries of median and radial 
nerves 124 
47 Hanging cast for fracture of humerus 126 
48 Shoulder spica cast for fracture about shoulder joint 127 
49 Unsuccessful management of compound comminuted fracture of right radius 
and ulna 135 
50 Management of compound comminuted fracture of radius and ulna by delayed 
internal fixation 136 
51 Suspension traction in 90-90-90 position for compound fracture of femur 143 
52 Management of compound oblique fracture of femur by delayed internal fixation. 144 
53 Internal fixation of displaced fracture of medial femoral condyle 147 
54 Two-wire skeletal traction for battle fracture of femur 150 
55 Balanced-suspension skeletal traction by half-ring leg splint and Pierson attach- 
ment 151 
56 Navy traction for fracture of femur 152 
57 Modlin modification of Navy traction for fracture of femur 153 
58 Linch modification of Navy traction for fracture of femur 154 
59 Skeletal traction by 90-90-90 suspension method for fracture of femur ... 155 
60 Anteroposterior and lateral roentgenograms showing fracture of tibia with loss 
of bone 166 
61 Skeletal traction in fractures of both bones of leg 168 
62 Roentgenologic results of skeletal traction in cast 169 XX 
CONTEXTS 
Figure Page 
63 Management of compound comminuted fractures of tibia and fibula by delayed 
internal fixation 171 
64 Management of compound comminuted fractures of tibia and fibula by delayed 
internal fixation 172 
65 Management of compound comminuted fractures of tibia and fibula 174 
66 Management of comminuted fracture of tibia and fibula, by plating of fibula 176 
67 Management of fractures of fibula and tibia, with loss of bone, by plating of fibula. 177 
68 Management of compound comminuted fracture of radius, with loss of bone and 
median-nerve palsy, by external skeletal fixation ... 208 
69 Management of segmental compound comminuted fractures of tibia and fibula 
by external skeletal traction 209 
70 Staged management of wound of left knee joint 218 
71 Staged management of penetrating wound of knee joint with comminuted 
fracture of femur 220 
72 Management of early suppurative arthritis of knee joint 222 
73 Management of early suppurative arthritis of knee joint 224 
74 Management of suppurative arthritis of knee joint 226 
75 Management of suppurative arthritis of knee joint 228 
76 Management of suppurative arthritis of knee joint 230 
77 Management of suppurative arthritis of knee joint 232 
78 Management of suppurative arthritis of hip joint 238 
79 Management of suppurative arthritis of hip joint 239 
80 Management of suppurative arthritis of hip joint 240 
81 Destructive injury of entire left leg 246 
82 Bilateral traumatic amputations of legs 247 
83 Bilateral injuries of lower extremities 248 
84 Traumatic amputation of right leg, multiple penetrating wounds of left leg 250 
85 Amputation stump of left forearm 251 
86 Technique of open circular amputation 252 
87 Application of skin traction after amputation of leg 253 
88 Plaster cast with elastic traction 254 
89 Traumatic amputation of right leg, compound fracture of bones of left leg 255 
90 Open circular amputation through middle third of forearm 256 
91 Healed stumps after amputation by open circular technique 257 
92 Closure of amputation stumps 258 
93 Closure of amputation stump 259 
94 Closure of amputation stump 260 
95 Amputation by open flap technique, with closure of flaps at reparative surgery. 261 
96 Amputation through leg near site of election, with preservation of posterior 
viable flap of skin 262 CHAPTER I 
Introduction 
The combat experience in the Mediterranean area lasted from November 
1942 until May 1945. During this period of approximately 30 months, battle 
casualties were treated by the officers of the United States Army Medical 
Corps in the various echelons of the theater. Casualties were often heavy, 
and they continued to be received, in smaller numbers, even during the infre- 
quent periods when combat activity was diminished. 
During the period from January 1942 to June 1944, admissions to United 
States Army hospitals in England were limited to casualties from the Army 
Air Forces and a few British casualties received from the Mediterranean 
theater. Ground forces were engaged in combat in the European theater, and 
battle casualties were heavy only between D-day, 6 June 1944, and V-E Day, 
8 May 1945. 
The medical officers in the Mediterranean theater thus had a much longer 
experience in the treatment of battle casualties than the medical officers in 
the European theater and had correspondingly greater opportunities to gather 
data for the evaluation of their techniques of treatment. 
The Mediterranean theater, with a relatively small number of troops and 
relatively few hospitals, was extremely fortunate in having assigned to it a 
considerable number of affiliated general hospitals. Many able young 
orthopedic surgeons were on the staffs of these hospitals. Col. Edward D. 
Churchill, MC, consultant in surgery to the theater surgeon, stimulated and 
encouraged his junior officers to record and analyze their surgical experiences. 
Lt. Col. (later Col.) Oscar P. Hampton, Jr., MC, consultant in orthopedic 
surgery for the theater, was indefatigable in spreading throughout the hospitals 
of the theater the principles upon which the surgery of wounds of the bones 
and joints is based. 
During the war and immediately thereafter, Colonel Hampton, with the 
assistance of many of his colleagues, collected invaluable data on military 
orthopedic surgery. The studies which were the result of these investigations 
and which are presented in this volume form an unusually complete and com- 
prehensive analysis of orthopedic surgery in an overseas theater. 
Mather Cleveland, M. D., 
Formerly Colonel, MC, AUS, 
Editor for Orthopedic Surgery. CHAPTER II 
Administrative Considerations 
During the approximately 2,500-mile advance by United States Army 
troops from Casablanca in North Africa, where landings were made in Novem- 
ber 1942, to Como on the Swiss border of Italy, which was reached early in 
May 1945, a continuous flow of casualties were treated in United States Army 
hospitals. This was the largest continuous combat experience for United 
States troops since the War of the Rebellion. 
Many of these casualties had suffered bone and joint injuries. All of 
them were treated under conditions without parallel in any previous war. 
They were treated initially by concepts and methods prevailing in civilian 
practice, many of which were soon found wanting in the circumstances of mili- 
tary surgery. Similarly, some of the techniques which had been employed 
surgeons of Allied armies already in the field and which were adopted by United 
States Army surgeons were also found wanting. Increasing experience and 
repeated critical evaluation of results frequently led to the modification of 
concepts originally accepted and methods originally used and sometimes led 
to their replacement by entirely new measures. Modification and replacement 
of the techniques originally used were, however, a matter of evolution; they 
were not accomplished by directives. 
The regimen for the management of bone and joint injuries which was in 
effect at the end of the war was based upon a program of staged management 
which was applicable to all wounds and which had evolved from continuing 
experience. Neither of its component parts, initial surgery and reparative 
surgery, was new, nor was the combination of the two components new. Such 
a program had been recommended by some surgeons and employed in some 
cases in World War I. It was not until the spring of 1944, however, that the 
scope and timing of the program were fully developed in World War II and that 
it was universally applied. This program was applicable to most wounds of 
the soft tissues and was of major importance in the management of bone and 
joint injuries, the end results of which depended, as much as upon any other 
single factor, upon the initial management and later reparative management 
of the compounding soft-tissue wound. 
EVOLUTION OF THE CONSULTANT SYSTEM 
Officers and enlisted men of the Army Medical Department assigned or 
attached to combat elements furnished the only medical support for the North 
African landings 8 November 1942, but mobile and fixed hospitals, staffed with 
3 4 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
their intrinsic professional personnel, were established soon afterward. It was 
not until March 1943, however, that the consultant system began to function 
in the theater, with the arrival of Col. Edward D. Churchill, MC, consultant 
in surgery to the theater surgeon. There was a lapse of another 6 months 
before, on the recommendation of Colonel Churchill, a consultant in orthopedic 
surgery was appointed. 
By the time the consultant in this specialty was appointed, it had become 
apparent that orthopedic surgery was sufficiently important in its own right 
in this active theater of operations to require more direct attention than a 
consult ant in surgery could spare for it from his other duties. This was because 
(1) a large proportion of all combat-incurred injuries involve the bones and 
joints and (2) a large proportion of these wounds present major problems of 
management. 
The landing at Salerno on the Italian mainland by the Fifth U. S. Army 
in September 1943 had resulted in a considerable increase in all casualties and 
in a corresponding increase in the number of bone and joint injuries. At the 
same time, certain personnel problems became apparent. Shortly after the 
landings in Italy, 11 general hospitals and several large station hospitals desig- 
nated to operate in Bizerte, Oran, and Naples, arrived from the Zone of Interior. 
Previous experience had already revealed the need for supervision of the man- 
agement of casualties with bone and joint injuries. In particular, it had showed 
that orthopedic surgeons without previous military experience, however wide 
their experience in civilian orthopedic practice might have been, required 
orientation in the principles and techniques of military surgery. 
Maj. (later Col.) Oscar P. Hampton, Jr., MC, chief, orthopedic section, 
21st General Hospital, was therefore placed on duty in the Office of the Sur- 
geon, North African Theater of Operations, as acting consultant in orthopedic 
surgery. His mission was (1) to visit the newly arrived general hospitals; 
(2) to appraise the professional qualifications of their orthopedic staffs; (3) to 
acquaint their staffs with previous experiences in the theater in the manage- 
ment of combat-incurred bone and joint injuries; and (4) to record observa- 
tions which might lead to improvement in the management of these injuries. 
When this mission was concluded, in December 1943, Major Hampton was 
dispatched to the Fifth Army, then fighting near Cassino, to communicate to 
forward surgeons the observations he had made in the base area, with par- 
ticular reference to the quality of initial wound surgery and transportation 
splinting. Throughout the war, the exchange of experiences between hospi- 
tals of forward and rear areas was to prove one of the most profitable func- 
tions performed by all consultants. 
After February 1944, when the position of consultant in orthopedic sur- 
gery to the theater surgeon was made permanent, Lieutenant Colonel Hampton 
continued to function in that capacity under the consultant in surgery until 
the consultant staff of the theater was deactivated in September 1945. 
Neither the II Corps, which operated in Africa, Sicily, and Italy, nor the 
Seventh U. S. Army, which operated in Sicily, Italy, and southern France, ADMINISTRATIVE CONSIDERATIONS 
ever had an officer assigned as consultant in orthopedic surgery. When Capt. 
(later Maj.) Floyd H. Jergesen, MC, of the 2d Auxiliary Surgical Group, was 
placed on temporary duty in the office of the surgeon, Fifth U. S. Army, late 
in 1943, to make a special study of gas gangrene with Maj. (later Lt. Col.) 
F. A. Simeone, MC, he was also appointed acting consultant in orthopedic 
surgery to the Fifth Army and served in this capacity until after the Cassino- 
Rome campaign in May and June 1944. Thereafter, as in the Seventh Army, 
the surgical consultant to the Fifth Army supervised the management of bone 
and joint injuries. 
In retrospect, delay in the appointment of a consultant in orthopedic 
surgery for the Mediterranean theater appears to have been wise. At the 
time of the North African landings, as has already been pointed out, few if 
any of the medical officers in the United States Army had had any experience 
with battle-incurred bone and joint injuries. Furthermore, none of the ortho- 
pedic surgeons who participated in the landings had served as observers with 
the Allied armies before the entrance of the United States into the war. Sound 
policymaking was obviously impossible until some experience in military 
injuries had been achieved. During the first months of combat, therefore, 
the surgeons in charge of the orthopedic sections in the various fixed hospitals 
worked out their special problems, observed the results of different methods 
of management, and in many instances recorded the data upon which sound 
future recommendations could be based. When a consultant in orthopedic 
surgery was finally appointed, comprehensive plans for the management of 
combat-incurred injuries were being evolved, and the experience in the theater, 
as far as it had gone, could be transmitted in an organized fashion to newly 
arrived personnel. 
Whether the decision not to appoint consultants in orthopedic surgery to 
the armies was equally wise is more open to question. A basis for the deci- 
sion was that even serious wounds of the extremities were usually, from the 
standpoint of initial wound surgery, second-priority cases, and that orthopedic 
surgeons were usually assigned to the evacuation hospitals in which the for- 
ward surgery of bone and joint wounds was chiefly performed. The policy 
of assigning orthopedic surgeons to evacuation hospitals may have been waste- 
ful of trained personnel, as will be pointed out shortly (p. 13). The appoint- 
ment of a consultant in orthopedic surgery to each army would have elim- 
inated the need for a trained orthopedic surgeon in each evacuation hospital 
and would have meant a considerable saving in specialized personnel, who 
were always in short supply. There would have been other advantages in 
the appointment of an orthopedic surgeon to each of the armies. Such a 
consultant, moving continuously from hospital to hospital, could have done 
much, in his supervisory role, to improve the initial surgery of wounds of the 
extremities. He could also have played an important role in the education 
of medical officers who had had no previous experience in military surgery 
and who, in many instances, had had no previous experience in bone and 
joint injuries. 6 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Functions of the Consultant 
Both as acting consultant in orthopedic surgery and in his permanent 
capacity, the consultant in orthopedic surgery routinely advised the theater 
surgeon, through the consultant in surgery, on a variety of matters, such as the 
following: (1) The personnel assignments to orthopedic-surgery sections, in- 
cluding not oidy those of trained orthopedic surgeons but those of other surgeons 
and other medical officers who had to assume the management of bone and 
joint injuries; (2) the organization and functioning of orthopedic sections; 
(3) the quality of the management of bone and joint injuries; (4) changes in 
concepts and techniques of orthopedic surgery, both as the consultant in ortho- 
pedic surgery personally observed these changes and as they were reported to 
him in Ids official capacity; (5) the results being obtained; and (6) future 
planning. 
Some of the consultant’s time was necessarily spent at headquarters in 
administrative work, but most of his time was spent in the field. With the 
approval of army surgeons, frequent visits were made to hospitals in the combat 
zone, particularly during offensives, when the flow of casualties was heavy. 
Methods of management were observed, and suggestions for improvement 
were made to the consultant in surgery for each field army. These suggestions 
chiefly concerned the principles of debridement and the application of trans- 
portation splinting as a preliminary to the further treatment of casualties in 
the communications zone. 
One of the chief problems in forward areas was the training of surgeons 
who had to care for casualties with bone and joint injuries but who had had no 
previous experience to qualify them for this duty. As a continuing effort, this 
was the responsibility of the chiefs of surgery in the various hospitals, but it 
was also a major responsibility of the consultants in surgery for the theater and 
the armies, and of the theater consultant in orthopedic surgery. 
The consultant in orthopedic surgery utilized his time chiefly in the hospitals 
of the communications zone, where fractures and other conditions of the bones 
and joints could be segregated and where more definitive management of these 
injuries was accomplished. This was in contrast to the situation in the hospitals 
of the army area, where bone and joint injuries were, for the most part, a part 
of the general surgical problem. The major portion of the consultant’s time 
was spent in hospitals close to the rear boundary of the army. These were the 
installations in which casualties were received from forward hospitals at the 
time when precise definitive surgery was necessary and could be most effectively 
carried out. 
The general plan was to visit each fixed hospital for several days at a time, 
actually living with the orthopedic staff, observing their work in the operating 
room, following them on ward rounds, discussing general and special problems 
in both formal and informal sessions, suggesting and implementing such changes 
in policies and practices as special circumstances might require, and rendering 
whatever other aid was requested. These were tours of inspection, it is true, ADMINISTRATIVE CONSIDERATIONS 
but the major emphasis was upon their instructional aspects. The most 
practical way to achieve this objective was to study, with the medical officers 
assigned to the orthopedic section, the cases under treatment at the time of the 
visit. 
These studies were comprehensive. They included the history of wounding, 
details of previous treatment, roentgenologic examinations, progress to date, 
plans for future care, anticipated disposition, and possibilities for later recon- 
structive surgery. It was always emphasized that, while the management of 
orthopedic problems was necessarily conducted by inclusive rides in time of war, 
the objective in each case was individual—to obtain the best result that could 
be obtained for the particular patient under consideration. 
Improved techniques observed in one hospital were communicated to other 
hospitals as the consultant visited them in their turn. When new regimens 
were in process of introduction, when the volume of work was excessive, or when 
specific clinical observations had to be made for future planning, the consultant 
in orthopedic surgery frequently remained in one hospital for a week or more, 
integrating himself, for all practical purposes, into the hospital staff for this 
period of time, in order to accomplish results more quickly. 
Although in all of these tours some attention was given to elective surgery, 
its performance was generally discouraged (p. 271). Emphasis was placed 
upon the necessity, in all military surgery, for the prompt return of the soldier 
to duty and upon the lack of justification for the use of hospital-bed space by 
any man whose future combat usefulness could not be assured. 
Special educational efforts had to be undertaken when such radical changes 
were in the making as (1) the application of reparative surgery to compound 
fractures, in the spring of 1944 (p. 58); and (2) the extension of the program to 
wounds of the hip joint some months later (p. 242). 
VISITS TO MEDICAL INSTALLATIONS 
The activities of the consultant in orthopedic surgery in the Mediterranean 
theater can best be illustrated by his (summarized) reports to the theater 
surgeon of two typical visits of instruction, one in September and the other in 
October and November 1944. 
September 1944 
This tour, which began 8 September and ended 26 September 1944, covered 
the following hospitals: 
Army hospitals.—Army hospitals visited included the 8th, 38th, and 94th 
Evacuation Hospitals and platoons of the 33d Field Hospital. The matters 
examined, which were later discussed with Lt. Col. (later Col.) Howard E. 
Snyder, MC, consultant in surgery, Fifth U. S. Army, were as follows: 
1. Amputations were discussed in the light of Circular Letter No. 46, 29 
August 1944, Office of the Surgeon, North African Theater of Operations, 8 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
United States Army.1 Emphasis was placed upon the importance of good skin 
traction and the use of the elastic cord which had become available for this 
purpose. 
2. The results of the methods then in use for handling wounds of the knee 
joints were reported. Emphasis was placed upon the importance of good im- 
mobilization in the forward area by the use of single hip spica casts, or, at 
at least, Tobruk splints. Emphasis was also placed upon the instillation of 
penicillin after the joint had been closed at operation and upon aspiration, with 
reinstillation of penicillin, through a window in the cast 24 to 48 hours after 
operation. 
3. It was recommended that injured hands be immobilized in the position 
of function and that a good occlusive dressing be applied. It was also recom- 
mended that a trial be given to the so-called boxing-glove type of plaster cast 
over mechanic’s waste and sheet cotton. This method was then being tested 
in a number of hospitals, and its more extensive use was suggested. 
4. It was pointed out that immobilization and the use of an occlusive 
dressing in wounds of the soft parts treated in forward areas were essential 
for successful reparative surgery in rear hospitals. 
64th General Hospital.—This hospital, which was visited 11-15 September, 
was the only general hospital at Leghorn, Italy. It was very busy with battle 
casualties. Some few were admitted for initial wound surgery. Others were 
received from evacuation hospitals. Many patients were admitted from station 
hospitals with large outpatient clinics. The casualties included both United 
States and British naval personnel. Although relatively few seriously wounded 
men were being admitted at this time, the treatment of many of the injuries 
was very time consuming. Arrangements for handling fresh battle casualties 
were excellent, and the work was well integrated with the reparative phase of 
the hospital work. 
Surgery on fracture cases was observed in the operating room, and ward 
rounds were made. In general, reparative surgery was satisfactory. There 
had been some modifications in the program, the evaluation of which could be 
made only at a later date. A few fractures had been managed by internal 
fixation. Results in the few wounds which had been closed at initial wound 
surgery were not considered satisfactory, and staged procedures were advised. 
The sections of Circular Letter No. 46 which applied to orthopedic surges 
were discussed. 
It was noted at this hospital that several soldiers of the 92d Infantry 
Division had received tetanus antitoxin instead of tetanus toxoid. A wound 
adjacent to the knee had been sutured in the battalion aid station with the 
foreign body still in situ. These and related observations were reported to 
Colonel Snyder, 
Hospitals in the Rome area.—The 33d General Hospital was not receiving 
patients at the time of this visit, and all remaining patients were already pre- 
1 See appendix, pp. 326-331. ADMINISTRATIVE CONSIDERATIONS 
9 
pared for transfer to other hospitals. The more serious fracture cases were 
examined on the wards. Under the stress of closing the hospital, a number of 
patients with fractures of the femur had been boarded for the Zone of Interior. 
Their transportability seemed doubtful, and it was suggested that notes be made 
on their records to warn the next receiving hospital that further definitive care 
might be needed before evacuation. 
The reparative-surgery program had been carried out well in this hospital, 
with strong (perhaps excessive) emphasis on internal fixation. 
The 12th General Hospital had an excellent program of reparative surgery 
in accordance with theater recommendations. The orthopedic section had an 
extremely conservative attitude toward the internal fixation of compound 
fractures. 
The 12th General Hospital made a number of suggestions, including the 
following: 
1. That dry fine-mesh gauze be substituted for vaseline gauze in all 
echelons. 
2. That hand injuries observed in forward areas be put up with mechanic’s 
waste between the fingers as well as over the entire hand in the application 
of pressure dressings. There was skepticism about the value of the boxing- 
glove plaster cast, but it was regarded as worthy of a trial. 
3. That simple interrupted sutures be used for delayed primary closures, 
instead of vertical mattress sutures. 
The 6th General Hospital was visited for only half a day, and the number 
of cases observed was necessarily limited. The reparative-surgery program 
was in full use, with satisfactory results. At a meeting of the surgical staff, 
Circular Letter No. 46 was freely discussed. Objection was raised to the “no 
deviation” clause under amputations, and a case was described in which each 
dressing produced hemorrhage until a skin graft was applied; then healing was 
prompt. The staff concurred in the principles laid down in this circular but 
felt that occasional exceptions should be permitted. It was suggested that, 
if and when good surgical judgment seemed to call for a deviation from the 
stated policies, the deviation should be permitted but full explanatory notes 
should be added to the record. 
In the light of the 60-day holding policy, the section on duration of traction 
for fractures of the femur was also questioned. It was agreed that Circular 
Letter No. 46 gave the hospital staff authority to maintain traction as long as 
a patient’s condition required it. 
At the 73d Station Hospital, a planeload of battle casualties had been 
received from France the night before. Many of the injuries were serious, 
including fractures of the femur and wounds of the knee joint. Arrangements 
had been made to transfer the most seriously wounded patients to a general 
hospital. Several fractures of the femur were in traction on the wards. It 
was suggested that in the future, if such patients were transportable, they be 
sent to a general hospital as soon as possible after admission. Some excellent 
results were seen in this station hospital, but a tendency was noted to hold, as 10 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
possible category B (limited duty) dispositions, patients who would almost 
certainly require category C dispositions. The whole question of disposi- 
tions was discussed with the chief of the surgical section. 
It was noted in all the general hospitals visited that many patients who 
had received penicillin in the evacuation hospitals were being received without 
the proper notification (“On Penicillin,,) in the appropriate place on the jacket 
of the Medical Field Record, as prescribed in Circular Letter No. 36, 1 July 
1944, Office of the Surgeon, North African Theater of Operations, United 
States Army.2 This omission was reported to Colonel Snyder. 
October-November 1944 
These visits of inspection, which began 15 October and ended 19 Novem- 
ber, covered the Continental Advance and Delta Base Sections. 
Continental Advance Base Section.—The 46th General Hospital was 
visited 16-24 October and again 17 November. The surgical service, on the 
first visit, was heavily loaded with both United States and French battle 
casualties. French casualties were reaching the hospital without initial wound 
surgery. Efforts to perform initial surgery on the French casualties and repara- 
tive surgery on both French and United States casualties had taxed the sur- 
geons to the limit, and reparative surgery had been possible to only a limited 
degree. Formal and informal conferences were held with the surgical service, 
laboratory service, and commanding officer, and the North African Theater of 
Operations, United States Army plan of reparative surgery, which consisted 
of surgery, blood replacement, and penicillin therapy, was described in detail. 
The reception of the plan was enthusiastic. At the request of the orthopedic 
surgeons, a number of patients were operated on to demonstrate the principles 
of the program. Many case histories were obtained, and serial photographs 
were arranged for. On the return visit to this hospital, 17 November, the 
new program was found to be functioning adequately. 
The 36th General Hospital was visited 25-28 October, 30 October-1 
November, and 16 November. At the time of the first visit, the surgical service 
was functioning with incomplete physical facilities, and the orthopedic section 
was particularly handicapped. Improvement was noted on the return visits, 
which were made at the request of the recently installed chief of the orthopedic 
service, for consultation on a number of cases of various types. This officer 
was doing an excellent job. 
The 21st General Hospital was visited 29 October. The surgical service 
was not yet ready for admissions, but the facilities planned for the orthopedic 
section were the best yet seen in the theater. The orthopedic staff, as the 
result of an extensive experience, was already competent in reparative surgery. 
The 180th Station Hospital was visited 1 November. At a staff meeting, 
the entire program of reparative surgery was presented and was followed by 
a prolonged question-and-answer session. 
3 See appendix, pp. 321-326. ADMINISTRATIVE CONSIDERATIONS 
11 
The 35th Station Hospital was visited 2 November, when the weather pre- 
vented travel to the Delta Base Section, as planned. Reparative surgery was 
discussed at length with the chiefs of surgery and orthopedic surgery. The 
hospital was busy with minor battle casualties and bad received some severely 
wounded patients from two plane crashes and a number of roadside accidents. 
Many patients were seen on the wards in consultation. The professional work 
was good. 
Delta Base Section.—The 43d General Hospital was visited 3-6 November, 
10-11 November, and 13-15 November. The surgical service was overloaded 
with United States Army casualties and German prisoners of war. Reparative 
surgery was in progress on the wounds of the soft parts. The chief of the 
orthopedic section was then hospitalized; later, he had to be evacuated to the 
United States, and a new chief of section was subsequently appointed by the 
hospital commander. Formal and informal conferences were held, and many 
patients were seen in consultation. Some were operated on, by request, to 
demonstrate the principles of the reparative-surgery program. Considerable 
progress was being made on orthopedic work in this hospital. 
The 3d General Hospital was visited 7 November. Orthopedic surgery 
was being conducted along the same principles as had been previously employed 
at this hospital. Some cases were well handled, but the management of others 
did not measure up to the theater standards. This situation was reported to 
the Delta Base surgeon. 
The 78th Station Hospital was visited 8 November. This hospital had 
received casualties from the Airborne Task Force, the most severely wounded 
of whom had received initial surgery at the 514th Clearing Company. Ward 
rounds were made and problems discussed. Transfers to general hospitals were 
being made correctly. 
The 70th Station Hospital was visited 12 November. Surgery on the 
usual good station-hospital level was being performed. 
The 80th Station Hospital was visited 12 November. The chief of surgery 
appeared to be doing an excellent job. All phases of reparative surgery were 
discussed with him. Several special problems, among them fractured femurs, 
were observed and discussed on the wards. 
The 514th Clearing Company was visited 9 November. This station now 
had roentgenologic facilities, and its equipment was considered satisfactory. 
Two surgical teams, one from the 36th General Hospital and one from the 43d 
General Hospital, were attached to this Company. Operations had numbered 
32 in September, 58 in October, and 16 to date in November. The work did 
not justify the attachment of two surgical teams, and the Delta Base Section 
surgeon was so informed. He planned to return the team from the 36th 
General Hospital to its proper station. The teams were advised to split all 
plaster casts (unsplit casts having been observed at the 78th Station Hospital) 
and to utilize elastic cord, a supply of which was on hand, for skin traction on 
amputation stumps. 12 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Additional activities.—The consultant in surgery, Seventh U. S. Army, was 
informed of the observations made in rear hospitals on the surgery performed 
in forward hospitals. Case reports were furnished to him, and ward rounds 
were made with him at the 36th and 46th General Hospitals. At his request, 
information was supplied to the surgeon, Sixth Army Group, concerning the 
observations which had been made on casualties being evacuated by train and 
air from Army holding stations to Continental Advance and Delta Base Sec- 
tions, and from Continental Advance to Delta Base Section. 
ASSIGNMENT OF PERSONNEL 
When the landings were made in North Africa, in the fall of 1942, the 
exact role to be played by qualified orthopedic surgeons in an overseas theater 
was still to be determined. This was chiefly because the exact surgical missions 
of the various echelons of medical care in the staged management of the wounded 
had not yet been clearly defined. 
Only a few of the evacuation hospitals which arrived early in North Africa 
had orthopedic surgeons on their staffs, though many had general surgeons 
experienced in the management of fractures. The initial experiences led to 
the decision that each such hospital should have an orthopedic surgeon on the 
staff. This was not because it was expected that all wounds of the extremities 
would affect bones and joints or because it was considered essential that an 
orthopedic surgeon should perform all initial surgery in bone and joint injuries, 
which was an obvious impossibility. The chief reason for the decision was 
that a qualified orthopedic surgeon should be available in each evacuation 
hospital for consultation on such special problems as wounds of the joints, 
complicated fractures of the femur, injuries which might require amputation, 
and similar serious problems. It was felt that the orthopedic surgeon, with 
his specialized knowledge and wider experience in plaster techniques, would be 
extremely useful to the general surgeons who would necessarily perform most 
of the initial surgery in evacuation hospitals. It was also intended, of course, 
that, as time permitted, the orthopedic surgeon should himself handle injuries 
of extreme severity, such as compound comminuted fractures of the femur and 
penetrating wounds of the knee and hip joint. 
Another reason orthopedic surgeons were assigned to forward hospitals 
had to do with the management and disposition of soldiers with non-battle- 
connected complaints, such as internal derangements of the knee, painful backs, 
and foot disabilities. Manpower, especially combat manpower, was always in 
short supply, and it was essential that as many of these soldiers as possible 
should be returned to duty as promptly as possible, without the loss of time 
and effort which would be expended in their transfer to general hospitals. On 
the other hand, it was equally important that men who really needed treatment 
and who could not be promptly returned to duty should be evacuated to ADMINISTRATIVE CONSIDERATIONS 
13 
hospitals in the rear without delay. These decisions were often delicate and 
could best be made against a background of orthopedic training and experience. 
For these reasons, many of the younger, well-trained and capable ortho- 
pedic surgeons, who had had previous experience in civilian traumatic surgery, 
were transferred to evacuation hospitals as soon as they arrived in the theater 
on the staffs of general hospitals. This proved to be a wise plan as long as 
policies concerning the management of bone and joint injuries were still in a 
state of flux. The anticipated effectiveness of these trained orthopedic surgeons 
was fully realized, and they made important contributions to the increasing 
efficiency of initial wound surgery. They themselves, however, were seldom 
content with these assignments, and requests for transfers to general hospitals 
were frequent, on the ground that as trained orthopedic surgeons they would 
be more useful in the performance of reparative surgery and definitive reduction 
of fractures than they were in evacuation hospitals, where initial surgery was 
limited to debridement, gross alinement of fractures, and transportation 
splinting. 
Although the weight of these arguments was fully realized, the policy of 
assigning orthopedic surgeons to evacuation hospitals continued the same in 
the Mediterranean theater throughout the war. In retrospect, this inflexibility 
does not seem to have been altogether wise. As policies of surgical manage- 
ment in forward areas became standardized and as surgeons in these areas 
became experienced in the management of wounds of the extremities, the 
original need for orthopedic surgeons in evacuation hospitals became much 
less pressing. At this time, in view of the shortage of trained orthopedic per- 
sonnel in rear hospitals and the demands of the regimen of reparative surgery 
for trained men, it would probably have been wiser to utilize in general hospitals 
many of the surgeons assigned to evacuation hospitals. The assignment of a 
consultant in orthopedic surgery to each army (p. 5) would further have 
reduced the need for experienced orthopedic surgeons in hospitals in the army 
areas. 
Orthopedic surgeons who were heads of orthopedic teams were occasionally 
attached to field hospitals in the division area in Sicily and in the early days 
of the fighting in Italy, but this practice wTas a misuse of qualified personnel 
and was soon discontinued. Injuries of the bones and joints were seldom, in 
themselves, of sufficient urgency to require treatment in field hospitals, and 
the few which were could be cared for by the well-trained general surgeons 
attached to these installations. Orthopedic surgeons, on the other hand, were 
seldom equipped to treat the serious wounds of the chest and abdomen which 
constituted the chief work in a field hospital, and they cmdd not, therefore, 
handle a proportionate share of casualties with these injuries or of casualties 
with multiple injuries involving the chest and abdomen as wrell as the extremi- 
ties. For these reasons, orthopedic teams were used only in evacuation hospitals 
after early 1944. 
396961°—57 3 14 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
FACILITIES 
In World War II, before a casualty with a bone and joint injury reached 
a general hospital in the communications zone, he had passed, successively, 
through a battalion aid station, a collecting station, a clearing station, and an 
evacuation or held hospital. The care he received in the division area was 
limited to measures designed to supplement the first aid he had 
received on the battlefield and to make him transportable to the evacuation 
hospital. Classification as to transportability was a major responsibility of 
the clearing station. No special orthopedic equipment other than splints was 
therefore usually required in these echelons of medical care (figs. 1, 2, 3, 4, 
and 5). 
Soldiers with wounds of the extremities, as already noted, were usually 
second-priority casualties. They were therefore not transferred to the held 
hospital adjacent to the clearing station unless shock, the presence of a tourni- 
quet, a traumatic amputation, an abdominal wound, a severe chest wound, or 
an impaired airway required immediate attention. 
Definitive initial surgery in the evacuation or held hospital was directed 
toward the management of the soft-tissue injury, not the bone injury, except 
for gross alinement of fractures and immobilization for transportation. Plaster 
of paris and auxiliary supplies and splints were therefore the only special 
equipment required for bone and joint injuries in the evacuation hospital (hgs. 
6, 7, and 8). A fracture table was essential equipment, and the portable frac- 
ture table provided by Medical Supply (Item No. 7099300) proved entirely 
satisfactory. 
Materials for internal hxation of fractures, overhead fracture frames, and 
material for the management of fractures in balanced-suspension skeletal trac- 
tion were authorized items of supply in evacuation hospitals. They were all 
superfluous items at this level. They are used in the dehnitive management 
of fractures, which is the mission of hospitals in the communications zone, 
though not of installations in the army area. 
In the general hospital in the communications zone (fig. 9), where fractures 
were reduced and other definitive care provided, desirable special facilities 
included, at a minimum— 
1. An operating room, at least 20 by 25 feet, to accommodate two operating 
tables and a large table for sterile supplies. It was also desirable to have an 
adjoining room in which patients could be anesthetized and in which the 
transportation casts applied in the evacuation hospital could be removed. 
2. A ward of 75 to 100 beds, to be used as a femur (traction) ward. It 
was essential that this ward be equipped for the taking of roentgenograms 
with portable apparatus and desirable that it be near the X-ray department. 
3. Other wards of 75 to 100 beds. When it was practical, it was best to 
admit patients to these wards according to the nature of their injuries, but 
anatomic subdivision was not always possible because of multiplicity of wounds 
and the variations in the bed status. The principle of segregation of special ADMINISTRATIVE CONSIDERATIONS 
15 
AFIP CA-4340-D 
Figure 1.—First aid in field, Fifth U. S. Army, Italy, December 1943. 
injuries, however, was sound and preferably was adhered to as circumstances 
permitted. 
4. A plaster room, about 20 by 30 feet, equipped with three plaster tables; 
a fully equipped table for dressings; and storage cabinets for splints, accessory 
materials, and sterile supplies. This plaster room was preferably located 
adjacent to the principal orthopedic ward. It was used for the changing of 
plaster casts as well as for minor surgical procedures, usually without anesthesia. 
Essential items of supply in a general hospital included an adequate number 
of overhead fracture frames, Army half-ring leg splints, and materials for 
balanced-suspension skeletal traction and for internal fixation of fractures, as 
well as materials for the application of plaster-of-paris casts. 
5. Facilities for the examination of ambulatory patients from other wards 
and of outpatients. The plaster room could be used for this purpose, if neces- 
sary, but this was less desirable than provision for a special consultation and 
examining room. 
Braceshops.—Although tables of organization included a qualified brace- 
maker in the personnel of all numbered general hospitals, tables of equipment 
provided little equipment for braceshops when these hospitals first came into 
the North African theater. It soon became evident, however, that there was a 
definite need for a few braces, special splints, belts, and similar items in an 
overseas theater which functioned on a 90- to 120-day holding policy. 16 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
U. S. Army photos 
Figure 2.—Scenes at battalion aid stations in World War II. A. Litter bearers bringing 
casualty into Fifth U.S. Army battalion aid station in Italy. B. Infantrymen at 
Fifth U.S. Army battalion aid station in Italy waiting for evacuation. They had been 
dug out of a wrecked building which had collapsed after being hit by a shell. ADMINISTRATIVE CONSIDERATIONS 
17 
Figure 2—Continued. C. Administration of first aid to infantryman in Fifth U.S. Army 
battalion aid station in Italy. This man, like the casualties in B, had been dug out 
of a wrecked building which had collapsed after being hit by a shell. D. Administration 
of plasma to wounded German prisoner outside of Fifth U.S. Army battalion aid station 
in Italy, April 1945. 
U. S. Army photos 18 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
U. S. Army photos 
Figure 3.—Scenes at collecting station on Anzio beachhead, March 1944. A. Infantry- 
man, wounded by enemy artillery, being carried into a collecting station after trans- 
portation to the station in the back of a jeep. B. Wounded infantryman being given 
plasma at medical collecting company. ADMINISTRATIVE CONSIDERATIONS 
19 
U. S. Army photo 
Figure 4.—Casualty being taken into admission tent of clearing station, 
Fifth U.S. Army, Italy, November 1943. 
The first braceshop to function in North Africa was set up at the 21st 
General Hospital, late in 1942, soon after the hospital was established at Bon 
Hanifia, the site of a former spa, some 65 miles south of Oran. Many of the 
tools were secured from the well-equipped machine shop that had been part of 
the former bathhouse and hotel facilities. Other tools, as well as supplies of 
steel, leather, and salvaged canvas, were obtained from the engineering and 
quartermaster departments in the base section. 
As this shop was the only equipped braceshop functioning at this time in 
the Mediterranean Base Section, requisitions were forwarded to it, through the 
office of the base surgeon, from other hospitals in the area. Eventually, the 
volume of requisitions became so large that this shop was formally designated 
as braceshop for the entire base section. This proved an efficient and econom- 
ical plan. As might have been expected, the orthopedic staff at the 21st General 
Hospital made the fullest use of the braceshop, but orthopedic surgeons in 
other hospitals in the base section were also assured of the braces and belts 
which they needed without the expenditure of a large overhead in their own 
hospitals. There was no waste of personnel. Requisitions from other hos- 
pitals in addition to his own kept the bracemaker at the 21st General Hospital 
busy at all times and justified the maintenance of a fully equipped and staffed 
shop. The requisition and provision of material were also simplified and 
expedited by the operation of a single shop rather than multiple shops. 
When the 21st General Hospital was moved from North Africa to Italy, 
the braceshop at the 46th General Hospital served the hospitals in the medical 
center at Oran by the same general plan. The bracemaker in charge had had 20 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
U. S. Army photo 
Figure 5.—Ambulance transportation of wounded, Fifth U.S. Army, Italy, 
April 1945. 
an extensive experience in civilian life, and bracemakcrs from other hospitals 
in the area at times worked under his direction. In Italy, the braceshop at the 
21st General Hospital served the 3 general and 2 station hospitals in the medical 
center at Bagnoli, just outside of Naples, as well as the orthopedic section of its 
own hospital. 
A shop planned for the 24th General Hospital and intended to serve the 
medical center at Bizerte did not become operational, as this hospital and the 
other hospitals the braceshop was intended to supply moved to Italy shortly 
after the equipment for the shop had been issued. Hospitals not served by 
area braceshops continued to operate their own small shops, to meet their 
special needs. In these isolated hospitals, the bracemakcrs usually served as 
orthopedic technicians, with bracemaking an incidental assignment . 
The output of the theater braceshops consisted chiefly of canvas belts for 
support of the back, metal braces for personnel returning to limited duty, and 
individual splints and appliances. Standard splints were repaired and altered, 
and shoes were also altered. Since patients with fractures which would not 
permit return to duty within the period of the theater holding policy were 
evacuated to the Zone of Interior while they were still in plaster, there were 
few calls for the type of brace which would be needed during reconstructive 
surgery and rehabilitation. ADMINISTRATIVE CONSIDERATIONS 
21 
U. S. Army photos 
lint re 6. Scenes in 33d Field Hospital, Fifth U.S. Army, Italy, September 1944. A. Re- 
moval, in operating room, of bandages placed on patient by medical aidmen in field. 
B. Dressing of wounds of distal portion of foot following initial surgery and application 
of a cast for fractures of the bones of the leg. 22 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
U. S. Army photos 
Figure 7.—Scenes in 8th Evacuation Hospital, Fifth U.S. Army, Italy, January 1944. 
A. Wounded soldiers lying in receiving room of hospital. B. Winterized wards of 
hospital. Winterizing was accomplished by building up wooden sides inside the side 
walls of the ward tent to the height of the caves and placing wooden frames, with 
doors, at the ends of the tent. Wooden floors were also provided. C. Operation of 
initial surgery for wounds of the extremity in progress. ADMINISTRATIVE CONSIDERATIONS 
AFIP CA-4340-A; U. S. Army photos 
Figure 8.—A. 94th Evacuation Hospital, Fifth U.S. Army, Italy, December 1943. B. Op- 
eration by orthopedic team from 2d Auxiliary Surgical Group at 94th Evacuation 
Hospital, Fifth U.S. Army, Italy, December 1943. Cast is being applied after initial 
surgery for compound fracture of the left femur, caused by shell fragment. Note use 
of portable fracture table. 24 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 9.—24th General Hospital, Florence, Italy. A. Exterior view of headquarters and 
surgical buildings. B. Operating room. C. Large surgical -ward, serving especially 
for patients in traction. 
U. S. Army photos ADMINISTRATIVE CONSIDERATIONS 
25 
HOSPITAL ADMINISTRATION 
Assignment of cases.—When the North African Theater of Operations 
was established, the assignment of responsibility for compound fractures was 
somewhat confused. Some chiefs of surgery felt that, as in World War I, 
these injuries should be the responsibility of general as well as orthopedic 
surgeons and should be treated in general surgical as well as orthopedic sections. 
In several hospitals, the chiefs of surgical sections elected to assign casualties 
with bone and joint injuries alternately to general surgical and orthopedic 
sections. 
These policies proved unwise and unsound. The general surgeon and 
the orthopedic surgeon frequently had wise counsel and skilled assistance to 
offer each other in the management of combat wounds, but only a brief experi- 
ence was necessary to demonstrate that the best results were obtained when 
hone and joint injuries were managed exclusively in orthopedic wards. Almost 
without exception, this was the policy in effect in all general hospitals in the 
theater by the spring of 1944. 
Segregation of bone and joint injuries, as already noted, was neither 
necessary nor practical in evacuation hospitals, where initial surgery wras 
limited to management of the compounding wound. In properly operated 
fixed hospitals, however, it was found best for orthopedic sections to receive 
all casualties with fractures and joint injuries except, for obvious reasons, 
those with associated fractures of the ribs, skull, and maxillofacial bones. 
Fractures of the bones of the hand were also exceptions to this policy in hos- 
pitals in which general surgeons experienced in the management of hand 
injuries were attached to the staff. Otherwise, these injuries were managed 
on orthopedic wards. 
Patients with concurrent wounds which relegated fractures to a place of 
secondary importance were admitted to the general surgical or other appro- 
priate wards, but personnel from the orthopedic section assumed responsibility 
for the bone and joint injuries. Failure to provide permissible treatment of 
the fracture would have resulted in needless deformity and might even have 
caused a spreading, life-endangering infection. 
Orthopedic surgeons also had the responsibility for all acute, recurrent, 
and chronic conditions affecting the function of the bones and joints of the 
extremities and of the back and shoulders. 
Consultations were answered on request from the remainder of the sur- 
gical service and from other services in the hospital. Examinations were 
carried out on the ward or in the outpatient department, according to the 
status of the patient. 
Caseload.—The proportion of the hospital census represented by the 
orthopedic caseload varied according to the total hospital census, which might 
be unusually high because of medical conditions or for other reasons. As a 
rule, during an active campaign, the orthopedic section accounted for about 
25 percent of the hospital population and for about 35 to 40 percent of the 26 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
surgical census. After the campaign ended, these proportions usually increased 
because of the long periods of hospitalization required by casualties with 
fractures. 
To take care of this load ideally in a 1,000- or 2,000-bed general hospital, 
the following personnel was necessary: 
1. A chief of the orthopedic section, who was responsible to and worked 
under the administrative control of the chief of the surgical service. Tech- 
nically, a classification of B-3153 was desirable, though, when their training, 
initiative, and industry warranted it, these assignments were often given to 
officers with classification of C-3153. Many of these officers rapidly attained 
the higher rating, particularly if they had had some previous civilian experience 
in acute trauma of the extremities. Many of them did outstanding orthopedic 
surgery in North Africa, Sicily, and Italy. 
If the chief of the orthopedic service were to perform his duties com- 
petently, he had to exercise his supervisory and executive functions to the 
fullest extent. They were not so exercised when he dissipated his time and 
effort by assuming the duties of a ward officer on any special ward. It was 
essential, instead, that he keep his time free for ward rounds, supervision of 
junior officers, emergency consultations, observation of seriously ill soldiers, 
and operating-room duties. At times, he had to spend the entire day in the 
operating room. The best section chiefs were those who utilized their time 
in this fashion. 
2. A senior ward officer, to serve in a twofold capacity, as assistant chief 
of the orthopedic section and as ward officer on the traction ward. As the 
reparative program for compound fractures developed (p. 53), it became 
extremely important to have on each service an experienced orthopedic sur- 
geon, or a general surgeon with special experience in traumatic surgery, who 
was qualified to make quick decisions when the pressure of work was too 
heavy for the chief of the section to make them all. These decisions frequently 
had to be made in the operating room. 
The assistant chief of section was usually either a C-3153 or a C-3150 
(general surgeon), though officers with D classifications, who were interested 
in traumatic surgery, frequently advanced, sometimes rapidly, to the higher 
rating. In the Mediterranean theater, it proved perfectly satisfactory for 
general surgeons to assume the management of fractures and joint injuries, 
provided that they functioned as members of the orthopedic staff, under the 
supervision of the chief of the orthopedic section. It was, however, neither 
desirable nor practical for a general surgeon to have the responsibility of 
fracture management if at the same time he had the responsibility for abdom- 
inal and chest injuries and for other unrelated injuries. 
3. Junior ward officers. These officers had classifications of D-3153 or D- 
3150, but, as in other categories, it was possible for officers with general-duty 
classifications to advance to specialty categories if they were interested in trau- 
matic surgery. Each junior ward officer usually carried a patient load of 75 ADMINISTRATIVE CONSIDERATIONS 
27 
to 100 patients, the number varying with the size of the hospital and the num- 
ber of admissions after a campaign. 
When convalescent sections were set up in general hospitals, it was found 
to be highly desirable for each ward officer to continue to supervise his own 
patients as they were transferred to these sections. This duty increased the 
officer’s caseload, but, as convalescent casualties required only a minimum of 
care, the burden seldom proved excessive, and the continuity of care thus 
secured was well worth the extra effort. 
4. Technicians. A qualified, industrious group of enlisted technicians 
was indispensable for the smooth functioning of an orthopedic section. Their 
training in plaster and splinting techniques was the responsibility of the chief 
of the orthopedic section in each hospital. An orthopedic section caring for 
400 to 500 patients required at least 5 technicians and also required the services 
of a bracemaker (p. 15). Properly taught technicians readily mastered all the 
principles and details of plaster, splinting, and skeletal-traction techniques. 
With experience and under minimal supervision, they could apply plaster 
casts, including spicas; erect Balkan frames (see fig. 9C); arrange pulleys for 
skeletal traction; and perform numerous similar duties, thus leaving medical 
officers free for strictly medical tasks. Technicians also made plaster bandages, 
if stock supplies were not available. 
It was the usual practice for the best qualified man in the group to serve 
as the chief technician. Among his other duties were the storage, maintenance, 
and supply of splints, accessories, and pi aster. 
Outpatient dispensaries.—After a short experience with the operation of 
outpatient dispensaries in general hospitals, it became clear that these dis- 
pensaries should be kept to an absolute minimum and should be chiefly used 
for seeing ambulatory patients in consultation and for periodic observation of 
convalescing patients. Any other plan handicapped the smooth functioning of 
the orthopedic section because it required the withdrawal from it of much- 
needed personnel. Outpatient clinics attached to station hospitals were 
better prepared to take care of the type of work ordinarily seen in a civilian 
orthopedic clinic, and it was particularly desirable and convenient for them 
to exercise this function in base sections. 
GRAPHIC RECORDS 
Early in 1944, the Army Pictorial Service provided, informally, photog- 
raphers to assist the consultant in orthopedic surgery in recording methods of 
splinting and other orthopedic procedures and in securing illustrations of the 
results of wound and fracture management. These illustrations proved very 
useful for instructional and demonstration purposes. 
Later, the 3d and 6th Medical Composite Detachments, Museum and 
Medical Arts Service, supplied both photographers and artists as the need 
arose. Photographs and drawings were thus accumulated to show variations 28 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
ill traction and splinting methods, serial wound management, the technique 
of special operations, and various other items. In many instances, it was 
possible to make complete case studies from the first observation of the casualty 
in a forward hosiptal, before initial surgery, to the end results of management 
in base hospitals, before disposition. Motion pictures were also made, some of 
them in color. 
ACCUMULATION OF DATA 
Throughout the period of active fighting, as well as after the war ended, 
several different plans were followed to accumulate data on casualties with 
bone and joint injuries. The following methods were used; 
1. Throughout the period of active fighting, efforts were made to stimulate 
the interest of the various chiefs of orthopedic sections in accumulating factual 
information on small groups of cases according to their special interests. 
2. In relatively quiescent periods, arrangements were made through the 
theater surgeon for several chiefs of orthopedic sections in general hospitals 
to travel about the theater to visit other general hospitals and to gather data 
on subjects of special interest to them and to the theater consultant in orthopedic 
surgery. These trips also served to acquaint the surgeons making the surveys 
with techniques and methods employed in other hospitals. 
3. After the war ended, arrangements were made through the theater 
surgeon to have additional surveys made by other orthopedic surgeons, who 
visited most of the hospitals and studied their records on special orthopedic 
problems. 
4. Still other medical officers were placed on temporary duty in the Office 
of the Surgeon, to study disposition-board proceedings and other records avail- 
able in that office, in an effort to gather as much data as was possible on several 
special orthopedic problems and on the results of the treatment employed 
for them. 
The data thus collected furnish some of the supporting information in 
various chapters of this history. CHAPTER 111 
Splinting in the Combat Zone 
CLASSIFICATION OF MILITARY SPLINTING 
The exigencies of military surgery in World War II required, as already 
noted, that all care of battle casualties be rendered in phases, in installations 
located, equipped, and staffed for various specific missions. The splinting of 
bone and joint injuries was similarly timed. It was necessarily interrupted 
for each phase of surgical management. It was carried out with material and 
facilities that varied according to the mission of the installation at which the 
care was rendered. It was provided again, with a new objective, after each 
phase of treatment had been completed. 
By a process of evolution, splinting in overseas military surgery in World 
War II (table 1) was eventually classified as follows: 
1. Emergency or first-aid splinting, which was provided within the divi- 
sional area of the combat zone as an integral part of resuscitation and to render 
the casualty transportable to a hospital equipped for surgery. 
2. Splinting after initial wound surgery, which was provided in an evacua- 
tion hospital or, as indicated, in a field hospital. It was not intended to obtain 
or maintain reduction of fractures. Its objective was to facilitate transfer of 
the wounded soldier to a fixed hospital in the communications zone. 
3. Splinting after reparative surgery, which was applied in a fixed hospital 
in the communications zone. It was sometimes designed to achieve reduction 
of fractures. It was always designed to maintain reduction and to provide 
prolonged immobilization. As a matter of convenience, it will be discussed 
under the headings of the management of regional and special injuries. 
4. With an occasional exception, such as fractures of the femur and of 
the hand, splinting for transportation to the Zone of Interior did not represent 
a special type. The casts applied after reparative surgery were sometimes 
changed before the casualty was returned to the United States, for reasons of 
cleanliness or because the casts had become too loose to be effective. As a 
rule, however, the definitive splinting applied for the fracture in the fixed 
hospital served until the cast was removed in the hospital in the Zone of In- 
terior in which treatment would be continued. 
396961°—57 4 ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Table 1.—Classification of splinting of compound battle fractures by phase of management, in relation to timing, objectives, and facilities 
Phase of management 
Time after 
wounding 
Anticipated 
duration 
Medical installation 
Surgical personnel 
Methods 
Materials, facilities 
Emergency, transportation 
0-12 hours.-. 
4-24 hours... 
Battlefield, battalion aid 
Medical aidmen 
Improvised,standard... ... 
Improvised, half- and full- 
to a forward hospital. 
station. 
ring splints, basswood, 
wire ladder splints, slings. 
Battalion aid, collecting, 
General-duty medical offi- 
Inspection, adjustment, re- 
clearing stations. 
cers. 
placement. 
Initial surgery, transporta- 
8-36 hours... 
1-10 days 
Field, evacuation hospi- 
General, orthopedic sur- 
Plaster casts, skin traction 
X-ray facilities, plaster, 
tion to a fixed hospital. 
tals. 
geons. 
(amputation), metal 
standard splints. 
splint (occasional). 
Reparative surgery, main- 
5-10 days 
21-120 days.. 
General, special station 
General, orthopedic sur- 
Skeletal traction, plaster 
X-ray facilities, plaster, 
tenance fracture reduo- 
hospitals. 
geons, physiotherapists. 
casts, internal and exter- 
standard splints, Klrschner 
tion. 
nal fixation, metal splints, 
wires, Steinmann pins, 
walking irons, simple 
Balkan frames, bone plates, 
braces. 
screws, external-fixation 
apparatus, braceshops. 
21-120 days. 
Plaster casts, simple metal 
Do. 
Interior.1 
splints. 
En route to Zone of Interior. 
10-14 days... 
Changes of cast2 
Plaster. 
None. 
Army general hospitals, 
Orthopedic surgeons, phys- 
Plaster casts, special indi- 
Complete, brace and pros- 
tive. 
special centers. 
ical and occupational 
vidual splints and pros- 
thetlc shops. 
therapists. 
theses. 
1 After partial or complet 
e bony union. 
2 Only if necessary. SPLINTING IN COMBAT ZONE 
31 
EMERGENCY SPLINTING 
Historical Note 
In World War I,1 splints and other appliances used by the United States 
Army Medical Corps were not standardized until late in 1917. A board ap- 
pointed by General Headquarters, American Expeditionary Forces, to investi- 
gate and report upon the advisability of standardization suggested that a 
manual of splinting be prepared for the use of medical officers. The manu- 
script was approved by the commanding general, American Expeditionary 
Forces, 9 September 1917, and 6 weeks later the Manual of Splints and Ap- 
pliances for Use of the Medical Department of the United States Army was 
delivered to supply depots in France. The printing of the manual, as well as 
the manufacture and procurement of the recommended splints and other 
appliances, was then the responsibility of the American Red Cross. 
A second board of officers was appointed in October 1918 to revise the 
manual on splinting and to examine the necessity for changes in the splints 
and other appliances in use. Although the board completed its work in only 
a few days, the second edition of the manual was not ready for distribution 
until 1 February 1919, more than 2 months after the end of World War I. 
No significant changes seem to have been made in the methods prescribed 
in this manual until 11 September 1940, during the prewar mobilization of the 
United States Army. This was 15 months before the entry of this country 
into World War II. The manual issued at this time (Medical Field Manual, 
FM 8-50, Splints, Appliances, and Bandages) served as the textbook for the 
training of officers and enlisted men of the Army Medical Department during 
the period of mobilization and for the first 2 years of United States participation 
in World War II. 
The methods described in this manual were based on the use of the splints 
standardized in the Army Tables of Equipment (then called the Basic Equip- 
ment List) before the beginning of mobilization. These methods were naturally 
modified in the light of experience in overseas theaters, but no formal revision 
of the manual was issued until 15 January 1944. 
Splinting is mentioned only incidentally, and with almost no details, in 
Orthopedic Subjects,2 one of the Military Surgical Manuals prepared by the 
Committee on Surgery of the Division of Medical Sciences of the National 
Research Council, which appeared in 1942. 
Improvised splinting was not mentioned in the manuals prepared in 
World War I. It seems to have been included for the first time in the second 
(1931) edition of the Military Medical Manual. It was only briefly discussed 
1 The Medical Department of the United States Army in the World War. Washington; Government Printing 
Office, 1927, vol. XI, pt. 1, pp. 549-590. 
2 Orthopedic Subjects. Prepared and edited by the Committee on Orthopedic Surgery of the Committee on Surgery 
of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals. Philadelphia & 
London: W. B. Saunders Co., 1942. 32 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
in this edition and was mentioned with similar brevity in each of the subsequent 
editions of this manual, including the sixth, which was issued in 1944. 
The Medical Field Manual (FM 8-50) issued in 1940, also contains no 
mention of improvised splinting. The 1944 revision, entitled “Bandaging and 
Splinting,” contains no direct text references to improvisations, but illustra- 
tions show the use of sticks as splints for the forearm and the use of a coat and 
a shirttail as slings. Soldiers Handbook (FM 21-100), issued 23 July 1941, 
contained a brief but excellent paragraph on the subject. First Aid for Soldiers 
(FM 21-11), issued 7 April 1943, contained a detailed description and many 
excellent illustrations of improvised methods of splinting. Long before this 
date, however, intensive and thorough instruction in improvised methods had 
been given to Medical Department enlisted men of the Regular Army, both 
before and during the period of mobilization and after the entry of the United 
States into the war. 
Equipment 
Standard United States Army equipment for emergency battlefield splint- 
ing in World War II included hinged half-ring leg splints; hinged full-ring arm 
splints; wire ladder and basswnod splints; and triangular, roller, and Carlisle 
compressed bandages. 
This equipment, while it was generally efficient, was extremely cumbersome. 
Throughout the war, the desire was repeatedly expressed, and the need wTas 
clearly evident, for a light, readily adjustable, easily transportable, universally 
applicable splint which medical aidmen could use on the battlefield. At the 
end of the war, this need had not yet been satisfied. 
General Considerations 
The emergency splinting of a fractured extremity had as a chief objective 
the preparation of the wounded man for his transportation, with minimum 
discomfort, from the battlefield to a hospital in which he would receive surgical 
care. It was also an important part of first-aid management. It minimized 
or prevented shock in bone and joint injuries. It reduced the need for narcotics. 
It was thus an essential step in the resuscitation which had to be accomplished 
before surgery could be undertaken. 
Reduction of the fracture was not an objective of emergency splinting. 
The purpose of emergency splinting was to prevent additional damage to the 
soft parts by fragments of bone and to keep the patient as comfortable as 
possible while he was on his way to the evacuation hospital. The criteria of 
its success were therefore comfort and relief from pain during transportation. 
Medical aidmen, during their training, were always instructed that it 
was desirable, when possible, to “splint ’em where they lie” and to use standard 
methods of splinting. As a practical matter, neither of these instructions was 
ahvays possible of accomplishment. For a variety of reasons, it was sometimes 
more expeditious to bring the wounded man to the battalion aid station on a SPLINTING IN COMBAT ZONE 
33 
Figure 10.—Improvised battlefield splinting for fracture of femur. A 
board is secured to the trunk by the wounded man’s own belt and to the 
injured right lower extremity by several turns of bandage. 
AFIP 45-5oa 
litter. The chief of these reasons was that delay on the battlefield might 
have resulted in additional hazards to the casualty as well as risk to the aidmen 
themselves. In the battalion aid station, the environment was safer; better 
equipment was available; and the splinting, which could be applied deliberately, 
was frequently more precise and more accurate than splinting applied nearer 
the front. None of these reasons, however, was an indication for failure to 
splint the wounded man on the battlefield whenever that was possible. 
Improvised splinting, as already mentioned, was taught along with 
standard methods during the period of training. The ingenuity of the United 
States Army medical aidman, when he found himself in circumstances of stress, 
often went beyond his formal teaching. A fractured lower extremity (fig. 10), 
for instance, was bandaged to a rifle, to a handy board, or to a limb from a 
nearby tree. A fractured upper extremity was held against the chest by the 
field jacket after the upturned shirttail had been fashioned into a sling. These 
and other improvisations proved extremely satisfactory, and, when they were 
adequate, they, like more conventional splinting, were left undisturbed as the 
casualty was evacuated through the successive echelons of the division medical 
battalion. 34 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
If for any reason either improvised or conventional splinting did not seem 
adequate, it was adjusted or replaced at the battalion aid station. All 
splints were carefully inspected at each subsequent installation and were 
adjusted as necessary, but they were not removed or replaced except for good 
reason. Even if it was necessary to remove the dressing and inspect the 
wound, it was seldom necessary to remove the splinting to accomplish this 
purpose. 
Regional Emergency Splinting 
Upper extremity.—Well-padded coaptation basswood or wire ladder 
splints furnished satisfactory emergency splinting in injuries of the bones and 
joints of the forearm and hand (fig. 11). It was promptly learned that a sling 
composed of a triangular or roller bandage must be added to keep the patient 
comfortable (fig. 11C). 
Difficulties frequently developed when the hinged full-ring arm splint was 
used under battlefield conditions for fractures of the humerus. This splint 
proved undesirable in almost every respect. Many of the wounded soldiers 
complained of constant discomfort when they were put up in it with traction 
applied by means of a hitch placed about the wrist and fastened to the end of 
the splint. The full elbow extension produced by traction predisposed to 
angulation of the fragments, and the angulation, in turn, introduced risk of 
damage to the brachial artery and the main nerve trunks. Still another danger- 
ous possibility from pressure of the ring was injury, which might be irreparable, 
to the axillary contents. 
For these various reasons, the hinged full-ring arm splint was employed 
less and less during the course of the Tunisian campaign, but it was still occa- 
sionally used in the theater, in spite of instructions to the contrary, until 
December 1944, because new units coming from the United States had been 
taught to apply it. 
Eventually, this splint was completely replaced for fractures of the arm 
and shoulder joint by two other methods which were simple to apply and which 
provided maximum relief of pain and discomfort. Both held the elbow in 
about 90° flexion. 
1. In the first of these methods, a Carlisle pad was placed in the axilla 
and a triangular bandage was applied as a sling to hold the elbow at, or almost 
at, a right angle. A second triangular bandage was used to bind the arm, in 
this position, against the chest, and was reenforced by a few turns of a roller 
bandage. During the latter part of World War II, this simple method came 
to be considered the method of choice for emergency splinting of fractures of 
the humerus and for fractures about the shoulder. 
2. The second method of emergency splinting (fig. 12) required the use of 
a padded wire ladder splint extending from the tip of the shoulder down the 
posterior aspect of the arm and forearm to the hand. The arm was held at 
the side, with the elbow almost at a right angle; then the splinted arm and 
forearm were bandaged against the chest by a roller or triangular bandage. SPLINTING IN COMBAT ZONE 
35 
Figure 11.—Emergency splinting applied for fractures of forearm and about elbow and 
wrist. A. Basswood coaptation splints used for fractures of forearm and wrist. Wire 
ladder splint used for fractures of forearm and about elbow. Note free use of Carlisle 
pads, loop of roller bandage for sling, and reenforcing turns of bandage which are added 
if shock or concurrent injuries make it desirable that soldier travel as litter case. B. 
Basswood splint (applied in battalion aid station) for compound fracture of forearm. 
C. Sling added to complete emergency splinting in compound fracture of forearm. 
D. Wire ladder splint and sling applied in clearing station for fracture of forearm by 
small-arms fire. 
AFIP FC-44-3, C-44-66, C-44-657 
Lower extremity.—Either single or double wire ladder splints, well padded, 
were used for fractures of the foot and ankle (fig. 13). Often a single splint 
was sufficient ; it was passed down the back of the leg, around the heel, and up 
the plantar surface of the foot. If false motion or instability at the site of the 
fracture was present with a single splint, a second was passed down one side 
of the leg, around the plantar surface of the heel, and up the other side of the 
leg. The foot was splinted at right angles to the leg, and roller bandages were 
used to hold the splint or splints in position. 
The half-ring leg splint proved, on the whole, quite satisfactory for frac- 
tures of the leg, knee joint, thigh, and hip joint (fig. 14). Three triangular 
bandages served as slings for the fractured portion of the extremity and two 
others for the intact portion. The foot was held almost at a right angle by a 
foot support, and the distal end of the splint was elevated by another foot 36 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 12.—Methods of emergency 
splinting, either of which is satisfac- 
tory, for fracture of humerus. Frac- 
tures in this location cause consider- 
able pain, and effective splinting is 
essential for the patient’s comfort dur- 
ing evacuation to a hospital. A. 
Technique of application of double 
triangular bandage and wire ladder 
splint reinforced by Velpeau band- 
age. B. Emergency splinting with 
wire ladder splint and sling for battle- 
incurred compound fracture of hum- 
erus. C. Wire ladder splint applied 
for emergency splinting of compound 
fracture about elbow. Note reinforc- 
ing bandages about body. 
AFIP FC-44-2, C-44-654, Fd-44-10 SPLINTING IN COMBAT ZONE 
37 
Figure 13.—Emergency splinting for in- 
juries of the lower third of leg and 
ankle. A. Emergency splinting with 
double wire ladder splint for injuries of 
foot and ankle. Note free use of padding, 
which is essential to protect bony promi- 
nences from pressure. Note also that 
foot is held at angle of 90°. B. Double 
wire ladder splint for emergency splinting 
for compound fracture of the lower tibia. 
C. Single wire ladder splint applied for 
emergency splinting for compound frac- 
tures of lower third of tibia and fibula. 
AFIP FC-44-4, C-44-652, Fd-44-10 
support, this one being turned downward. Late in the war, a single gadget 
slipped over the end of the splint took the place of both supports. A standard 
webbing strap was placed about the heel and ankle and fastened to the end of 
the splint, thus providing moderate fixed traction. The strap was applied 
with the shoe on, but the shoelaces were then loosened or cut, to allow for 
possible swelling of the ankle and foot. 
A casualty was not comfortable during evacuation in the half-ring leg 
splint unless the distal end of the splint was elevated and made secure. This 
was accomplished by fixing the lower half of the foot support used to maintain 
elevation of the distal end of the splint in the bar by which the splint was 
attached to the stretcher. The bar was standard equipment. 
A number of other precautions were necessary when the half-ring leg 
splint was used: 
1. Deflexion or unfolding of the hinged half ring, with sagging of the 
upper end of the splint, was likely to result in a painful drag on the thigh. 
This could be almost entirely prevented if care was taken to see that the half 
ring was folded completely into tlie 90° position when the splint was applied. ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP Ca-45-736, Ca-45-738, Fd-45-55 
Figure 14.—Emergency splinting with Army half-ring leg splint for injuries of thigh, knee 
joint, and leg. A and B. Fixation of splint by litter bar. This accessory proved a 
valuable adjunct for comfortable emergency splinting. C. Application of Army half- 
ring splint with traction, at collecting station, for compound fracture of middle third 
of tibia. Basswood coaptation splints had been used for emergency splinting. 
D. Substitution, in a clearing station, of standard splinting (traction in an Army 
half-ring leg splint) for the improvised splinting shown in figure 10. SPLINTING IN COMBAT ZONE 
39 
2. If the injury was near the hip or the knee, the splint was bent 15° 
to 20° at the knee before it was applied, so that those joints would be put up 
in some degree of flexion. 
3. In fractures of the lower third of the femur, the popliteal vessels had to 
be protected against injury from the sharp bony fragment likely to project 
posteriorly. The risk of injury to the popliteal artery was decreased if the 
extremity was put up in slight flexion at the knee instead of in complete exten- 
sion. 
4. Pressure necrosis, which was a possibility underneath the strap crossing 
the foot, was guarded against by avoiding strong traction. Strong traction, 
as a matter of fact, was not required, since the objective was merely to im- 
mobilize the fracture, not reduce it. The results were therefore accomplished 
by moderate or even minimal traction. It was necessary to inspect the strap 
at each halt in the line of evacuation, to be sure that pressure had not become 
excessive. 
TRANSPORTATION SPLINTING 
The routine use of plaster of pans for transportation splinting in the evacua- 
tion hospitals of the combat zone in World War II was a major advance over 
the methods of splinting used in World War I, when for all practical purposes 
only the splints and appliances described in the manual issued in 1917 (p. 31) 
were provided in forward areas and plaster was seldom used.3 
Medical planning for World War II contemplated the use of plaster in the 
forward zone, partly because United States surgeons were fully trained in 
plaster techniques and partly because these methods had been used with 
satisfaction in forward installations during the Spanish Civil War as well as 
in Allied forward hospitals before the entry of the United States into the war. 
Standard United States Army Medical Department equipment for hospitals 
in the combat zone therefore included ample supplies of plaster of paris and 
sheet wadding, in addition to standard splints. Portable fracture tables 
became available after the Tunisian campaign in 1942-43, Up to that time, 
some hospitals were supplied with Meyerding sacral rests. Those which did 
not have them made use of wooden blocks, tin cans, and other improvised 
substitutes, which were more or less satisfactory. The chief objection to 
these improvisations was that they were wasteful of personnel. At least one 
person was required to hold each lower extremity while a hip spica, for instance, 
was being applied. 
3 It should be remembered that the First U. S. Army functioned in World War I for only about 11 weeks, from 2 
September to 11 November 1918. The number of casualties during this period was large but amounted to only a small 
fraction of those sustained in the European theater or Mediterranean theater during World War II. There was no con- 
sultant system in World War I, except on paper, until hostilities were almost concluded. Those of us who served in 
World War I, I have found, cannot recall seeing any circulars or directions concerning the proper splinting for evacuation 
of wounded. The Army ring splint was used to evacuate patients from field hospitals to evacuation hospitals, and, in 
smany instances, it was doubtless reapplied before they were sent to the rear from evacuation hospitals. Plaster-of-paris 
plints, however, were also used. I recall applying them myself, and I have checked with a fellow medical officer who 
served in a nearby evacuation hospital and who spent his entire time applying plaster-of-paris splints to immobilize 
fractures for evacuation. [Editor’s note.] 40 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
General Considerations 
The objective of transportation splinting in a forward hospital was to 
maintain gross normal alinement of the injured extremity, to immobilize the 
adjacent joints in the position of function, and to accomplish these purposes 
without causing nerve or circulatory damage or causing pain by pressure on 
bony prominences. 
Some of the techniques used in the hospitals of the combat zone early in 
the North African experience proved completely unsatisfactory and dangerous 
as well. Among them were skintight, unpadded plaster casts and skeletal 
fixation with incorporation of transfixion pins or wires in the cast (p. 55). 
The ideal transportation splint proved to be a well-padded plaster-of-paris 
cast which held the fracture in grossly normal alinement and which immobilized 
the joints above and below the injury in the position of function. Once the 
lesson was learned, no exceptions were permitted to the rule that all circular 
plaster casts applied to the extremities must be split or bivalved in the operating 
tent of the forward hospital before the patient was taken off the operating table. 
There were two reasons why it was not safe to postpone this procedure: (1) 
There were no ward officers in the usual sense of the term in forward hospitals, 
and the splitting or bivalving of the cast was therefore the responsibility of 
the surgeon, who could not count on time to leave the operating room to split 
casts on the ward; and (2) theoretically, provision had to be made for a tactical 
situation which might demand immediate evacuation and allow no time for 
such details as splitting casts. 
Plaster casts for transportation purposes were made relatively thick and 
heavy, to prevent breakage after they had been split or bivalved. Muslin 
bandages were wound around them snugly after they had been split, to protect 
their integrity and increase their stability. 
After the cast had been applied, a diagram was drawn on it showing the 
location and general contour of the fracture (fractures), the location of the 
wounds of entry and exit, and the extent of the skin loss. Those who cared 
for the casualty in the course of his evacuation, as well as those who received 
him in the general hospital, thus had a readily available source of information 
concerning his injuries. 
The application of good transportation splinting often required the help 
of several persons. A single assistant could not possibly support a lower 
extremity in which both the tibia and fibula were fractured so that the frag- 
ments were kept in satisfactory alinement, while at the same time the foot was 
kept in 90° dorsiflexion, in neutral version, and the knee in mild flexion. An 
attempt to put the lower extremity in plaster with aid from a single assistant 
who grasped the toes and provided both elevation and traction almost invari- 
ably resulted in immobilization with posterior bowing, with the foot in plantar 
flexion and inversion and the knee in complete extension. This is as pernicious 
a position as can be imagined for immobilizing an extremity with a fracture 
of the tibia and fibula. Properly, the plaster was applied for such an injury SPLINTING IN COMBAT ZONE 
41 
while one assistant supported the fracture and another held the foot in correct 
position. 
Improvised methods (fig. 15) were designed to reduce the number of 
helpers necessary after initial wound surgery, personnel shortages always 
being a problem. Thus the use of a narrow, removable support of flexible 
metal under the knee while the cast was applied to the lower extremity kept 
the joint in slight flexion and made it possible for a single assistant to support 
the fractures of the lower leg in reasonably good alinement and at the same time 
hold the foot in the position of function (fig. 15A). 
A plaster Velpeau or shoulder spica was extremely useful in transportation 
splinting for injuries of the upper arm and shoulder but was difficult to apply 
because of lack of standard equipment. The hinged full-ring arm splint, al- 
though unsatisfactory for the purposes for which it was intended (p. 34), was 
very useful in the application of plaster about the shoulder (fig. 15B). The 
end of the splint was placed on the operating table and the ring on some con- 
venient available support, such as a sawhorse. The patient’s head rested com- 
fortably in the ring during the application of the cast. The splint was easily 
pulled out from beneath the cast after the plaster had hardened. A long, 
narrow board or a narrow strip of strong metal could also be used in this fashion 
(fig. 15C), but it was less convenient for the surgeon and considerably less 
comfortable for the patient. 
If the hand was suspended from a stand used for intravenous therapy by a 
roller bandage tied about the thumb and fingers, long arm plaster casts could 
be applied for fractures of both bones of the forearm with the fragments in 
reasonably good position and the wrist and elbow joints in the position of 
function. 
These are merely examples of some of the shortcuts and improvisations 
employed. They were highly advantageous when casualties were heavy, 
demands urgent, and surgical personnel in short supply. Numerous others 
were devised as special necessities developed. 
Regional Splinting 
Arm and shoulder joint.—For several years before the war, the hanging 
plaster cast had been popular in the United States for fractures of the humerus 
and injuries about the shoulder joint. It was therefore natural that it should 
have been rather widely used in the early stages of the North African campaign. 
It soon became evident, however, that while this cast might be satisfactory in 
civilian practice, it was not an adequate transportation splint in military 
circumstances. Reports from general hospitals which received casualties put 
up in hanging casts were always to this effect. Most patients with fractures 
of the humerus were necessarily transported recumbent after initial wound 
surgery, with the result that the traction produced by the weight of the cast in 
the hanging position was lost and little immobilization was maintained during 
transportation. Ambulance rides,over rough terrain helped to increase the 42 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-652, FD-44-9, C-45-759, C-44-542, CA-44-137 
Figure 15.—Improvisations designed to save time and economize on personnel in applica- 
tion of splinting in evacuation hospital after initial wound surgery. A. Application 
of plaster cast of lower extremity in evacuation hospital. Note narrow removable 
support of flexible metal which is readily improvised and is exceedingly valuable in the 
proper application of the cast. Note that the cast has been split down the outer side. 
Note also data on cast. B. Use of hinged full-ring splint to facilitate application of 
plaster Velpeau or shoulder spica. C. Application of plaster Velpeau or shoulder 
spica is facilitated with patient lying on narrow metal strip, one end of which rests on 
the operating table and the other on an improvised headstand. D. Application of 
hip spica. The patient rests on a portable fracture table placed on top of a wooden 
table improvised in a fixed hospital. The same type of portable fracture table is 
placed on a standard folding operating table for the application of hip spica casts in 
forward hospitals. E. Improvised canvas sling, stretched between crossbars fixed to 
a litter, for application of body cast or plaster Velpeau. SPLINTING IN COMBAT ZONE 
loss of immobilization and added to the patient’s discomfort. Because of 
universally adverse criticism, the hanging cast was seldom used after the first 
months of 1943. 
In the early North African experience, fractures of the humerus were also 
immobilized by the so-called U-plaster cast, which the British had used widely 
in the Middle East. It was not satisfactory and was soon discarded. Another, 
later method, which also never achieved popularity among United States 
Army medical officers, was the so-called elephant-tusk splint (fig. 16), which 
was introduced during the Italian campaign. Because it could be removed 
and replaced, it was theoretically useful (1) in injuries of the arm or shoulder 
associated with chest injuries which required thoracentesis and (2) in vascular 
injuries which required repeated inspection of the entire arm and forearm. 
The plaster Velpeau and the shoulder spica both proved excellent trans- 
portation casts, and one or the other was always used after the fighting for 
Cassino and Anzio began in the winter of 1944. Both maintained the arm at 
or near the side and the elbow at 90°. This position permitted transportation 
with minimum discomfort. 
The plaster Velpeau (fig, 17) was, for a number of reasons, the better of 
the two techniques: It provided maximum comfort. It was easy to apply and 
remove. It fitted within the bars of the litter, which was an important con- 
sideration in comfortable transportation. If thoracentesis was necessary for 
an associated chest injury, access to the chest could be provided by windows 
cut into the cast. If radial-nerve paralysis was present, excellent temporary 
support could be provided for the thumb and the proximal phalanges of the 
fingers by extending the plaster sufficiently to hold them in extension. When 
the plaster Velpeau was applied correctly, it was not necessary to split it, since 
it did not completely enclose the arm. 
There were, it is true, some theoretical objections to the use of a plaster 
Velpeau for transportation splinting. The chief was that the adducted position 
of the arm at the side was unsuitable for fractures of the upper third of the 
humerus. This was not a sound argument, for two reasons. The first was that 
a surgeon in a forward hospital was not concerned with the definitive reduction 
of fractures. The second was that the comfort provided by the cast predisposed 
to muscular relaxation, so that it was the exception, at the general hospital, 
not to find the upper humeral fragment adducted and in reasonably good 
alinement with the distal fragment. 
The shoulder spica (fig. 18) provided just as comfortable transportation 
as the plaster Velpeau in injuries of the arm and shoulder, but it had a number 
of disadvantages in a forward hospital: The spica had to be applied with special 
precautions, preferably with the arm in the position of internal rotation at the 
shoulder and with the elbow and arm held anteriorly rather than laterally. 
Otherwise, the cast would not fit within the bars of the litter or cot, and the 
elbow would project and might be traumatized during transportation. Finally, 
the spica required more personnel for its application, and the use of more 
plaster, than the Velpeau. 44 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP FC-44-U 
Figure 16.—Modification of elephant-tusk splint for fractures about shoulder joint and 
elbow. This splint has only a limited field of usefulness, but every military surgeon 
should be familiar with it. The shoulder and elbow are points of stress, and the cast 
most often breaks at these points. A and B. Technique of application of elephant-tusk 
splint. C and D. Anterior and posterior views of completed splint. SPLINTING IN COMBAT ZONE 
45 
AFIP FC-44-0 
A. Diagrammatic showing of steps of application of plaster Velpeau. For several reasons, 
this cast provides excellent transportation splinting for fractures of the humerus. It can 
be constructed from only 2 plaster slabs and 2 or 3 rolls of plaster bandage. There are no 
points of stress, so breakage need not be feared. The entire hand, if desired, can be left free. 
B. Plaster Velpeau used as transportation 
splinting for compound fracture of lower 
third of humerus. The hand in this case 
projects farther forward than usual. 
AFIP CA-44-612 
C. Plaster Velpeau applied in evacuation 
hospital after initial surgery for compound 
fracture in region of shoulder. Note data 
on cast. 
AFIP FD-44-924 
Figure 17.—Plaster Velpeau bandage for injuries of shoulder joint, arm, or elbow 
3969610—57 5 46 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP Fc-45-2 
A. Diagrammatic showing of shoulder spica so applied 
that forearm and elbow are held forward and therefore 
within bounds of litter bars. Note that the circular 
portion of the cast about the arm has been split. 
B. Shoulder spica applied in evacuation hospital, following initial surgery 
for compound fracture of humerus with injury to radial nerve. Note support 
temporarily provided for thumb and proximal phalanges of fingers. Note 
also data on cast. 
AFIP C-44-480 
Figure 18.—Application of shoulder spica for injuries about shoulder joint and of arm SPLINTING IN COMBAT ZONE 
47 
Forearm and elbow joint.—The preferred transportation splint for wounds 
of the forearm and elbow joint was a plaster cast extending from the upper arm 
to the proximal palmar crease. It was so applied that the elbow was held at 
90°, the forearm in mid pronation, and the wrist in slight cocknp. A sling 
provided additional immobilization and at the same time added to the patient’s 
comfort. It was particularly important that the sling be supplied when the 
casualty had no other injury. Under these circumstances, he would be treated 
as walking wounded, and without a sling the hand would be in the dependent 
position and would rapidly become edematous. 
If there was no radial-nerve injury, all casts applied to the upper extremity 
were trimmed away to the proximal palmar crease, to permit active use of the 
fingers and thumb. Particular care was taken to avoid restriction of motion 
in the metacarpophalangeal joints. If radial paralysis was present, the plaster 
was extended beyond the palmar crease, to support the proximal phalanges of 
the fingers in some degree of extension, and the thumb was immobilized in 
partial abduction and extension. The distal phalanges of the fingers wTere 
left free for active motion. 
Thigh and hip.—Although the hinged half-ring traction splint was standard 
United States Army equipment, it wras seldom used in transportation splinting, 
even during the early stages of the North African campaign. 
During both phases of the Tunisian campaign, United States Army medical 
officers had ample opportunity to observe the British use of the Tobruk splint. 
This splint, so named because it first came into use during the evacuation of 
Tobruk, w as practically always used by the British for transportation splinting 
of fractures of the femur, and its use was recommended in the preparatory 
United States Medical Department directives4 for the invasion of Sicily. 
United States Army surgeons wdm served in Sicily never liked the Tobruk 
splint for fractures of the femur. They found it difficult and time consuming 
to apply and did not regard the immobilization provided as satisfactory. 
For these reasons, the Tobruk splint was not generally accepted in the 
Mediterranean theater during the remainder of World War II, even after 
its application had been greatly simplified and it had proved highly effective 
for transportation splinting in injuries of the knee (p. 49) and the lowTer third 
of the femur. 
In spite of the unpopularity of the Tobruk splint, every United States 
Army military surgeon should have been familiar wdth it. It was far more 
desirable than the hip spica when injuries of the large bowel for which 
colostomy had been performed were associated with fractures of the femur. 
It was particularly useful for fractures of the lowrer third of the femur and 
wounds of the knee joint. It was also useful when either plaster or water 
was in short supply or when speed of application W’as important. 
4 (1) Circular Letter No. 13, Office of the Surgeon, North African Theater of Operations, 15 May 1943, subject: 
Memorandaon Forward Surgery. (2) Circular Letter No. 16, Office of the Surgeon, North African Theater of Operations, 
9 June 1943, subject: Memoranda on Forward Surgery Especially Applicable to Amphibious Operations. (See appendix, 
pp. 299-303 and 304-307, respectively.) ' 48 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 19.—Hip spica applied in evacuation hospital for transportation splinting of com- 
pound fracture of femur. The cast has been split along the outer side. Note that 
knee spread is held to a minimum, so that the cast fits within the bars of the litter. 
Note also the data on the cast, including the highly informative diagram of the injury. 
AFIP C-44-338 
Early in the North African campaign, the single hip spica was widely used 
for fractures of the femur and fractures about the hip joint. Later, the double 
spica (fig. 19) came into general use. It was really a spica and a half, since the 
cast on the uninjured side was carried only to the knee. On the injured side, 
the cast extended from the foot to the costal margin. A plaster slab extended 
beyond the toes. The plaster was molded about the pelvis and was trimmed 
low in front, to permit the injured man to sit semierect during travel. Knee 
spread was held to a minimum, so that the cast would fit between the bars 
of the litter or cot on which the casualty was transported. Such a spica cast 
emerged as the recommended transportation splinting for fractures of the 
femur. SPLINTING IN COMBAT ZONE 
49 
Certain precautions were necessary in the application of the spica. In 
fractures of the upper third of the femur, the hip and knee were both flexed at 
35° to 40°, In fractures of the lower third, in order to guard against pressure 
in the popliteal space by rotation of the lower femoral fragment, the knee was 
flexed at 30° to 35°, which required a compensating degree of flexion of the 
hip. Care was taken to insure that the heel and buttock were held in the same 
horizontal plane when the cast was applied. Otherwise, the upper rim of the 
cast could produce uncomfortable pressure against the back or the abdomen 
when the patient was recumbent in bed or on a cot and the heel and buttock 
necessarily assumed the same plane. 
If the spica was bivalved from toes to hip, cross sticks were incorporated 
between the thighs both anteriorly and posteriorly. As a rule, it was necessary 
to split only the leg section of the spica, on the outer aspect, and a single 
anterior cross stick was then all that was necessary. 
Knee joint.—Satisfactory methods of transportation splinting for wounds 
of the knee joint were slow in developing. Long leg casts were used in the 
early days of the North African invasion and continued to be used by most 
surgeons in forward areas until the spring of 1944. This technique was employed 
in spite of the early British experience, which had showed that the hip spica 
was preferable for such injuries, and in spite of reports from United States 
Army general hospitals to the effect that casualties transported in long leg 
casts often suffered a great deal of pain. 
The hip spica began to be used for injuries of the knee joint in the latter 
part of 1943, but it was employed only sparingly until the spring of 1944. 
Then its use was recommended officially, as part of the effort to improve the 
results in wounds of the knee joint. The long leg cast, however, was easier 
to apply and it continued to be used frequently, especially when casualties 
were heavy. This was unfortunate, for, even when injury to the adjacent 
bones was minimal, adequate immobilization of the knee was of paramount 
importance in reducing the risk of infection. It was also essential if the 
patient were to travel comfortably. These criteria could not be met by use 
of a long leg plaster cast. 
It was eventually found that a single hip spica, well molded about the 
pelvis, with the hip and knee joints each held in 15° to 20° flexion, provided 
the most satisfactory kind of transportation splinting for an injury about the 
knee joint. The portion of the spica encircling the trunk was kept narrow 
and did not extend above the costal margin, so that the soldier might sit 
semierect without discomfort, as in spicas applied for fractures of the femur. 
The simplified form of the Tobruk splint (fig. 20) could be used as a 
substitute for the plaster hip spica for wounds about the knee joint, and its 
ease of application often made it a desirable substitute. Because it had 
proved so unsatisfactory in its original form for fractures of the femur, it 
never became widely popular for this purpose in Fifth U. S. Army hospitals. 
The simplified form of the Tobruk splint was, however, recommended for ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP FC-44-1 
Figure 20.—Application of modified Tobruk splint. A. Application of adhesive tape for 
traction; sheet cotton and plaster. B. Stabilization of half ring by loop of muslin bandage 
incorporated in plaster. SPLINTING IN COMBAT ZONE 
51 
wounds of the knee joint by the consultant in surgery, Seventh U. S. Army, 
just before the invasion of southern France. 
In the original Tobruk splint, traction was provided by strips of adhesive 
plaster passed down each side of the thigh and leg. A long leg plaster cast, 
which included the foot, was applied over these strips, which emerged from 
the cast just above the malleoli. The injured extremity in the plaster cast 
was then placed in a Thomas splint and the traction strips were tied to the 
end of the splint. Traction was provided by means of a windlass. Additional 
turns of plaster were passed around the leg and the bars of the splint. 
In the simplified Tobruk splint (fig. 20), the traction strips of adhesive 
were placed down each side of the extremity, as in the original technique, 
and the limb, heavily covered with sheet cotton, was placed in an Army half- 
ring splint. The traction strips were then passed around the footrest, which 
supported the foot at about 90°, and were tied to the end of the splint. Tongue 
depressors passed between the traction strips just proximal to the distal end 
of the splint served as windlasses to provide some traction. Several turns 
of plaster were next applied loosely about the limb and the splint, from just 
above the malleoli to the groin. They were molded about the uprights and 
along the posterior and anterior surfaces of the thigh and leg. The distal 
end of the splint was elevated by means of a second foot support, which was 
turned downward. A figure-of-eight plaster bandage bound the foot to the 
foot support. This precaution, which prevented rotation of the leg, increased 
the patient’s comfort. 
The full-ring Thomas splint would have been more satisfactory to use 
with the Tobruk splint than the half-ring splint, hut the latter had been 
standardized equipment since the beginning of World War II, and the full- 
ring splint was not available in evacuation hospitals. Deflection of the half 
ring at any time after it was applied caused the upper end of the plaster to 
press against the thigh and produced considerable discomfort. This could be 
avoided by fixed traction on loops of a bandage passed through the half ring. 
The ends of the loops of bandage were incorporated in the plaster about the 
thigh and the half ring was thus stabilized in the correct position. 
Surgeons of the forward hospitals of the Fifth and Seventh U.S. Armies 
who used the Tobruk splint by the modified technique just described were 
almost unanimous in stating that it can be applied more quickly and more 
easily than a hip spica. 
Leg, ankle joint, and foot. -Fractures of bones of the leg, ankle joint, and 
foot were put up in molded plaster casts (fig. 21). If only the bones of the foot 
were broken, the cast was stopped at the knee. For injuries about the ankle 
and for fractures of the tibia, fibula, or both bones, it was carried to just below 
the groin. The foot was held at 90°, in neutral version, with the arches well 
molded. A plantar slab extended beyond the toes, to protect them from the 
pressure of blankets and from other trauma during transit. Hyperextension of 52 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-663 
Figure 21.—Transportation splinting in fractures of lower extremities. 
Long leg cast applied in evacuation hospital, following initial surgery. 
The cast has been split down the outer side, and a muslin bandage is 
being applied about it to maintain its integrity. Note the excellent 
position of the knee and ankle joints, the plaster support for the 
protection of the toes, and the data inscribed on the cast. 
the toes was avoided. The knee was immobilized in about 15° flexion. Failure 
to provide this small degree of flexion increased the difficulty of obtaining 
fixation of the foot at the proper angle, since complete extension of the knee 
increased the tension on the gastrocnemius muscle. CHAPTER IV 
The Management of Compound Battle Fractures 
Part I. The Evolution of the Program of 
Staged Management 
CONCEPTS AND PRACTICES BEFORE WORLD WAR II 
Orthopedic practices in general use at the end of World War I called for the 
management of most compound battle fractures in splints or appliances based 
on the general principles of splinting. Skin traction was used for continuous 
traction. Only occasional fractures were put up in skeletal traction, and plaster 
was not generally used because freedom of joint movement was considered 
desirable. 
In the management of compound fractures, great emphasis was placed 
upon the sterilization of the wound. Infection was combated by local applica- 
tions of such agents as BIP (bismuth subnitrate, iodoform, and paraffin) or by 
the elaborate irrigation ritual of the Carrel-Dakin method. Evaluation of the 
results accomplished during the last months of the war, when these methods 
had become fairly well stabilized, showed a high incidence of infection, which 
was likely to run a prolonged course; a high incidence of malunion and non- 
union; and rates for amputations and for fatalities which exceeded reasonable 
expectancies. 
After the war, the Carrel-Dakin method continued to be used in the man- 
agement of civilian compound fractures and joint injuries, at first enthusi- 
astically, then with increasing dissatisfaction. It was tedious and troublesome to 
apply, and the end results left much to be desired. Gradually, for these reasons, 
it fell into disuse. Meantime, a method usually credited to H. Winnett Orr 
was increasing in popularity. This method had been devised to meet the dual 
problems of an infected wound and a fractured bone. The wound was left 
open, to secure drainage, and the fracture was managed by skeletal fixation in a 
plaster cast. One objective of the method was the prevention of the trauma 
and reinfection which experience had shown was likely to occur with frequent 
dressings. 
The first wartime test of the closed plaster technique (which, incidentally, 
was a revival of the “occlusive” method described by Ollier in 1872) came dur- 
ing the Spanish Civil War, when it was employed by Trueta 1 and others with 
1 Trueta, J.: Treatment of War Wounds and Fractures With Special Reference to the Closed Method as Used in the 
War in Spain. New York: Paul B. Hoeber, Inc. 54 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
a number of modifications. It was eventually used in some 20,000 cases. In 
1,073 open fractures personally treated by Trueta, the reported results were 
excellent. There were only 6 deaths, and only 2 of these, both after operations 
for gangrene, were directly related to the compound fractures. Results were 
classified as poor in 91 other cases, in 4 of which amputation was necessary. 
As these results became generally known, the closed plaster method became 
increasingly popular, and, when World War II broke out in 1939, it was natural 
that it should be employed in the Allied armies, as well as in the German and 
the Russian Armies. 
The steps of the closed plaster technique vere described by Trueta as 
fellows: 
2. Once the patient is anesthetized, thoroughly wash the entire extremity and the 
wound with water, soap and a nail brush, until the whole is completely clean and the wound 
itself is bleeding; shave all hair. Paint the surrounding skin with a weak alcoholic solution 
of iodine, without touching the wound in any circumstances. 
3. Excise the skin edges of the wound, remove all contused tissue and widen the wound 
as much as may be required. Excise carefully and unhesitatingly all nonviable muscular 
and cellular tissues, noting in particular the colour of the injured muscles, their contractility 
on stimulation with forceps, and their capacity to bleed. 
4. Open up the neighbouring cellular spaces affected by the contusion and, where 
necessary, incise the soft tissues, following up the cellular spaces in the depths of the wound, 
always keeping in mind the need for adequate drainage. Remove any haematoma present. 
5. Remove the majority of bone fragments that are completely denuded of periosteum 
or displaced, and all foreign bodies found at the site of fracture. There is no need to be 
concerned much about any pieces of bullet that are difficult to locate; but it is most important 
to excise carefully all foreign organic matter (pieces of clothing, wood, etc.). The procedures 
described above—namely, the removal of all foreign matter, the excision of all the tissues 
immediately surrounding the wound, including devitalized soft parts in the vicinity, and the 
opening up of cellular spaces—is known technically as debridement. 
6. If the thigh, knee joint or leg is fractured, reduce the fracture by traction on an 
orthopaedic table or by hand. In arm fractures which require traction or abduction, appb 
the appropriate apparatus. Details may be found in the chapters dealing with wound 
of the different regions. 
7. Once the fracture is reduced firmly dress the wound with sterile gauze and imme- 
diately immobilize with plaster, including the two adjoining joints if possible. 
8. Give an injection of tetanus antitoxin. 
Drainage and Suture 
In cases in which deep cavities are present drainage must be arranged by opening up the 
aponeurotic planes and the intermuscular spaces; this drainage can generally be maintained 
by the insertion of sterile gauze, but in some cases no inconvenience results from the insertion 
of a rubber tube which may be buried under the plaster and retained until the first change 
of the cast. No complication of any kind can be attributed to drainage; on the other hand, 
retained discharge, the result of bad drainage, may bring about disaster. 
The immediate reaction to this method of treatment was sometimes 
severe. The temperature might rise to 104° F., and the axillary or inguinal 
lymph nodes might become enlarged. These phenomena were not regarded by 
Trueta as indications, in themselves, for the premature removal of the cast or 
for cutting windows into it. The only indication for removal of the plaster MANAGEMENT, COMPOUND BATTLE FRACTURES 
55 
ahead of the time determined upon—from 10 days to a month after operation, 
depending upon circumstances—was the appearance of such symptoms and 
signs as edema of the distal portion of the extremity; inability to move the 
toes or fingers; and evidences of progressive infection, including lassitude, a 
progressive increase in the intensity of the pain, and a rising pidse rate. As a 
rule, the cast was kept in place without change for 10 to 15 days in summer and 
for a month in winter. The seasonal distinction was explained by the fact that 
the strong odor which emanated from the wound in this method of treatment 
was not wrell tolerated during the summer by the patient’s associates in the ward. 
UNITED STATES EXPERIENCES WITH THE CLOSED 
PLASTER METHOD 
Since United States experiences with the closed plaster method had been 
reasonably good in civilian practice and since British and other European 
surgeons had apparently had good results with it in the first months of World 
W ar II, it was natural that United States Army medical officers should be 
prepared to use it in the North African invasion. The circumstances early in 
the invasion were not conducive to a coordinated plan of timed surgery such 
as was developed later. Evacuation hospitals were widely separated, and often 
the medical officers in them had no knowledge of what hospitals were behind 
them. The situation, in short, was an invitation to the one-stage management 
of compound fractures which was offered by the closed plaster method. 
In the early experience in North Africa, the general plan of management, 
although it was not really official, was as follows: After debridement in a 
forward hospital, the wound was dressed with vaseline gauze; the fracture was 
reduced; and a plaster cast was applied, in which skeletal transfixion pins were 
sometimes incorporated. The patient was then transferred to a general hos- 
pital where, in the absence of specific indications to the contrary, the cast was 
left in place for 4 to 6 weeks. At the end of this time, it was assumed, wound 
healing would be progressing satisfactorily by granulation, and the fracture 
would also be well on its way toward healing. 
In theory, this was not an unsound policy. In practice, it proved unwork- 
able, and the results were poor. Patients were frequently febrile when they 
were received in general hospitals; often the temperature was very high. If 
the casts had been split or bivalved, as theater regulations required (p. 40), 
the plaster was often disintegrating and ineffective. If the casts had not been 
split, the circulation was sometimes threatened. Transfixion pins were often 
broken, and infection about them was frequent. Even when the fracture had 
been adequately reduced in the forward hospital, position was likely to be lost 
in transit over long distances and rough roads, and a second reduction was 
necessary at the general hospital. Finally, when the casts were left in situ the 
theoretical length of time, blister formation, excoriations of the skin, and 
pressure sores were frequently present when they were removed. 56 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Because of the poor condition in which so many casualties were received 
in general hospitals, it was found inadvisable to allow the casts to remain in 
place for the specified length of time, and they were usually changed at once. 
Inspection was likely to reveal two reasons for the infection: (1) Devitalized 
tissue had not been completely excised, and (2) the wound was actually plugged 
by the pack of vaseline-impregnated gauze. Displacement of fractures was 
frequent, but, if only a week or two had elapsed since wounding, the displace- 
ment could usually be corrected by manipulation or skeletal traction. If 2 
weeks or more had elapsed, in many cases this was not possible, and faulty 
reduction had to be accepted. 
Even in the relatively small number of cases in which conditions appeared 
to be favorable when the casualties were received at the general hospital, 
surface impressions were not always correct. When the cast was finally 
removed, at the end of several weeks, unsuspected infectious processes were 
often revealed. In many cases, purulent exudate had been dammed back by 
the dressings which plugged the wound, and the infection had been buried 
beneath the closed plaster. Moreover, reduction of the fracture was often 
lost as the cast became loose as a result of atrophy of the musculature as well 
as decreased swelling. 
These observations in the first months of the North African invasion made 
it clear that a strict application of the closed plaster regimen was not practical 
in the circumstances which then prevailed. Initial surgery was often inade- 
quate, perhaps because it was, of necessity, performed bj' surgeons without 
previous experience in military surgery. 
By the early spring of 1943, the closed plaster method bad been modified 
to meet these circumstances. All casts applied after initial surgery in the 
forward area were removed at the fixed hospital not later than the 15th day 
after wounding. The surgeon who assumed charge of the patient thus had 
an opportunity to inspect and appraise the wound when the dressings were 
removed and before it was re-dressed. It was also possible to manipulate the 
fracture, institute traction, or carry out whatever other measures of fracture 
management the particular case required. Finally, the wound was covered 
with an occlusive dressing, and, if traction had not been instituted, a fresh 
plaster cast was applied. 
The 15th day after wounding was arbitrarily set as the upper time limit 
for these manipulations. It is true that some fractures were reducible after 
longer time lapses but most of them were not, and additional postponement of 
attempts at correction would have introduced the risk of serious trauma to 
the soft parts, which in turn was conducive to infection. 
At this period in the war, the attention of surgeons in general hospitals 
was chiefly concentrated on the reduction of fractures. It was believed that 
an open wound was necessary to permit prolonged drainage and that inter- 
ference with the wound would reactivate infection. Secondary surgery, when MANAGEMENT, COMPOUND BATTLE FRACTURES 
57 
the cast was removed, was therefore 'imited to the unroofing of areas of dead 
tissue and the excision of presenting and protruding tags of similar tissue. 
The depths of the wound were seldom investigated. Slow healing of the 
wound by granulation, with resultant scar formation, was accepted as the best 
that could be expected in the circumstances. 
As the months passed and experience increased, concepts of wound man- 
agement and fracture management began to alter. It began to be realized, as 
later experience amply proved, that, if devitalized tissue was not completely 
excised at the first surgical attack on the injury, infection was a likely outcome. 
If large hematomas remained in undrained dead space, they were likely to 
undergo purulent decomposition. If dead tissue were allowed to remain in the 
wound, neither systemic nor local chemotherapy nor a combination of these 
methods could prevent wound infection. Once wound infection had developed, 
local necrosis of living tissue would follow, and a vicious circle was likely to be 
established. 
Several clinical observations of considerable importance, as follows, were 
made during this period of the war: 
1. Although the sulfonamides had no ability to prevent local infection, 
invasive infection was extremely infrequent when they were used, and infected 
wounds seldom manifested the cardinal signs of inflammation. 
2. Systemic chemotherapy, though it could not prevent local infection, 
was apparently extremely effective in preventing the type of invasive infection 
of streptococcic origin which had been associated with so many compound 
fractures in World War I. 
3. Unreduced fractures which required repeated manipulations or whose 
position in traction required repeated readjustments were peculiarly likely to 
become infected. 
4. Infection was also likely to occur in injuries in which the fracture was 
exposed in the wound and dead space was difficult to obliterate. This was 
particularly true of fractures of such bones as the tibia, the ulna, and the 
tarsus, all of which lie immediately beneath the skin. 
The significance of these various observations was not immediately realized. 
The fear of reactivating infection persisted, and wounds containing grossly 
devitalizing tissue continued, for the most part, to be managed in the general 
hospitals by a hands-off policy, in anticipation of the spontaneous sequestra- 
tion of dead tissues. Delayed surgical excision was thought to be neither 
feasible nor safe. For the same reason, inadequate reduction of many frac- 
tures, particularly of the tibia, the fibula, and the bones of the forearm, and 
fractures about the joints, continued to be accepted because it was feared 
that infection would follow operative manipulation and reduction. As the 
result of these concepts and practices, the incidence of malunion and nonunion 
of compound fractures continued too high through most of 1943, and wound 
healing was prolonged and sometimes was not obtained at all. 58 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
DEVELOPMENT OF THE PROGRAM OF 
REPARATIVE SURGERY 
The closed plaster method of management of compound fractures was for 
all practical purposes written off early in 1944 because, even with the modifica- 
tions which had been introduced, the results were not satisfactory. Analysis 
of the results, furthermore, showed that improvement could be accomplished 
only by a fundamental change in surgical concepts. Superficial alterations of 
technique would not accomplish the purpose. In particular, it would be 
necessary to discard the concept that surgery in an infected field could not be 
performed because of the risk of precipitating a limb-endangering osteomyelitis 
if not a life-endangering generalized infection. 
The changed approach to battle-incurred compound fractures and the 
revised concept of their management were both embodied in the reparative- 
surgery program which had been instituted in the Mediterranean Theater of 
Operations late in 1943. At this time, the delayed closure of clinically clean 
wounds of the soft parts began to be practiced by a number of surgeons and 
was enthusiastically encouraged by the consultant in surgery for the theater. 
Though this story is told in detail in another volume of the clinical series of 
this history, it must be briefly summarized here, because it provides the back- 
ground for the experience in the reparative surgery ol compound fractures. 
It was always a general principle of military surgery in World War II 
that wounds should be left open following debridement. The wartime ex- 
perience with primary closure of soft-tissue wounds was brief and unhappy. 
Wound healing by granulation, however, had not provided the answer to the 
problem, and, as just indicated, delayed closure of soft-tissue wounds began 
to be practiced late in 1943, at first occasionally, then more frequently, and 
with informal official encouragement. 
This was not a new idea. It had been practiced to some extent in World 
War I, with, however, one essential difference. No matter at what time de- 
layed primary closure was to be instituted, cultures were taken from the 
wound when it was exposed for dressings, and closure was not scheduled if the 
bacterial count was high. In effect, this meant that the wound must be 
dressed one or more times to obtain the material for culture. It meant, further, 
that each of these dressings offered fresh opportunities for infection. Finally, 
it meant that a considerable amount of laboratory work was prerequisite to 
the closure of any wound. For two reasons, therefore, the policy of delayed 
primary wound closure had only a limited application in World War I: (1) If 
bacterial counts were high, as they frequently were, the optimal time for wound 
closure was missed, and healing by granulation had to be accepted. (2) Multiple 
dressings and extensive laboratory studies were so time consuming as to be 
completely impractical when the flow of casualties was heavy. 
In World War II, delayed primary wound closure was based upon an 
entirely different concept. It was preferably accomplished within 4 to 7 days MANAGEMENT, COMPOUND BATTLE FRACTURES 
59 
after wounding if the wound looked clinically clean and if surgical limitations 
(that is, loss of tissue, dead space, or excessive tension if the wound were to 
be sutured) did not contraindicate it. Bacterial counts were not made. The 
decision to close the wound or leave it open longer was based entirely on very 
careful inspection and clinical appraisal. If tags of devitalized tissue could 
be excised and hematomas and dead space could be eliminated, wound closure 
was not regarded as contraindicated. If skin deficits prevented closure by 
suture, reparative surgery was still performed if closure could be effected by 
rotation or advancement of flaps of skin or by the use of split-thickness skin 
grafts. In other words, the criteria for closure were not bacteriologic but 
clinical. The requirements were (1) a clean wound, either present on inspection 
in the general hospital or secured by some additional excisional surgery; and 
(2) freedom from the surgical limitations just listed. 
Even if the casualty was not seen in the general hospital until 10 days or 
more after wounding, delayed closure of clean wounds was still practiced. 
Granulation had usually begun in such cases, and closure involved, just as in 
World War I, actual excision of the wound. Even after this lapse of time, 
cultures and bacterial counts were omitted. The decision for or against closure 
was based on the clinical impression that invasive wound infection was or was 
not present. If it was not present, closure was accomplished after what 
amounted to a second debridement. 
The extensive bacteriologic studies carried out by Lyons and Rustigian, 
which are also reported in detail in another volume of this clinical series, com- 
pletely confirmed the soundness of these practices. These observers were able 
to demonstrate that cultures taken from blood clots and from bits of devitalized 
tissue removed from an otherwise clean wound which healed after delayed 
closure with no evidence at all of infection exhibited bacterial flora entirely 
comparable to that found on cultures of similar material secured from wounds 
in which infection was established. The mere presence of these bacteria, 
therefore, was obviously not the cause of wound infection. 
From these observations, the following concepts were derived: 
1. Wound suppuration becomes established as the result of the decomposi- 
tion of devitalized tissue and hematomas in dead space. 
2. Pathogenic bacteria are present in all war wounds, but they are unlikely 
to survive if the tissue from which they secure their nutriment is eliminated 
at debridement. 
3. If this pabulum is removed and if living tissue is protected from invasive 
infection by an effective antibacterial agent, then the bacterial flora of clinically 
clean wounds can be disregarded, infection or sepsis is not a complication to 
be feared, and whatever reparative surgery may be indicated can be performed 
on established surgical principles and will be followed by sound wound healing 
in the great majority of cases. 
By the time of the fall of Rome, in June 1944, the consultant in surgery 
for the Mediterranean theater was able to report that up to that time at least 60 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-332, C-44-367 
Figure 22.—Staged surgery of wound of soft tissue of calf. A. Appearance of wound 
before initial wound surgery. B. Appearance of wound at completion of initial surgery. 
Note exposed fascia and tendon in wound. Note also extent of resection of damaged 
muscle tissue. C. Wound healing after closure by suture at reparative surgery 6 days 
later. Split-thickness relaxing incisions have been made to avoid excessive tension 
on the suture line. 
25,000 soft-tissue wounds had been closed by delayed primary suture on the 
indication of their gross appearance alone. Bacterial counts were not made 
in any of these injuries, partly because identification of species and tests for 
pathogenicity would have required weeks of arduous laboratory work and 
partly because preliminary qualitative or quantitative bacteriologic analysis of 
the flora of the wound by smear and culture would not have provided informa- 
tion of either diagnostic or prognostic value. In at least 95 percent of the 
soft-tissue wounds managed by these principles, healing occurred with no loss 
of life or limb and without serious complications (figs. 22, 23, and 24). The 
most usual explanation in the 5 percent of unsuccessful closures was failure to 
remove residual dead tissue in the deep recesses ol the wound before the wound 
was sutured. MANAGEMENT, COMPOUND BATTLE FRACTURES 
61 
AFIP C-44-331, C-44-368 
Figure 23.—Staged surgery of wound of soft tissues of right arm. A. Appearance of 
wounds of entry and exit before initial wound surgery in operating tent of evacuation 
hospital. B. Appearance of wound of entry (the smaller of the wounds shown in 
view A) after excisional surgery. Exploration disclosed that the median and ulnar 
nerves and the profunda brachii artery had been severed. Considerable muscle tissue 
was devitalized. The artery was ligated, and the damaged muscle tissue excised. 
The severed nerves were merely identified. C. Healed incision 3}4 weeks after delayed 
closure at reparative surgery. D. Healed wound of exit (shown in view A) after 
coverage by split-thickness skin grafts. 
APPLICATION OF THE REPARATIVE-SURGERY PROGRAM 
TO COMPOUND FRACTURES 
The writing off of the closed plaster management of compound fractures, 
even with its modifications, occurred, as already noted, early in 1944. By this 
time, the effectiveness of the reparative-surgery program for wounds of the 
soft parts had become fully established. It was logical to extend this program, 
which had proved so eminently successful, to the management of compound 
fractures, in which results, to date, had often left a great deal to be desired. 
The program had already been applied, informally, to small groups of cases 
in half a dozen hospitals, with generally good results. Its expansion into a 
396961°—57 6 62 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C A-44-347 
Figure 24.—Reparative surgery of wound of left axilla and shoulder. A. Appearance of 
wounds in operating room of base hospital just before reparative surgery. Note axillary 
artery and severed nerve trunk visible in axillary wound. B. Appearance of wounds 
at conclusion of reparative surgery. By extending the axillary wound with an incision 
along the posterior margin of the chest wall, it was possible to advance and rotate a 
flap of skin, after which it was possible to cover the axillary contents and close the 
wound without excessive tension on the suture line. C. Healed wounds 15 days after 
delayed closure. 
theater wide program of management in the late spring of 1944 could not have 
occurred under more propitious circumstances, for the following reasons: 
1. The educational program in forward hospitals concerning standardized 
principles of excisional surgery and transportation splinting had begun to bear 
fruit, and debridement, as a general rule, was now being performed completely 
and correctly. 
2. The chain of evacuation from Cassino, by ambulance and train, to MANAGEMENT, COMPOUND BATTLE FRACTURES 
63 
general hospitals in Naples and Caserta was relatively short. After 23 May 
1944, air evacuation from the Anzio area was also functioning well. 
3. The functions of forward and general hospitals in the management of 
compound fractures had been completely clarified. The mission of forward 
hospitals was the salvage of life and limb by initial wound surgery, together 
with the application of transportation splinting, without effort at definitive 
reduction. The mission of fixed hospitals in the rear was the prevention of 
infection or its treatment, closure of the wound, and reduction of the fracture. 
It was recognized, in short, that the management of compound fractures in 
overseas theaters was a two-stage procedure. The mission of forward hospitals 
did not include fracture management, and the splinting applied in them was 
designed primarily for transportation and not to maintain precise alinement 
of bones. 
4. A bed status had been established in general hospitals which permitted 
patients to be held the length of time necessary for the employment of reparative 
surgery and fracture management. 
5. Supplies of blood had become available in sufficient quantities to permit 
transfusions in more liberal amounts than had previously been possible or than 
had been regarded as necessary. 
6. Penicillin had become available in sufficient quantities for general use. 
The extension of the reparative-surgery program to the management of 
compound fractures was intimately related to the availability of penicillin. The 
original plan had been to establish an orthopedic center in the theater to test 
the surgical possibilities of this new agent as soon as it could be supplied in 
sufficient quantities for this purpose. This plan was later discarded. Instead, 
Maj. Oscar P. Hampton, Jr., MC, theater consultant in orthopedic surgery, 
and Maj. Champ Lyons, MC, who had done much of the original work with 
penicillin in the Zone of Interior, were constituted a team to be attached, in 
turn, to each of five general hospitals in the Naples area, for periods of 1 to 2 
weeks, to initiate in them a program of reparative surgery under penicillin 
protection for compound fractures. 
This project was set up with no preconceived notions. No effort was made 
to prove anything at all about penicillin. It was merely used as a probable 
safeguard while surgical eradication of an infectious process was undertaken. 
The first cases selected for treatment in each hospital were invariably infected 
compound fractures. Surgery was aggressive. It included not only the drain- 
age of abscesses but also the excision of devitalized tissue, foreign bodies, and 
sequestra; freshening of wound edges; reduction of fractures, with, if necessary, 
stabilization by internal fixation; and closure of wounds by suture about 7 days 
after this operation. Liberal blood transfusions were an essential part of the 
program. 
Within a few weeks, the soundness of these new policies had become so 
apparent that the program was extended to include all fractures and all joint 
injuries. Subsequent appraisal of results showed that when the original injury 
did not make prolonged drainage inevitable and reduction of fractures impos- 64 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
sible, the reparative-surgery program was found to be capable of accomplishing, 
in large measure, its original objectives; namely, (1) elimination of wound 
infection; (2) rapid wound healing, with minimal scar formation; (3) optimum 
reduction and stabilization of fractures; and (4) maximum functional restora- 
tion of the wounded part. These objectives were achieved by a three-point 
plan of management consisting of (1) adequate blood replacement, to overcome 
anemia, permit the prolonged anesthesia so often necessary in compound 
fractures, and aid in wound healing and in the defense against infection; (2) 
antibiotic therapy, to protect living tissue against invasive infection; (3) precise 
surgical therapy, designed to repair defects caused by the missile or resulting 
from initial wound surgery and planned, at the same time, to prevent infection 
or to control it if it was already present. 
Blood replacement and antibiotic therapy, valuable as they were proved 
to be, were recognized from the beginning as merely adjunct measures. Good 
surgery was the keystone of the reparative-surgery program for compound 
fractures. Wound healing by granulation was inevitable and had to be permit- 
ted in a certain proportion of all compound fractures, but it was no longer 
accepted in any instance in which the program of delayed closure of wounds 
by suture or skin graft was applicable. 
Part IT. The Initial Surgery of Compound Fractures 
SURGICAL TIMING 
The surgery of wounds involving bones and joints was ideally rendered in 
three phases, initial wound surgery in the combat zone and reparative surgery 
in the communications zone, with reconstructive surgery, if it was necessary, 
a function of hospitals in the Zone of Interior. One of the most important 
medical developments in World War II was the perfection of surgical timing, 
by which hospitalization, evacuation policies, and the scheduled transportation 
of patients from one medical installation to another were progressively corre- 
lated with the temporal necessities of surgical management. As always in 
warfare, tactical circumstances and the maintenance of combat efficiency re- 
quired the evacuation of the injured soldier who was not to return to duty within 
the theater farther and farther away from the battlefront, both to remove him 
from the combat zone and to leave hospital facilities near the front available 
for the freshly wounded, whose need for care was urgent. This military ne- 
cessity required, in turn, that medical care be rendered in phases, by different 
surgeons, at different times and in different places. Professional and logistic 
considerations were problems which could be solved only in relation to 
each other. 
The pattern of wartime surgical care is thus radically different from the 
pattern of civilian care. This is one of the things that makes their introduc- MANAGEMENT, COMPOUND BATTLE FRACTURES 
65 
tiou to military surgery so difficult for medical officers, however competent 
they may be, who are fresh from civilian practice. It is a matter of the first 
importance that they learn and adhere to the prescribed routine, and it is here 
that the educational efforts of consultants have a particularly wide field of 
usefulness. 
Because of their character, bone and joint injuries lent themselves partic- 
ularly well to surgical timing. In them, as in other wounds of the extremities, 
surgical care was rendered in phases, in installations equipped and staffed to 
supply the special phases of care required at the time after wounding when 
the casualty reached them. It cannot be too strongly emphasized that it was 
the timing of each phase of management, not the location of the installation in 
which the surgery was performed, which was of supreme importance. 
As the consultant in surgery for the Mediterranean theater, Col. Edward 
D. Churchill, MC, repeatedly emphasized, surgical considerations established 
the necessity for (1) as short a timelag as possible between wounding and initial 
wound surgery; (2) an optimum 4- to 7-day delay between excisional initial 
surgery and reparative wound revision and closure; and (3) suitable holding 
periods in hospitals coincident with those stages of wound management.2 
The timelag between wounding and the institution of first-aid measures, 
although it was often lengthened by the intensity of combat, seldom exceeded 
a few hours. The timelag between the institution of first-aid measures and 
initial wound surgery for bone and joint casualties was influenced by a variety 
of factors, including the intensity of combat, the numbers of casualties, the 
distance of the evacuation hospital from the frontline, the condition of the 
roads, the availability of transportation, and the delay required for resuscita- 
tion. As a rule, it did not exceed 12 to 16 hours. 
From the standpoint of reparative surgery, it was preferable that casualties 
reach a general hospital in the communications zone by the 4th day after the 
first operation and essential that they reach it not later than the 7th to the 
10th day. Since the majority of casualties with injuries limited to the bones 
and joints became transportable from forward hospitals within 2 to 3 days 
after initial wound surgery, this requirement could usually be met without 
difficulty. Hospitalization for periods varying from 2 to 12 weeks, depending 
upon the nature and location of the fracture, was necessary after reparative 
surgery. 
The chief thing that an inexperienced medical officer had to learn, whether 
or not he had had experience in orthopedic surgery in civilian practice, was 
that battle-incurred compound fractures are materially different from those 
resulting from traffic and other civilian accidents. For example— 
1, Battle-incurred fractures in World War II were usually produced by 
high-velocity missiles or shell fragments which had, for all practical purposes, 
the effect of an internal explosion. The shattering effect of the energy imparted 
by the missile produced bone fragments which frequently themselves acted as 
2 Churchill, E. D.: The Surgical Management of the Wounded in the Mediterranean Theater at the Time of the 
Fall of Rome. Ann. Surg. 120:269-283, September 1944. 66 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
secondary missiles, being driven into the muscle tissue and adding greatly to 
the original soft-tissue damage. These fragments, like the original missiles, 
had a tearing, disruptive action which led to extensive damage in multiple 
directions, often far from the site of injury. 
2. Battle-incurred compound fractures were always compounded from 
without in. The missiles passed through clothing which was often soaked 
with the mud, grime, and filth of the battlefield. They often blasted or carried 
fragments of the clothing and other material into the wound with them. 
3. The timelag from wounding to operation, which is usually minimal in 
civilian injuries, while very occasionally as short as 3 to 4 hours, not infrequently 
was as long as 12 to 24 hours. The mere lapse of many of these periods of 
time implies that at operation the wounds had passed beyond the stage of 
simple contamination and were potentially infected. 
Convalescent hospitals in either the combat or communications zone 
played little part in the management of casualties with bone and joint injuries. 
The mission of these hospitals was to receive lightly wounded men after their 
professional care had been completed at evacuation hospitals and to prepare 
them for return to combat duty after a short period of what amounted to re- 
habilitation. Very few soldiers with injuries of the bones and joints had in- 
juries whose care could be completed within the holding periods permitted at 
evacuation or convalescent hospitals. In the great majority of instances, for 
that matter, care could not be completed at general hospitals in the communi- 
cations zone, and evacuation to the Zone of Interior was necessary. 
FIRST AID 
The preliminary management of compound fractures is briefly summarized 
in this chapter, to make the record complete. The only measures employed 
on the battlefield and in the battalion aid stations and collecting and clearing 
stations were those necessary to check hemorrhage, prevent further damage to 
soft tissues, relieve pain, avert or control shock, and prevent further contamina- 
tion of the wound while the wounded soldier was being evacuated from the 
frontline to a hospital staffed and equipped to perform initial wound surgery. 
These steps included— 
1. The application of sterile occlusive dressings. These dressings were 
inspected at each of the echelons of the division medical service but were re- 
moved and replaced only for cause, which was chiefly the suspicion of fresh 
or recurrent hemorrhage. 
2. The control of hemorrhage by compression dressings. If they were 
not effective and if the bleeding vessel could not be visualized and controlled 
by the application of a hemostat, a tourniquet was used. Casualties with 
bone and joint injuries became first-priority cases once a tourniquet was 
applied. 
3. The administration of morphine, in limited doses, if the pain was too 
severe to be controlled by simpler measures. The routine administration of MANAGEMENT, COMPOUND BATTLE FRACTURES 
67 
morphine in the large doses given early in the war was later replaced by a more 
discriminating use of morphine, in smaller doses, and of sedatives, according 
to the requirements of the individual patient. Actually, a man who had suf- 
fered a compound fracture was frequently promptly relieved of pain by the 
correct application of emergency splinting (p. 32), 
4. Plasma transfusion. Transfusions of plasma while the casualty was 
in one of the stations en route to an evacuation or field hospital had a single 
objective, to provide lifesaving resuscitation and make him transportable. 
Plasma was administered as necessary in the battalion aid station, the collecting 
station, or the clearing station. Blood was not available in these medical 
echelons of the Mediterranean theater during World War II. If, however, 
the blood pressure was found to be critically low in the clearing station, expe- 
rienced medical officers, instead of holding the patient there to administer 
plasma, frequently transferred him to the adjacent field hospital, where whole 
blood was always available. 
5. Emergency splinting, which was an essential step in all bony and mas- 
sive soft-tissue injuries of the extremities. This subject is discussed in detail 
in a separate chapter (p. 31). 
6. Other measures. These included the administration of a booster dose 
of tetanus toxoid and the institution of chemotherapy. Until near the end 
of the war, chemotherapy included the local use of sulfonamide powder or 
crystals. 
PREPARATION FOR INITIAL WOUND SURGERY 
The routine preoperative management of casualties with bone and joint 
injuries in a forward hospital consisted of the following steps: 
1. A rapid examination, after the clothing had been cut away, to deter- 
mine the location and extent of the injuries and to evaluate the soldier’s general 
condition. 
2. Inspection of the dressings and of the emergency splinting. It resusci- 
tation occupied any considerable time or if operation was delayed for other 
reasons, the inspection was repeated at regular intervals. It was frequently 
necessary to reinforce the splinting or to adjust it when the patient was first 
examined. If the lower extremity was in a half-ring leg splint, the traction 
hitch was examined, to be certain that pressure on the dorsum of the foot was 
not excessive. Careful attention to splinting frequently eliminated the 
necessity for the administration of morphine or other drugs to control pain. 
3. Conservation of body warmth, by the use of blankets under the patient 
as well as over him. Excessive covering and external heat, which would cause 
sweating and loss of body fluids, were avoided. 
4. The prompt use of a tourniquet if there was evidence of bleeding. 
Patients with tourniquets already in situ were, as already noted, first-priority 
cases. 68 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
5. Roentgenologic examination, which was an essential part of the pre- 
operative routine in all hone and joint injuries. Roentgenograms, which were 
made in the usual anteroposterior and lateral views, were planned to include 
not oidy the known area of damaged bone and retained foreign bodies but also 
as large a portion of the surrounding areas as possible. 
6. Induced vomiting or gastric lavage, unless the stomach had already 
been completely emptied by vomiting or more than 12 hours had elapsed since 
intake of food. 
7. Withholding of food and fluids by mouth. If the patient complained 
of thirst, he was permitted to rinse Ids mouth or to suck a moist sponge. 
Resuscitation.—Many casualties were in moderate or severe shock and 
required some resuscitation as part of the preoperative preparation. The 
measures employed to combat shock included— 
1. The use of the Trendelenburg position unless complicating chest or 
head wounds contraindicated it. The patient was very gradually restored to 
a level, recumbent position when the systolic blood pressure reached 80 mm. Hg. 
2. Oxygen administration by nasal tube if cyanosis was present. 
3. Blood and plasma transfusions according to the indications of the 
special case. The necessity was determined entirely by clinical findings 
(table 2). Detailed laboratory studies were impractical in the preoperative 
wards of an evacuation hospital, and medical officers, as their experience 
increased, became more and more skilled in the interpretation of clinical 
observations in terms of blood replacement. 
In practice, the liberal use of whole blood proved the most effective single 
measure of resuscitation for casualties in actual or impending shock. Most 
men with compound fractures required some replacement of lost blood before 
and during operation. Often they required large quantities. 
In at least half of all cases, patients with fractures of the femur required 
a minimum of 1,000 cc. of blood before they could be subjected to initial 
wound surgery. Studies in the 16th Evacuation Hospital showed that 28 of 
100 casualties with fractures of the femur required between 1,500 and 2,000 cc. 
of blood before and during operation and that only 9 required no blood at all. Of 
100 patients with compound fractures of the radius, ulna, or both bones of the 
forearm, in contrast, only 3 required between 1,500 and 2,000 cc. of blood, and 
63 received no blood at all before and during operation. Patients with com- 
pound fractures of the humerus and of the tibia, fibula, or both bones of the 
leg formed an intermediate group in respect to the need for whole blood. Of 
the 400 patients with compound fractures of the bones included in this survey 
(table 3), only 110 (27.5 percent) required no blood at all before and during 
operation, while 48 (about 12 percent) required between 1,500 and 2,000 cc. 
Blood could not be administered by any rule of thumb. The individual 
man’s condition determined how much he needed and when he "was fit for 
surgery. Enough had to be given to overcome the most severe symptoms and 
signs of shock, plus enough to prepare him for the additional strain of anesthesia 
and operation and to compensate for the estimated blood loss on the operating MANAGEMENT, COMPOUND BATTLE FRACTURES 
69 
Degree of shock 
Clinical observations 
Average blood 
loss (corrected 
values in round 
numbers, in 
percentage of 
normal) 
Blood pressure 
(approximate) 
Pulse quality 
Skin temper- 
ature 
Skin color 
Skin circulation 
(response to pres- 
sure, blanching) 
Thirst 
Mental state 
Blood 
vol- 
ume 
Hemo- 
globin 
Percent 
Percent 
Normal ... 
Normal . 
Normal . 
Normal - - 
Clear and distressed 
14 
20 
Slight 
Decreased 20 percent 
or less. 
do 
Cool 
Pale 
Definite slowing _ 
do 
do 
21 
30 
Moderate 
Decreased 20 to 40 per- 
cent. 
Definite decrease in 
volume. 
do 
do 
do-_ 
Definite 
Clear and some apathy 
unless stimulated. 
34 
46 
Severe- 
Decreased 40 percent 
to nonrecordable. 
Weak to impercep- 
tible. 
Cold 
Ashen to cyanotic 
(mottling). 
Very sluggish 
Severe 
Apathetic to comatose: 
little distress except 
thirst. 
46 
55 
Source: Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds. Washington: U. S. Government Printing Office, 1952, 
pp. 28, 56. 
Table 2. —Relationship of degree of shock and average blood loss in 67 patients with all types of wounds 70 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
table. It was a very easy matter to underestimate the amount of blood lost 
at wounding and during transportation, as well as later at operation. 
Table 3.—Flood replacement before and during initial surgery in 100 consecutive compound 
fractures of each of the long bones 1 
Blood replacement (in ec.) 
Radius, ulna, 
or both 
Humerus 
Tibia, fibula, 
or both 
Femur 
Total 
fractures 
Percentage 
2,000 
1 
10 
11 
2. 8 
1,500 
2 
5 
12 
18 
37 
9. 3 
1,000 
17 
36 
35 
50 
138 
34. 4 
500._ _ 
17 
36 
38 
13 
104 
26. 0 
None 
63 
23 
15 
9 
110 
27. 5 
Total cases 
100 
100 
100 
100 
400 
100. 0 
1 These observations were made at the 16th Evacuation Hospital in the Mediterranean Theater of Operations. 
In most of the casualties with bone and joint injuries, systolic blood 
pressures could be restored to 100 mm. Tig before operation. If this level 
could be attained without too much delay, that was naturally desirable. If it 
could not be, experience showed that operation should be undertaken only (1) 
after a combination of blood replacement and other measures had raised the 
blood pressure to 80 mm. Hg, which was a safe and satisfactory level for men 
of military age; (2) when the trend of the pulse rate was downward and the 
trend of the quality upward; and (3) when other symptoms and signs of shock 
were decreasing or had disappeared. It was not safe, however, to undertake 
operation until a sufficient quantity of blood was available to cover possible 
losses at operation. 
Plasma transfusion was stopgap therapy and was eventually used only for 
that purpose; that is, to elevate the blood pressure to a level compatible with 
life and to maintain it at that level until transfusions of whole blood could be 
given and operation undertaken. The chief usefulness of plasma was in the 
echelons of the division medical battalion, but it was also used as indicated in 
evacuation and field hospitals. 
Another important clinical fact which was eventually confirmed during 
World War 11 was that the wounded man did best if he was resuscitated as 
rapidly as possible and operated on with equal promptness. A wounded man 
who had been brought out of shock could readily slip back into it. The second 
attempt at resuscitation was always more difficult than the first and was some- 
times not as effective. This was as true of patients with extensive compound 
fractures as of those with injuries of the chest or abdomen. The aim of re- 
suscitative therapy was not to restore the casualty to his normal status nor to 
repair the organic damage caused by even a brief period of depressed blood 
pressure. Both of these objectives, in fact, were unattainable within a limited 
time and without the corrective effect of operation, which was itself a part of MANAGEMENT, COMPOUND BATTLE FRACTURES 
71 
the resuscitative procedure. The aim of resuscitation in an evacuation hospital 
was merely to make the patient fit for initial wound surgery, and his best 
interests were served if he was operated on as soon as that objective had been 
achieved. 
Objectives of initial wound surgery.—The objectives of initial wound 
surgery (debridement), regardless of the type of injury, were threefold: (1) 
To save life, (2) to save limb, and (3) to prevent or eradicate infection. The 
attainment of these objectives was accomplished by (1) the arrest of hemor- 
rhage; (2) the removal of foreign bodies and foreign material within the wound; 
(3) the excision of tissues which had been destroyed by the missile (missiles) 
or devitalized by the impairment or destruction of the blood supply to the 
part; (4) the provision of drainage, which was accomplished by nonclosure 
of the wound; and (5) transportation splinting. Transportation splinting is 
discussed in detail under a separate heading (p. 39). When these objectives 
had been accomplished, the result was a wound easily managed at reparative 
surgery. 
APPRAISAL OF THE WOUND 
After the wounded man with an injury or injuries of an extremity had 
been adequately treated for shock in the shock or preoperative tent of the 
evacuation hospital, he was transferred to the operating tent, accompanied 
hy the roentgenograms which had been taken of the injured area. 
Only occasionally was the soldier removed from the litter on which he 
had been transported and placed on an operating table. As a general rule, 
the litter was placed on the table or was supported by its handles on boxes or 
sawhorses, and itself served all the purposes of a standard operating table. 
This plan had a number of advantages. It conserved the time and effort of 
the operating-room personnel. More important, it spared the patient the 
move from the litter to the operating table before operation, and from the table 
to the litter at the end of the procedure. This was highly desirable, because 
casualties who had previously been in shock were likely to suffer recurrent 
shock if they were moved about. 
Examination in the admitting tent of an evacuation hospital (p. 67) was 
essential to identify the wounds and determine the patient’s status. A de- 
tailed examination, however, was impossible under the circumstances which 
prevailed in that area, and it was therefore deferred until he had reached the 
operating room. It was, as a matter of fact, to the advantage of a patient in 
shock not to disturb him for such an examination until he had been properly 
prepared for operation. When he was placed on the operating table, under 
a good light, with the emergency splinting and dressings removed, and with 
roentgenograms available for reference, it was possible to make a thorough 
examination and complete appraisal of the injuries. The routine was as 
follows: 
1. The site of entry of the missile (missiles) was determined, and the site 
of exit "was sought for. 72 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
2. When the sites of entry and exit had been identified, the course of the 
missile was determined. If a site of exit was not found, the course was postu- 
lated from the site of entry to the point at which the retained missile was 
demonstrated by roentgenograms. After this information had been secured, 
it was possible to plan the incision or incisions which would provide most 
convenient and most satisfactory access to the devitalized tissue and retained 
foreign material which had to be removed, as well as to whatever nerve or 
vascular injuries might be present. 
3. Determination of the presence or absence of arterial pulsations distal 
to the wound (wounds) of an extremity was an essential part of preoperative 
appraisal. If pulsations could not be obtained, the major blood vessels which 
might be damaged had to be visualized and treated according to the indications. 
4. Function of major nerve trunks also had to be investigated, though 
this was not always an easy matter, since damage to bone and muscle might 
prevent active movement of the digits of the hand or foot, even when the 
motor nerve supply remained intact. On the other hand, careful investigation 
of the status of motor function and sensory supply usually permitted the 
surgeon to arrive at some definite conclusion concerning the integrity of the 
major nerve trunks. By observation of only the motions of the thumb, for 
example, it was possible to decide whether or not there had been functional 
damage to each of the three major nerve trunks of the upper extremity. If 
the distal phalanx of the thumb could be extended or if the entire thumb 
could be abducted and extended, it could be assumed that the radial nerve 
was intact. Active flexion of the thumb against the side of the hand estab- 
lished the integrity of the ulnar nerve. When there was evidence of loss of 
function in the supply of a major peripheral nerve, the nerve was usually 
exposed during initial surgery to permit an accurate estimate of the degree 
of damage. 
GENERAL PRINCIPLES AND PRACTICES 
Initial wound surgery, whatever modifications might be necessary in 
individual wounds, was ideally conducted on the basis of certain principles 
and practices, as follows: 
1. The length of the timelag from wounding to operation was of no 
importance in the decision whether, or when, to perform initial wound surgery. 
Fresh wounds were operated upon as promptly as possible. Old wounds 
(that is, wounds of more than 48 hours’ duration) were managed in the same 
manner except that invasive spreading infections, with cardinal signs of 
inflammation such as cellulitis and lymphangitis, were best managed by anti- 
biotics, immobilization, and the application of warm wet dressings until an 
optimum time for surgery could be selected. There was no hesitation, however, 
in draining septic hematomas, fascial-plane abscesses, and large masses of dead, 
autolyzing tissue when the casualty was first seen. MANAGEMENT, COMPOUND BATTLE FRACTURES 
73 
2. A precise knowledge of regional anatomy was essential. Indeed, the 
initial surgery of war wounds of the extremity amounted to a postgraduate 
course in surgical anatomy. The surgeon had to know the location of the 
nerve and blood supply of every muscle and had to respect blood vessels and 
nerves in his dissection. This was particularly important when there were 
large wounds in the region of heavy muscles, such as the gastrocnemius-soleus 
group in the calf and the rectus femoris in the thigh. The technique had to be 
both careful and precise, for irreparable damage could be done if major blood 
vessels and nerve trunks were damaged in the course of the operation. 
3. Roentgenograms were made routinely in two views, so as to cover as 
broad a field as possible about the wound or wounds. They were available for 
use in the operating tent. 
4. An adequate light and a competent assistant were basic requirements. 
5. A wide field was prepared, to allow for extension of the original incision 
or for counterincision as might be necessary. 
6. The operative procedure was carried out in an orderly manner. There 
was no place in initial wound surgery for haphazard, bloody, cut-and-slash 
techniques. 
7. Adequate exposure was essential for the complete excision of devitalized 
tissue. Bold incision was therefore the first step at operation. As a general 
rule, the line of incision was placed parallel to the long axis of the limb, though 
on the hand, the foot, or the buttock the incision might follow the natural lines 
of the skin. The creation of circular skin defects had to be avoided, though 
excision of a small area (2 to 3 mm.) of devitalized skin on the margins of the 
wound might be indicated. 
8. Dead and devitalized tissues had to be completely excised. This was 
the most important single step in preventing infection. Failure to excise 
devitalized muscle seeded with pathogenic bacteria led to the sepsis for which 
combat-incurred wounds are notorious. If tissue devitalized by the missile 
or produced by the surgeon in the course of operation was left in situ, wound 
healing would not occur until it had sloughed away. The fascial layers had to 
be incised as freely as the skin, since free access to devitalized muscle is neces- 
sary for thorough excisional surgery. 
9. Retained foreign bodies, especially if they were of any considerable 
size, were best removed at initial surgery. It was important that they be 
identified and, if possible, removed, because the path which led to them was the 
track along which devitalized muscle would be found. Moreover, foreign 
bodies, especially high-explosive shell fragments, were likely to carry into the 
wound bits of clothing, shoe leather, or other foreign material, which would be 
removed when the fragments themselves were removed. Deep recesses con- 
taining foreign bodies might be approached by counterincisions planned 
anatomically over fascial planes rather than by cutting through normal muscle 
structure. 
10. Fine hemostats were used whenever they were available, and only the 
smallest possible amount of tissue was ligated. Structures within the wound 74 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
were not traumatized more than was necessary by the use of tissue forceps. 
Sponging was done very gently. 
11. Ligatures for the control of bleeding vessels were as fine as possible. 
They could be either absorbable or nonabsorbable, but the young surgeon 
found his operating time shortened when nonabsorbable sutures were used 
because they were bulkier and therefore easier to handle. 
12. Incisions and counterincisions were left open, and no sutures were 
used following the excisional phase. The provision of drainage, which was 
inherent in this policy, was a cardinal principle of the management of such 
injuries. There were only two exceptions to this rule: The synovial mem- 
brane was closed in wounds of the joints (p. 216), and flaps of skin were tacked 
loosely in wounds of the hand to cover cartilaginous surfaces and tendons which 
would otherwise be left exposed. 
13. The unsutured wound was carefully dressed with fine-mesh gauze so 
that all raw surfaces were covered. The purpose of the dressing was merely 
to hold the raw surfaces of the wound apart and permit drainage from its 
depths. The portion of the dressing placed in the depths of the wound always 
had to be placed loosely. Otherwise, as the wound and the area about it began 
to swell, the dressing would become dangerously tight. 
TECHNICAL CONSIDERATIONS 
The wide variation in the location of battle injuries of the extremities and 
in the extent of the damage to the deeper structures required variations in the 
surgical procedure which made it impossible to outline the step-by-step tech- 
nique for initial surgery which could be outlined for an appendectomy, for in- 
stance, or the repair of an inguinal hernia. The principles and policies just 
listed served as a guide to what had to be done. Certain technical considera- 
tions, however, were applicable to all types of wounds (fig. 25). 
Incision.—The location of the wound usually, though not always, deter- 
mined the location of the surgical incision. Wherever it was located, care was 
taken to make it of adequate length. It was always better to make it too long 
rather than too short; the unnecessary length did no harm, since an incision 
heals from side to side, not from end to end. It was also desirable that the 
surgeon, at the initial operation, plan the skin incision so as to expose the 
devitalized deeper structures. 
Instead of an incision through the wound, a standard longitudinal incision 
was frequently used, so placed as to open into muscle planes and offer a better 
access to devitalized muscle tissue. It was never wise to extend an incision 
proximally and distally from the center of a wound which ran in the opposite 
direction, or from the center of a circular wound. These practices created a 
crucial type of incision, which handicapped the closure of the operative incision 
at reparative surgery and might even prevent closure entirely, particularly at 
the point at which the wound of entry was crossed by the surgical incision. 
If an incision had to be extended proximally and distally from the wound pro- MANAGEMENT, COMPOUND BATTLE FRACTURES 
75 
Figure 25.—Technique of initial wound surgery of soft-part wound. 
A. Incision of skin, in long axis of extremity and excision of the trau- 
matized skin border. B. Exposure of depths of wound, excision of 
devitalized fascia. Damaged muscle in depths of wound is visualized. 
C. Saucerized wound. Debridement is almost completed. The last 
of the devitalized muscle is being cut away with scissors. 76 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP FA-45-50, FA-45-47 
Figure 20.—Staged surgery of wound of thigh. A. Anterior wound of thigh compounding 
fracture of femoral shaft. Appearance 3 weeks after reparative surgery. B. Lateral 
wound of soft parts 4 weeks after reparative surgery. Note that in these wounds the 
proximal and distal incisions extending from the transverse wounds of entry were cor- 
rectly made at initial wound surgery. Z-plasty incisions, which can be closed without 
difficulty, were thus obtained, rather than cruciate incisions, difficult to close, which 
would have resulted had the surgical incisions been made across the center of the 
transverse wounds. (These wounds were debrided by Maj. Howard B. Shorbe, MC, 
2d Auxiliary Surgical Group.) 
duced by the missile, it was best to begin each limb at an opposite comer of the 
wound, so as to leave, in effect, a Z-shaped incision (fig. 26). This kind of 
incision was particularly desirable in areas in which the skin was normally 
tight, as over the anterior surface of the leg. 
Skin devitalized by the entrance of the missile had to be excised, but as 
little as possible was removed and no normal skin was sacrificed. The skin 
incision was made with a knife, and surgical perfectionists demanded that a 
knife also be used for the excision of the skin edges about the wound. Expe- 
rience showed, however, that, when this practice was followed, there was usually 
a tendency to excise more skin than was necessary. If the surgeon’s technique 
was such that the excision could be limited to removal of 2 to 3 mm. of skin, 
then the scalpel was preferable, since its cutting edge was sharper than the 
cutting edges of scissors. On the other hand, the advantages of excision by 
scalpel were more theoretic than real, and trimming of the skin edges of a 
wound with scissors was easier and generally more rapid. 
Excisional surgery.—Once the skin incision had been made and the wound 
laid fully open, there was no objection to the careful use of a pair of sharp 
scissors for excision of devitalized fascia and muscle. Strong encircling fascia, 
such as the fascia lata, was opened widely, and all grossly traumatized areas 
were excised. MANAGEMENT, COMPOUND BATTLE FRACTURES 
77 
AFIP CA-44-135 
Figure 27.—Initial surgery of large, ragged wound of anterior surface of right thigh. 
A. Appearance of wound before initial surgery. B. Wound after adequate excision 
of devitalized tissue. 
The decision as to just what muscle tissue should be excised was decidedly 
less simple, because devitalization was not so easily determined. A time- 
honored criterion of death of muscle is its failure to contract when it is pinched 
with thumb forceps, and this test was frequently used. Muscle which con- 
tracted when pinched was unquestionably viable, but the reverse was not true; 
failure of contraction did not necessarily mean that the muscle was dead and 
should be excised. Muscle which bled freely when it was cut, even if it did 
not contract when it was pinched, was probably still viable. 
If bleeding did not occur, then the muscle was definitely not viable and 
the excision had to be carried back until muscle which bled on section was 
reached. On the other hand, even though there was some bleeding when 
damaged muscle was cut, it was always best to carry out excisional surgery if 
the tissue appeared macerated or the muscle bundles were separated (fig. 27). 
In other words, while it was essential that excisional surgery be thorough, it 
was the responsibility of the military surgeon to be certain that the incision he 
undertook was justified and that he was not extending it beyond indicated 
limits. 
The wound, as has been repeatedly emphasized, was left open when initial 
wound surgery was concluded. A saucerized type of wound was generally 
desirable, though there were exceptions, particularly when the original injury 
was of the through-and-through variety. Large dead spaces, in which serum 
and wound exudate could collect, were eliminated by counterincisions and de- 
pendent drainage. Rubber-tissue drains were not used after initial wound 
surgery except when they were essential to insure dependent drainage of residual 
dead space. 
Dressing of the wound.—The raw surfaces of the wound were covered 
with fine-mesh gauze. After the program of reparative surgery was in effect 
396961°—57 7 78 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
at the fixed hospitals in the theater, dry gauze was regarded as best for this 
purpose, since drainage of wound exudate was provided by capillary attraction 
when it was used. When the gauze was removed, several days after the first 
operation, a clean, relatively dry surface was usually found. Petrolatum-im- 
pregnated gauze could also be used, but capillary attraction was not provided 
through its meshes and when it was removed the surface of the wound was 
likely to have a slimy and less healthy appearance than when dry gauze was 
used. 
Whether dry or petrolatum-impregnated gauze was used, the wound was 
dressed in the following manner: Single strips of gauze were arranged side by 
side around the perimeter with the ends of the strips in the depths of the wound, 
until all raw surfaces had been covered (fig. 28). It was not the intention to 
Figure 28.—Appearance of wound after strips of dry or petrolatum- 
impregnated fine-mesh gauze had been loosely introduced into 
depths at completion of initial surgery. 
pack the wound. The purpose of the dressing was merely to hold the raw 
surfaces apart and provide drainage from the depths of the wound. Inex- 
perienced military surgeons, partly because of their inexperience and partly 
because of a desire to reduce the oozing of blood from the raw surfaces, were 
inclined to pack the wound tightly. When this was done, there was no pro- 
vision for the swelling which normally follows an operative procedure, and the 
tightly packed dressings became even more undesirably tight. 
After the fine-mesh gauze strips had been placed in the wound, they were 
covered with standard gauze dressings. 
MANAGEMENT OF BONE FRAGMENTS 
It was impossible to avoid moving bony fragments about during the de- 
bridement of compound fractures, and it was easy, unless great care was taken, 
to tear them away from attached soft tissue. All manipulations of fragments MANAGEMENT, COMPOUND BATTLE FRACTURES 
79 
therefore had to be very gentle. Sponging had to be done carefully in the region 
of the fractures, for jagged fragments could become entangled in the meshes of 
the gauze and could be avulsed from their remaining attachments, especially 
when the sponge was removed from the wound. 
To the end of the war, there was no universal agreement in the Medi- 
terranean theater as to the management of bone fragments. A few surgeons 
believed that all fragments should be allowed to remain in situ or should be 
replaced after they had been removed and cleansed, on the ground that seg- 
mental bone defects would thus be avoided and the chances of union increased. 
The background of this policy was the concept that these fragments were, in 
effect, bone grafts, which could be expected to participate in the process of 
healing. 
The majority of surgeons took the opposite point of view. They willingly 
admitted that the removal of bone fragments introduced the risk of segmental 
defects and that segmental defects, in turn, militated against the union of frac- 
tures. In their opinion, however, these fragments should be removed because, 
since they were totally devoid of soft-tissue attachments and were therefore 
without blood supply, they were, in effect, devitalized tissue, which might serve 
as a nidus of infection and prevent healing of both the injured bone and the 
compounding wound. 
The whole disagreement was, to a certain extent, academic. Surgeons of 
both schools of thought naturally left in situ all fragments with any sort of 
soft-tissue attachments, regardless of their size, since it could be assumed that 
some degree of vascularization would persist through these connections. Frag- 
ments totally devoid of soft-tissue attachments were usually small (three- 
fourths inch in diameter or less), and their removal seldom created defects of 
sufficient size to prevent good contact between major bone fragments. 
The policy therefore evolved of removing all small fragments of bone 
totally devoid of soft tissue and of leaving in situ those with even the smallest 
amount of attachment to the soft parts. If a large fragment was totally de- 
tached and its removal would create a segmental bony defect, the chance of 
leaving it in place was usually taken, even though it had no soft-tissue attach- 
ment. Fragments of bone totally devoid of soft tissue were, as a rule, small 
fragments of cortical bone, which made up only a relatively minor portion of the 
bony circumference at the level of the fracture. 
The policy of removing totally separated fragments of bone from the 
wound had a sound basis. It was repeatedly observed in general hospitals in 
the earlier months of the war that when compounding wounds, without soft- 
tissue deficits, failed to heal within a few weeks, exploration of the depths of 
the wound was likely to reveal totally loose fragments of bone which were acting 
as sequestra. For this reason, delayed healing and nonhealing were particularly 
frequent in compound fractures of the tibia, in which fragments of cortex were 
often indriven into the medullary canal and remained in that location until 
they were removed surgically. 80 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
FRACTURE MANAGEMENT 
The management of compound fractures at initial wound surgery was 
limited to the correction of gross malposition. Splinting was applied only for 
transportation purposes (p. 39). Definitive reduction was postponed until the 
reparative stage of surgery, which was carried out in the fixed hospital. There 
were the following sound reasons for this policy: 
1. Initial wound surgery was usually performed in an operating tent in a 
forward hospital, often with the wounded man lying on the same litter on which 
he had been brought into the hospital (p. 71). Neither environment nor cir- 
cumstances were conducive to the accurate reduction of fractures. 
2. Roentgenologic controls, which are essential for accurate fracture reduc- 
tion, were not feasible in evacuation hospitals. 
3. Even if precise fracture reduction could have been obtained under these 
unfavorable circumstances, reduction would likely have been lost during 
application of the plaster cast. 
4. Even if precise reduction could have been maintained during the applica- 
tion of the cast, displacement of the fragments would have been almost inevi- 
table after the cast had been split or bivalved, as was required in forward areas, 
to guard against circulatory impairment during transportation. 
5. The early experience in the North African theater had shown that the 
use of internal fixation and of skeletal fixation in casts as primary procedures in 
forward hospitals was attended with a high incidence of infection and ex- 
tremely unsatisfactory end results. 
6. The limited personnel in forward hospitals did not warrant the expendi- 
ture of time and effort which would have been required to reduce compound 
fractures properly. The delays thus entailed, in fact, might have put other 
wounded men awaiting surgery in jeopardy of life as well as of limb. 
POSTOPERATIVE REGIMEN 
The postoperative regimen after initial wound surgery consisted of standard 
measures, with additional blood replacement as necessary. Casualties with 
compound fractures of the femur and other serious injuries often required addi- 
tional transfusions. The fingers or toes were inspected at regular, frequent 
intervals, to evaluate the circulatory status of the injured part, so that band- 
ages and casts could be loosened if any vascular impairment became evident. 
Repeated inspection was also necessary to detect early signs of gas-bacillus 
infection, which readily developed in limbs which were the site of compound 
fractures associated with vascular damage. Finally, repeated inspections were 
necessary to detect early evidence of continuing or recurrent hemorrhage. 
EVACUATION 
The soldier with a compound fracture was held in the evacuation hospital 
after initial wound surgery only long enough for him to recover from the MANAGEMENT, COMPOUND BATTLE FRACTURES 
81 
immediate effects of operation and for the surgeon who had operated on him 
to be certain that he could be transported safely to the rear. A casualty with 
an injury of a bone or joint generally became transportable within 24 to 48 
hours. His transportability was determined not only by his actual status but 
also by certain external considerations, such as the tactical situation, the mode of 
transportation available, the distance to be traversed, and the number of casual- 
ties to be moved. If there was any doubt at all about the soldier’s status, it 
was usually the policy to keep him in the forward hospital a day or two longer, 
particularly if it seemed that the transportation time might be unduly pro- 
longed by delays at airfields or other holding points or for other reasons. 
Part III. The Reparative Surgery of Compound Fractures 
Under the concept of reparative surgery as it developed in the Mediter- 
ranean theater, surgery of some kind was indicated on every casualty with a 
compound fracture as soon after his arrival at a fixed hospital as he could be 
properly prepared for the operation. The procedure, depending upon the 
necessities of the special case, was excisional, reparative, or both. This concept 
represented an entirely new development of World War II. 
Four to seven days after wounding was regarded as the optimum time for 
the reparative stage of wound surgery, and particularly for the closure of a 
compounding wound, though a maximum of 10 days was still within permis- 
sible limits. Operation within these time limits was a perfectly practical ob- 
jective. It gave time for the transfer of the patient from an evacuation to a 
fixed hospital; for the proper evaluation of his status after he had arrived; 
and for preoperative preparation, including roentgenologic examination and 
blood replacement. In a series of 188 compound fractures treated during a 
push period at the 23d General Hospital during the breakout from the Anzio 
beachhead, the average time between wounding and reparative surgery was 
8.3 days. This was a usual, not an exceptional, accomplishment. 
From the physiologic standpoint, the time lapse of 4 to 7 days between 
initial and reparative surgery allowed for the sequestration of bits of residual 
devitalized tissue which had been overlooked or which could not be excised at 
initial wound surgery. By the end of this interval, it was possible to make a 
decision concerning the viability of questionably devitalized tissue which had 
been deliberately left in situ at the first operation. It was not too long a time 
to permit further debridement, if it should be indicated, before infection could 
become established. Purulent exudate formed by the decomposition of dead 
tissue would not yet have had time to exert a locally necrotizing action, and 
heavy granulation tissue would not yet have formed and fixed in position the 
deep and superficial soft parts. Finally, this interval was within the golden 
period for the management of fractures. It was too soon for them to have 
become fixed by callus formation, and they were still amenable to closed or 
open manipulation. 82 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
PREOPERATIVE PREPARATION 
Roentgenologic examination.—New roentgenograms were made as soon as 
the casualty was admitted to the general hospital. The films made in the 
evacuation hospital were supposed to travel with the patient, but this rule 
was not always observed. Even when they were available, however, they 
were used only for comparison, as they had been made before initial wound 
surgery, during and after which conditions were likely to have changed. More 
recent roentgenograms permitted an accurate appraisal of the position of bony 
fragments, the precise loss of bone, and the location of any retained foreign 
bodies. 
Blood replacement.—Secondary anemia, often of a considerable degree, 
was present in a large number of the casualties with bone and joint injuries 
when they were received at fixed hospitals. This was in spite of the generally 
adequate use of blood in the forward hospital. A series of 138 fractures of 
the long bones treated at the 23d General Hospital well illustrates this point. 
Thirty-three patients (24 percent) had hematocrit values under 30. Eighty 
others (58 percent) had values between 31 and 40, and only 25 (18 percent) 
had values of 40 or higher, the desirable level for the reparative operation. 
Only 2 of the 38 patients with fractures of the femur fell into the 40 or higher 
group. In another series of 166 fractures of the long bones observed at the 
21st General Hospital, the proportions were substantially the same; 37 casu- 
alties (22 percent) had hematocrit readings under 30, and only 31 (19 percent) 
fell into the group with readings regarded as safe for operation without further 
preparation. 
Since operation with low hematocrit levels would have introduced a com- 
pletely preventable risk, the correction of secondary anemia was the first step 
in preoperative preparation. Transfusions were given, as a rule, until the 
desired level of 40 or better was reached. The copper sulfate falling-drop 
technique proved a simple and satisfactory method of determining this value 
as well as the total serum-protein value. 
Preoperative requirements were roughly calculated as 500 cc. of whole 
blood for each 3 to 4 points of deficit on the hematocrit reading or for each 
0.9-gm. percent deficit in hemoglobin. Except when hemorrhage created an 
emergency, which was not often in a fixed hospital, the total volume of blood 
administered in a 24-hour period did not exceed 1,000 cc. 
Additional blood was also given as indicated while the reparative opera- 
tion was in progress as well as during the postoperative period. The principles 
of administration were the same, regardless of the location of the injury. On 
the other hand, the necessity for blood replacement was usually far greater in 
certain fractures, especially fractures of the femur (p. 68), than in others. 
No absolute proof can be adduced to show that such intensive blood 
replacement was necessary for good results. There is, however, a good deal 
of indirect proof. More liberal transfusions became the practice at about the MANAGEMENT, COMPOUND BATTLE FRACTURES 
83 
same time that penicillin became available and the program of reparative 
surgery in compound fractures came into general use. Results in these injuries 
were greatly improved after this threefold plan of management was instituted, 
though it is naturally impossible to assign credit for the improvement to any 
single phase of the program. The risk of prolonged anesthesia and of a long and 
taxing operation was naturally far less in a patient whose anemia had been 
corrected. It was also the general impression that casualties who had received 
liberal blood transfusions were much less likely to suffer from chronic wound 
infections and much more likely to show prompt healing of wounds than those 
in whom this measure had been omitted. The postoperative course was also 
always much smoother in patients who had received ample transfusion therapy. 
Antibiotic therapy.—Before the spring of 1944, when penicillin became 
generally available, it was the policy to continue in the fixed hospital the sulfa 
drug which had been given in the forward hospital. The same policy was 
followed with penicillin. The surgeons in the general and station hospitals 
had had the benefit of the teachings of Maj. Champ Lyons, MC, in the proper 
use of penicillin after it had become available for use in battle casualties. As 
a result, this agent was always used as an adjuvant to surgery in an effort to 
provide a wider margin of safety for the aggressive surgical measures of repara- 
tive surgery. 
Penicillin therapy initiated in a forward hospital was continued in the 
general hospital in all wounds involving the bones and joints. It was also used 
after operation until wound healing was well on the way to completion. This 
was usually 5 to 10 days after the reparative operation. If drainage from the 
wound persisted, penicillin was usually given for a longer period. 
TECHNICAL CONSIDERATIONS 
Reparative surgery could not be undertaken unless holding policies were 
such that the casualty could be kept at bed rest in the same hospital until 
healing of the wound was complete. When the injury was a compound fracture, 
this requirement also implied healing of the fracture to a stage at which trans- 
portation could safely be permitted. The early experience in the theater had 
shown that the transfer of the wounded from one hospital to another while 
sutures were still in place after delayed wound closure and while the wound 
was still unhealed, was always hazardous and could be attended with serious 
complications. 
All reparative surgery was performed under general anesthesia, in an 
operating room set up for any type of surgery which might be indicated. This 
meant that instruments and equipment were available for skeletal traction 
and internal fixation, as well as for the repair of soft-tissue defects by suture 
or by graft. 
The plaster cast and dressing applied after initial wound surgery were not 
removed until the patient was on the operating table and fully anesthetized. 84 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
This practice was an important feature of the reparative stage of military 
wound surgery for several reasons, as follows; 
1. A fundamental concept of the staged management of combat-incurred 
injuries was that every wound required some additional surgery, either further 
debridement or closure of the wound by suture or skin graft, after initial 
surgery. Reduction of the fracture was also necessary, since fracture manage- 
ment was not a function of forward hospitals (p. 80). 
2. Since these procedures had to be carried out in the operating room, 
under anesthesia, there was no reason to subject the patient to painful dressings 
on the ward or to the risk of hemorrhage. 
3. The risk of secondary contamination on the ward was avoided by the 
practice of removing in the operating room the cast and dressings applied 
after initial surgery in a forward hospital. 
4. This practice conserved the time and effort of medical and ward 
personnel. 
Because of the varieties of injuries encountered, it was not possible to 
recommend a step-by-step technique for the reparative surgery of compound 
fractures. The operation, however, always followed a definite plan. 
Appraisal and Revision of the Wound 
Wound revision was conceived of as an extremely careful completion of 
excisionaJ surgery, to remove tissue that might lead to suppuration. The 
entire wound, including the fracture site, was exposed by gentle retraction and 
explored to verify the adequacy of initial surgery. Incisions were enlarged, 
if necessary, to facilitate exposure. Any remaining foreign material, accessible 
foreign bodies, totally detached fragments of bone, or devitalized soft tissue 
was removed. Old blood clot was cleaned out. Means of obliterating or drain- 
ing dead space were considered. 
In the clinically clean case, wound revision consisted, at the most, of the 
excision of remaining tags of devitalized tissue. In compound fractures, 
however, further excisional surgery Avas not infrequently indicated. This 
was particularly true of large, deep wounds, such as wounds of the thigh 
associated with a compound fracture of the femur. 
Reduction to a minimum of residual devitalized tissue was the keystone 
of the staged plan of management of battle-incurred compound fractures. 
Failure to explore the depths of the wound and to follow up the exploration 
with the necessary excisional surgery was repeatedly shown to account for 
many of the failures to obtain wound healing when the program of delayed pri- 
mary wound closure was being tested in the Mediterranean theater late in 
1943 and early in 1944. Adequate excisional surgery usually resulted in the 
prompt subsidence of infection (fig. 29). To perform the kind of surgery 
necessary, the formerly accepted concept—that operation in an infected field 
would not only fail in its objectives but might, be followed by serious conse- 
quences—had to be discarded. MANAGEMENT, COMPOUND BATTLE FRACTURES 
85 
A. Roentgenograms of left leg made 
when patient was received in fixed 
hospital 5 days after wounding; initial 
wound surgery had been performed 2)2 
hours after wounding. 
AFIP C-44-243 
B. Roentgenograms made 5 days 
after the reparative operation. Al- 
though further sequestration seemed 
probable at this time, it did not 
occur; when the cast was changed 4 
weeks later, the wound was clean, 
drainage had ceased, and there was 
clinical evidence of bony stability. 
If this fracture site had been explored 
when the patient was received in the 
general hospital, and if the totally 
detached bone fragments which were 
acting as devitalized tissue had then 
been removed, osteomyelitis of the 
tibia might have been prevented. 
Figure 29.—Control of infection in compound comminuted fracture of upper half of left 
tibia and upper third of right femur by correct excisional surgery. In this case, when 
the cast on the left leg was changed for the second time in the fixed hospital 18 days 
after wounding, purulent, foul-smelling drainage suggested an incipient osteomyelitis. 
Twelve days later, the wound was explored, and several dead, totally detached, in- 
driven fragments of bone were removed. 
AFIP C-44-243 86 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Fracture Management 
Thorough visualization of the depths of the wound to determine its clinical 
status permitted full view of the fracture site. Reduction could therefore, for 
all practical purposes, be conducted, at least in part, as an open operation. 
Direct inspection was supplemented by study of the roentgenograms taken 
just before operation. It was thus possible to decide, with all the evidence at 
hand, the best means of obtaining and maintaining reduction. 
The method of fracture management depended upon the circumstances of 
the special injury. Whenever possible, the ends of the fragments were ad- 
justed under direct vision, after they had been freed from intervening soft 
parts. Twisted and rotated fragments were alined. In most cases, the de- 
cision was to accomplish reduction either by manipulation and plaster im- 
mobilization or by skeletal traction. Internal fixation was employed only 
under special circumstances. 
Internal fixation.—Internal fixation, per se, was by no means an objective 
of the reparative-surgery program. It was usually neither advisable nor pos- 
sible because of severe comminution. The program permitted its use, however, 
with the limitations to be outlined below, when it was indicated to maintain 
fracture reduction. Fixation was obtained by plating, multiple screws, or 
wire sutures. 
Rigid stabilization of the fracture in reduction by a plate or by multiple 
screws offered certain advantages: (1) Anatomic apposition and alinement 
wore secured, in anticipation of faster bony union with no deformity; (2) dead 
space was obliterated and the traumatizing manipulations just mentioned 
were avoided (fig. 30); (3) handling of the extremity for necessary subsequent 
wound care was facilitated (fig. 31); (4) early joint motion and muscle exercise, 
in anticipation of a more rapid return to function, could be permitted; and 
(5) the management of concurrent injuries which precluded traction and re- 
quired repeated trips to the operating room was facilitated. 
The use of internal fixation was, however, limited by three factors other 
than comminution. These were (1) the desire to minimize intrawound trauma 
caused by the operative procedure, which could produce additional devitalized 
tissue; (2) interference with the covering of all exposed bone cortex with vascular 
soft parts (fig. 32); and (3) the desire to avoid the periosteal stripping which 
may be necessary to permit the application of a bone plate and which carries 
the danger of massive sequestration (fig. 33). Periosteal stripping, which 
deprives the outer cortex of bone of its nourishment, is an important considera- 
tion in surgery in a field known to be contaminated and potentially infected, 
and tins consideration therefore always had to be recognized in the reparative 
surgery of compound fractures. Practically, if the wound was regarded as 
clean and if the other factors were favorable, especially the availability of 
vascular soft parts for covering bone, as in the arm or thigh, there was less 
hesitancy in stripping sufficient periosteum to permit the required surgery. MANAGEMENT, COMPOUND BATTLE FRACTURES 
87 
If, on the other hand, the wound was regarded as dirty or doubtful, stripping 
was restricted or avoided. 
When the factors that might restrict its use were not unfavorable and 
the contour of the fracture permitted, rigid internal fixation was frequently 
employed in order to gain the advantages of a well-reduced and stabilized 
fracture. Fixation through the compounding wound was at times practical 
but had the disadvantages of retraumatizing tissue. It also had the disad- 
vantage of placing the metal on bone usually devoid of periosteum, as well as 
at the bottom of dead space created by excision of devitalized muscle. For 
plating, therefore, a separate standard approach to the fracture was advisable, 
to permit covering of the bone and metal by periosteum and vascular soft 
parts (fig. 34). 
In actual practice, when internal fixation was indicated, multiple-screw 
fixation (by 2 or more screws) was frequently used (figs. 35, 36, and 31). Many 
fractures by their obliquity lent themselves to this technique. Little or no 
additional periosteal stripping was required to permit placement of the screws, 
and intrawound trauma was not excessive. If the fracture, because of com- 
minution, did not permit rigid fixation, one or more wire sutures were some- 
times used to hold major fragments in approximation. These could usually 
be placed without additional periosteal stripping, a factor of particular impor- 
tance in a wound with recognized established infection. In comminuted 
fractures with segmental bone loss, wire sutures permitted approximation of 
the major fragments. 
Bony union is a prime consideration in any fracture, and contact of the 
fragments greatly enhances the chances of union. The shortening of an extrem- 
ity to overcome segmental loss and obtain contact of fragments by internal 
fixation of some kind was therefore often a justifiable and indicated procedure 
that was permissible under reparative fracture surgery (figs. 37 and 38). A 
nerve-trunk or a muscle-group deficit associated with a fracture at times was 
the indication for the deliberate removal of attached bone fragments and 
shortening of the extremity. In this way, continuity of all the severed major 
structures was achieved, with the objective of maximum functional restoration 
of the extremity instead of merely a good fracture result as demonstrated by 
roentgenograms (fig. 39). 
There were a number of special types of fractures in which internal fixa- 
tion was frequently employed at the first operation of reparative surgery, to 
achieve special objectives. Among them were (1) fractures about joints, such 
as fractures of the condyles of the femur or the humerus, to permit anatomic 
replacement of articular surfaces; (2) fractures of long bones deep in muscle 
tissue, such as fractures of the femoral shaft and upper radius, in which circum- 
stances favored early reattachment of soft parts to the bone; (3) fractures 
which experience had shown were difficult to hold in reduction by other 
means, such as fractures of the olecranon and fractures associated with 
massive loss of soft tissue (fig. 38); and (4) fractures with segmental loss of 
bone, to achieve contact of the fragments and prevent nonunion (fig. 32). 88 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 30.—Compound comminuted fractures of left femur 
and patella, multiple penetrating wounds of knee, thigh, 
and buttock. Inadequate initial surgery; additional ex- 
cisional surgery 5 days later, with both femoral and patellar 
wounds left open. Septic course; failure of reduction by 
skeletal traction in 90-90-90 position. Final management 
by delayed internal fixation. A. Extremity in skeletal trac- 
tion 1 month after injury; femoral fragments distracted, gas- 
abscess formation. B. Drainage of fascial-plane abscess by 
posterolateral fasciotomy 21 days later. C. Plating of frac- 
tured femur at same operation after removal of totally sepa- 
rated bone fragments. D. Partial suture of wound. E. 
Instillation of penicillin into knee joint at same operation. 
Arthrotomy through transverse wound and connecting lateral 
parapatellar incision revealed dead, detached patellar carti- 
lage and autolysis of femoral and tibial cartilage at contact 
points and points at which patella had rested upon condyles. 
Curettage of raw condylar areas, excision of patella, and 
closure of synovial membrane and skin. 
AFIP C-44-215 MANAGEMENT, COMPOUND BATTLE FRACTURES 
89 
Figure 30—Continued. F. Staged closure of compounding wound of 
femur over small drain, 6 days after operation shown in views B, C. and D. 
G. Appearance of wound 13 days after reparative surgery and 7 days 
after staged closure shown in view F. Healing has been obtained, except 
for small granulating areas in old compounding wound and at proximal 
end of drainage incision. II. Roentgenograms made 5 months after 
wounding. It was thought that a small area of sequestrum formation 
might be present at this time. I. Roentgenograms showing solid bony 
union and excellent anatomic alinement of femoral fracture, 13 months 
after wounding. The metal was later removed because of some absorption 
about one of the screws. Granulation tissue present under plante was 
curetted. J. Healed wounds of knee and thigh, 13 months after 
wounding. 
This patient, 4 weeks after wounding, presented septic knee joint, 
grossly septic wound of thigh, unreduced fracture of femur, and gas 
abscess which could have been mistaken for gas gangrene. He could 
logically have been considered a candidate for amputation. This gloomy 
outlook was altered by complete excisional surgery, closure of dead 
space, fracture stabilization, adequate drainage, and staged wound 
closures, together with adequate blood replacement and protection of 
living tissue from invasive infection by systemic therapy. End result 
was control of septic process in knee and thigh and union of fracture in 
anatomic alinement. 
AFIP C-44-215, C-44-247; U. S. Army photos 90 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 31. {See opposite page for legends.) 
AFIP Fd-44-17 MANAGEMENT, COMPOUND BATTLE FRACTURES 
91 
Internal fixation was preferably avoided when the disadvantages exceeded 
advantages, as in fractures of the tibia, in which periosteal stripping was 
hazardous because overlying skin is not a sufficiently vascularized soft part 
and in which the presence of metal may interfere with even skin closure. 
When the indications and advantages were not clear cut, it was thought 
best to perform wound closure and attempt reduction of the fracture by manip- 
ulation or traction. If the attempt was unsuccessful, a planned open reduc- 
tion and internal fixation could be carried out later, perhaps after healing of 
the compounding wound. The important point was that if poor anatomic 
results could be prevented by surgical measures performed on sound principles, 
results of this kind were no longer accepted for fear of lighting up infection. 
Wound Closure and Drainage 
The hazards of an open wound in a compound fracture are the sequestra- 
tion and sloughing of exposed bone cortex, tendon, and fascia; reinfection at 
dressings; and slow wound healing by granulation. The advantage of an 
open wound is continuing drainage from the depths of the wound until healing 
by granulation has sealed off the fracture site. The gaping wound forms a 
natural channel for drainage. When the wound is not dependent, however, 
and infection intervenes, there may be pocketing, puddling, or pooling of 
purulent exudate in the fracture site or adjacent fascial planes with continuing 
local necrosis of the collagenous tissues. 
In reparative surgery of compound fractures, the hazards of an open 
wound were recognized, and an attempt was made to overcome them by wound 
closure. The need was also recognized for providing a means of egress for the 
possible breakdown of any residual devitalized tissue not yet separated and of a 
Figure 31.—Reparative management of massive wound of left thigh with associated com- 
pound fracture of femur. A. Massive wound of thigh compounding fracture of femur 
shown at reparative surgery, 6 days after wounding, with the extremity in the 90-90-90 
position. Note the distal end of the proximal bony fragment projecting in the wound. 
B. Anteroposterior and lateral views of fracture before reparative surgery. The 
patient was transported in a Tobruk splint. C. Exposure of fracture site by gentle 
retraction, after which the fracture was stabilized by multiple-screw fixation with 
minimal periosteal stripping. D. Partial closure of wound, with drainage established 
by dry fine-mesh gauze inserted into residual dead space about fracture site. The 
remaining defect probably represents the skin loss at wounding. Ten days later, 
coverage was successfully effected with a split-thickness skin graft. E. Anteroposterior 
and lateral roentgenograms made in Zone of Interior hospital 3 months after reparative 
surgery. The fracture is uniting in excellent position and almost in anatomic alinement. 
Internal fixation by multiple screws was selected in preference to other methods in this 
injury because the huge compounding wound of the thigh would probably have decreased 
the effectiveness of skeletal traction. Staged operative procedures were necessary to obtain 
complete wound healing. The contour of the fracture permitted satisfactory stabilization 
with screws without additional periosteal stripping. (This patient was managed by Maj. 
Charles M. Henry, MC, 36th General Hospital.) 92 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-2fi3, C-44-302, (England GH)RC-80, (England GH)RC-84 
Figure 32. {See opposite page for legends.) MANAGEMENT, COMPOUND BATTLE FRACTURES 
93 
contaminated hematoma in unobliterated dead space. In the light of these 
facts, the complete closure of wounds compounding fractures was justified only 
when the pabulum for wound infection was nil. A deep abscess about a frac- 
ture site underneath a sutured or healed epithelial bridge could produce nothing 
hut irreparable damage. An increased margin of safety was obtained, therefore, 
by providing drainage, dependent if possible, by utilizing wounds or counter- 
incisions as indicated. Drains were carefully inserted, so as not to cause tissue 
necrosis, and were removed between the 3d and 10th day, depending upon the 
indications, before rigid sinus formation had occurred. 
The problem of closure of the compounding wound was approached with 
the major objective of covering exposed bone cortex, tendon, and fascia with 
healthy soft parts, and with the minor objective of reducing skin defects to a 
size compatible with adequate drainage. Closure was accomplished, whenever 
possible, by simple, loosely tied, interrupted sutures. Sliding or rotation of 
flaps often permitted closure of the wound (fig. 36). It was recognized that 
soft parts must adhere to the bony cortex to permit revascularization, whereby 
the dying bone could be absorbed and replaced by new living bone (fig. 40). 
Otherwise, sequestration was inevitable. Wound closure, therefore, was 
Figure 32.—Management of compound comminuted fracture of middle third of right tibia 
and fibula, with multiple penetrating wounds of left leg, by delayed internal fixation. 
A. Wounded left leg prepared for reparative surgery in fixed hospital 5 days after 
wounding and initial wound surgery. Note the multiple wounds. B. Stabilization of 
fracture of tibia through incision connecting anterior wounds. After an unsuccessful 
attempt to fix the fracture by multiple screws, the periosteum was stripped over a long 
middle fragment, and stabilization was accomplished by the anteromedial application 
of a long plate to strut the comminuted fragments. C. Closure of surgical wound. 
Note that two posteromedial wounds have been connected to form a relaxing incision, 
to permit closure of the surgical wound and also to provide for drainage. D. Roentgeno- 
grams made in fixed hospital before and after reparative surgery. Note hairline reduc- 
tion of tibia in postoperative films. E. Roentgenograms made in Zone of Interior 
hospital 3 months after wounding. Stabilization of the fracture had been accomplished, 
but the plate, with some cortical bone, was still exposed, although there was no evidence 
of infection. A week later the plate, screws, and four sequestra wTere removed; firm 
union of the fracture was found at operation. F. Roentgenograms made 11 months 
after wounding, showdng solid union of fracture. 
In retrospect, this fracture of the tibia might have been adequately stabilized by plating 
the fibula or might have been managed by skeletal traction in a cast. Either of these meth- 
ods would have avoided periosteal stripping and the application of metal at a point at 
which it was likely to interfere with the healing of soft parts over bone. The anteromedial 
surface of the tibia is not a good location for plating if there is any question of wound heal- 
ing, though in this case the location of the wounds determined the location of the incision 
and of the site on which the metal had to be placed. 
396961°—57 8 94 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
A. Drawing of compounding wound at 
this time. B. Closure of wound with 
drainage of residual dead space by dry 
fine-mesh gauze. 
AFIP Fd-44-18 
C. Appearance of wound 9 days later. 
Healing is now practically complete. 
AFIP Fd-44-18 
E. Reduction of fracture by two-wire 
skeletal traction. Wire lifting distal fem- 
oral fragment is visualized, but wire 
inserted in tibial tubercle for longitudinal 
traction is not seen. The fracture united 
in good apposition, length, and alinement. 
(This patient was managed by Lt. Col. 
Roderick E. Begg, MC, and Capt. John 
E. Manning, MC, 46th General Hospital.) 
AFIP Fd-44-18 
D. Firmly healed wound 1 month after 
reparative surgery. 
Figure 33.—Staged management of compound comminuted fracture of left femur, reparative 
phase. In this case, because of the tactical situation, initial surgery for a very large 
posterior wound compounding the fracture had to be delayed until 60 hours after 
wounding. In spite of the long timelag, excisional surgery at the initial operation was 
thorough, and the wound was quite clean when it was observed in the operating room 
at the general hospital 9 days later. MANAGEMENT, COMPOUND BATTLE FRACTURES 
95 
Figure 34.—Management of compound comminuted fracture of middle third of left femur 
by delayed internal fixation. A. Anteroposterior and lateral roentgenograms of left 
femur before reparative surgery. B. Anteromedial wound exposed in operating room. 
The extremity is in the 90-90-90 operating position. C. Stabilization of fracture in 
reduction through posterolateral incision by bone plate. An additional screw was 
inserted through the compounding medial wound. D. Closure of surgical incision 
with drainage. E. Closure of compounding medial wound with drainage. 
After operation, the extremity was placed in skeletal traction in a Thomas splint with 
Pierson attachment. Active and passive knee motion and quadriceps exercises were insti- 
tuted promptly. When the patient reached the Zone of Interior 8 weeks after wounding, 
the wounds were well healed, the fracture had united in anatomic alinement, and a full 
range of knee motion was possible. He was returned to duty in a motor pool in a general 
hospital 12 months after wounding. 
The approach to the fractured femur via a standard anatomic plane permitted the bone 
which was exposed by surgery to be covered by healthy soft parts and also permitted depend- 
ent drainage. The fracture was reduced anatomically and was stabilized, so that the 
extremity could be handled as necessary for care of the soft-tissue wounds. Management 
of the fracture by skeletal traction would probably have provided adequate reduction, but 
joint exercises would have been delayed and hospitalization would have been prolonged 
overseas. 
AFIP C-44-210 96 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-287 
Figure 35.—Staged surgery of bilateral compound battle fractures of shaft of femur, repar- 
ative phase. This soldier received 1,500 cc. of whole blood in a forward hospital before 
and during initial wound surgery, 1,500 cc. in the general hospital before the reparative 
operation, 500 cc. during the operation, and 500 cc. after operation. In spite of these 
massive transfusions, the highest hematocrit reading after blood replacement was 41. 
A. Anteroposterior views of each femur in the general hospital, with double hip spica 
used for transportation splinting still in situ. B. Lateral views. MANAGEMENT, COMPOUND BATTLE FRACTURES 
97 
AFIP C-44-287 
Figure 35—Continued. C. Medial stellate compounding wound of left thigh after suture. 
D. Lateral compounding wound of left thigh after suture. Drainage was maintained 
for several days through the posterolateral fascial plane. 98 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP 044-287 
Figure 35—Continued. E. Anteroposterior and lateral views of left femur showing inade- 
quate reduction with tibial pin for traction in Army half-ring leg splint. F. Same as 
view E, after addition of femoral wire for lift of distal fragment (two-wire traction). 
The distal fragment is now in excellent apposition and alinement. MANAGEMENT, COMPOUND BATTLE FRACTURES 
99 
AFIP C-44-315, C-44-287 
Figure 35—Continued. G. Two-wire skeletal traction applied to left lower extremity. 
Note sound healing of compounding wound 3 weeks after reparative surgery. H. Ac- 
tive motion of left knee (65° to 70°) 6 months after wounding. At this time, the frac- 
ture of the femoral shaft is firmly united, and all compounding wounds are well healed. 100 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-287 
Figure 35—Continued. I. Rather severe compounding wound of fracture of right femur. 
Patient is on operating table, ready for reparative surgery. Note loss of muscle tissue 
and skin. Note also tourniquet about limb, to reduce further blood loss. J. Exposure 
of fracture of right femur through incision extending distally from wound. The frac- 
ture was easily reduced and firmly fixed internallv with multiple screws. K. Partial 
wound closure, loose packing of remaining defect with dry fine-mesh gauze. Note 
establishment of dependent drainage through posterolateral fascial plane. Wound 
healing by granulation had to be accepted in this instance because of the size of the 
soft-tissue defect. MANAGEMENT, COMPOUND BATTLE FRACTURES 
101 
Figure 35—Continued. L. Postoperative anteroposterior and lateral roentgenograms 
showing excellent reduction of fracture of right femoral shaft. The internal fixation 
was protected by balanced-suspension skeletal traction. M. Appearance of right 
thigh 8 weeks after reparative operation. All wounds are healed, but the granulating 
area is not yet scarified. There is no sinus to bone. 
AFIP CA-44-474, C-44-287 102 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-287 
Figure 35—Continued. N. Range of active motion in right knee 6 months after reparative 
surgery. The fracture is soundly united, and all wounds are well healed. O. Anterior 
view of thighs and upper legs, showing healed wounds, 6 months after reparative surgery. 
(This patient was managed by Capt. John J. Modlin, MC, 21st General Hospital.) MANAGEMENT, COMPOUND BATTLE FRACTURES 
103 
designed to obviate the hazards of exposed bone cortex, the salvage of which 
was probably the most important attainment of reparative surgery of com- 
pound fractures (figs. 41, 36, 37, and 40). 
In actual practice, some compounding wounds were closed with drains of 
rubber tissue or dry, fine-mesh gauze, which emerged through the most de- 
pendent portion of the wound or through a counterincision (figs. 35, 37, and 38). 
In others, surgical limitations, such as dead space which could not be obliter- 
ated or loss of soft tissue, precluded closure of the wound by suture. In these 
instances, partial closure, so as to protect denuded bone cortex, was often 
possible (fig. 42). In still other instances, usually following extensive wound 
revision for dirty wounds, the entire wound was left unsutured in order to 
provide the advantages of drainage through an open wound (figs. 30 and 34). 
In such cases, closure of the wound was usually carried out a few days later, if 
the wound was clinically clean. 
If closure could not be undertaken because of loss of tissue, the wound 
was loosely packed with dry, fine-mesh gauze in the expectation that healing 
would occur from the depths by granulation (figs. 42, 31, and 35). 
POSTOPERATIVE MANAGEMENT 
Immobilization of the compound fracture was instituted immediately 
after reparative surgery. Special techniques are discussed under the heading 
of management of regional fractures (p. 115). 
Compounding wounds closed by suture were dressed within 2 to 4 days 
after operation, to make certain that wound healing was progressing as had 
been anticipated. When the extremity had been put up in plaster, the wound 
was reached through a window cut into the cast; care had to be taken, when 
the window was replaced, to avoid so-called window edema, which could be 
prevented by using the same amount of padding as had been used originally. 
Ideally, inspections and dressings were carried out under a strict aseptic 
technique, including the use of masks to cover the nose and mouth, to reduce 
the chances of droplet infection. Practically, this ideal was seldom achieved. 
RESULTS 
The delayed primary closure of combat-incurred wounds was carried out 
infrequently and in only a limited number of cases in World War I (p. 58). 
Under the principles of reparative surgery, the program of staged wound 
closure was established in World War II as a logical and surgically sound 
policy in wounds of the soft parts and in compound fractures. 
It is true that wounds limited to the soft parts are naturally inclined to 
heal, but they healed faster and with less scarring under the program of repara- 
tive surgery. With this method, multiple dressings of open wounds, which 
were often extremely painful, were eliminated. The chances of secondary 
infection of granulating wounds were reduced. Scar formation was minimized. 104 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP CA-44-520 
Figure 36. (See opposite page for legends.) MANAGEMENT, COMPOUND BATTLE FRACTURES 
105 
Figure 36.—Compound fractures of left tibia and fibula managed by internal fixation of 
tibia by multiple screws. A. Anteroposterior and lateral views of fractures before and 
after fixation of tibia, which has been stabilized in reduction by multiple screws through 
anteromedial wound. Note that the contour of the fracture permits stabilization by 
this method. In addition, the screws could be placed without significant periosteal 
stripping, and soft parts were available to cover all exposed bone and metal. The 
fractures were compounded by anteromedial and posterolateral wounds. B. Healed 
anteromedial wound. Closure without tension was effected by a posteromedial relaxing 
incision. The supplementary incision might have been split grafted at the same oper- 
ation, though this was not done. Drainage was established through the smaller pos- 
terolateral wound. Healing by granulation occurred in this wound and in the relaxing 
incision. C. Anteroposterior and lateral views of fractures G months after internal 
fixation of tibia, showing healing of fracture in anatomic alinement. Note that only 2 
of the 3 screws have been effective in stabilization. D. Solidly healed anteromedial 
wounds 8 months after reparative surgery. Note the shorter, more anterior scar on the 
leg, resulting from the incision made in a Zone of Interior hospital to remove the screws, 
because of some tenderness over the head of one of them, before the patient was returned 
to duty. (This patient was managed by Maj. Joe M. Parker, MC, 21st General Hos- 
pital.) 106 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 37.-—Severely comminuted compound fracture in middle third of right humerus 
associated with extensive loss of muscle and skin over anterior surface of arm and clin- 
ical signs of radial-nerve paralysis. Staged management. This patient was admitted 
to a general hospital 6 days after initial surgery, during the formative phase of the 
reparative-surgery program. The arm was placed in balanced skeletal traction, and the 
large wound was dressed in anticipation of healing by granulation. Eight days later, 
the wound was draining profusely, and adequate reduction of the fracture had not been 
achieved. The wound was then revised under anesthesia, and all residual devitalized 
muscle tissue was excised. The radial nerve, damage to which had been suspected, 
was found intact. Several totally separated fragments of bone were removed, and the 
segmental defect thus created was overcome by approximating major fragments with a 
wire suture through the cortex of each fragment. Available muscle tissue and fascia 
were sutured to cover exposed bone, and a shoulder spica cast was applied. Three weeks 
later, the granulating defect on the arm was successfully covered with a split-thickness 
graft. A. Anteroposterior and lateral views showing inadequate reduction of fracture 
in skeletal traction. B. Apposition of major fragments achieved by wire-suture fixa- 
tion after removal of totally loose comminuted fragments. C. Healed soft-tissue wound 
after application of split-thickness graft through window in cast. Access could not be 
obtained to the wound over the anterior chest wall near the axillary fold, and it was still 
unhealed when the shoulder spica was removed 10 weeks after reparative surgery. 
Additional surgery was required in the Zone of Interior because of scar-tissue contrac- 
ture of the anterior axillary fold. D. Anteroposterior and lateral roentgenograms made 
in Zone of Interior showing solid healing of compound fracture of humerus. 
AFIP CA-44-519 MANAGEMENT, COMPOUND BATTLE FRACTURES 
107 
The incidence of permanent disability was decreased, and the period of tem- 
porary disability was shortened. 
The program of reparative surgery also proved a sound surgical method 
in the management of clinically dirty wounds and wounds in which infection 
had become established. These wounds had always furnished serious diffi- 
culties in military surgery. The problem was largely solved by the application 
of the principles of reparative surgery. By this routine, dirty wounds and 
infected wounds were promptly converted into clean wounds, and staged 
reparative procedures could then be instituted. 
The reparative-surgery program proved as applicable to combat-incurred 
compound fractures as to soft-tissue wounds. When it was applied, wound 
infection was reduced. If infection did develop, secondary wound revision 
was instituted. The aggressive policy (1) of excising the pabulum upon which 
pathogenic bacteria could feed and (2) of instituting drainage was in sharp 
contrast to the former plan of waiting for the sequestration of devitalized 
tissue, including devitalized bone, a plan which was always attended by the 
further necrosis of living tissue. 
The World War II experience supplies complete refutation for the former 
concept that surgery carried out in an infected field is inevitably followed by 
generalized infection. So far as is known, no deaths, amputations, or serious 
systemic sequelae could be attributed to the program of reparative surgery. 
Reduction of fractures was greatly improved after the introduction of 
reparative surgery, for the reason that inadequate and unsatisfactory reduction 
was no longer accepted if it could be corrected by either surgical or nonsurgical 
measures. Segmental bone defects, in which nonunion is almost the rule if 
they remain uncorrected, were also seldom accepted. Internal fixation was 
chosen on definite indications to maintain anatomic position and permit early 
joint motion and exercise. In many instances, functional results were thus 
greatly improved. 
The complete healing obtained in most cases following suture of the wound 
converted the compound fracture into a simple or closed fracture. Even if 
healing was not complete, the fracture site was often rapidly closed off, so that 
the same effect was achieved. Small skin defects either were left to heal by 
granulation or were covered by skin grafts. As a rule, when wound healing 
was not as good as had been hoped for, the unsatisfactory result could be 
attributed not to any defect in the surgical program but to errors in judgment 
as to what was surgically feasible or to errors in surgical technique. 
In some cases encountered in the Mediterranean theater, the nature of 
the injury was such that prolonged drainage from the depths of the wound 
was inevitable, no matter what method of management was used. These 
injuries were characterized by numerous partially detached bone fragments 
and a great deal of associated dead space. The clinical course was usually 
the same. Drainage persisted until the denuded bone had been revitalized or 
had sequestrated and could be removed surgically. Sinus formation was 
frequent and persistent when sequestration occurred. When the sinus led to 108 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP FcW4-19 
Figure 38.—Severe compound comminuted fracture of middle third of shaft of right hu- 
merus with loss of more than 4 cm. of bone. Management by approximation of major 
fragments with single wire suture and wound closure. A and B. Anteroposterior and lateral 
roentgenograms made on patient’s admission to evacuation hospital before initial wound 
surgery. At this operation, the brachial artery and the median and ulnar nerves were 
found intact, but the radial nerve was severed. MANAGEMENT, COMPOUND BATTLE FRACTURES 
109 
AFIP Fd-44-19 
Figure 38—Continued. C. Lateral compounding wound seen in operating room in general 
hospital 9 days later. D. Closure of wound by suture, without excessive tension. E. Large 
and small medial wounds of same extremity ready for reparative surgery. F. Same wounds 
at conclusion of reparative surgery. The smaller wound has been sutured; the larger has 
been covered with a split-thickness skin graft. 
396961c— 57 9 110 
ORTHOPEDIC SURGERY US MEDITERRANEAN THEATER 
AFIP Fd-44-19, 54-3045-1 
Figure 38—Continued. G. Anteroposterior and lateral views showing the minimal contact 
of major fragments obtained by wire suture. H. Same as view G, 7 months after reparative 
surgery, showing nonunion of fracture. A tantalum cuff encloses the repaired radial nerve. 
The soft-tissue wounds in this case healed promptly, and the prompt healing greatly facili- 
tated nerve repair. The fracture was finally united after bone grafting several months later. 
The failure of the attempt to obtain union by use of a wire suture at reparative surgery does 
not in any way lessen the correctness of the effort. (This patient was managed by Maj. 
Charles M. Henry, MC, 36th General Hospital.) MANAGEMENT, COMPOUND BATTLE FRACTURES 
111 
AFIP CB-44-56, (England GH) KC-83 
Figure 39.—Staged management of associated humeral-radial fracture and nerve injury. 
Inspection of the radial nerve at reparative surgery 10 days after wounding showed 
destruction of inches of nerve tissue. The fractured humerus was shortened by 
excision of portions of the comminuted fragments; then the major fragments were 
plated. The nerve ends were united with one suture and wrapped in fibrin film. Prompt 
healing after closure of wound by suture; definitive nerve suture 16 days later; excellent 
end result. A. Steps of reparative operation 10 days after wounding. B. Steps of 
definitive nerve repair 16 days later. C. Anteroposterior and lateral roentgenograms 
showing united fracture in perfect alinement 6}4 months later. At this time, there was 
evidence of returning function in the radial nerve supply. Orthopedic surgery was 
performed by Maj. Joe M. Parker, MC, and neurosurgery by Lt. Col. Henry G. 
Schwartz, MC, 21st General Hospital. 112 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 40.—Reparative management of mildly comminuted fracture of right tibia resulting 
from penetration of limb by high-explosive shell fragment. A. Anteroposterior and 
lateral roentgenograms at general hospital 10 days after wounding. The compounding 
wound had been left open after debridement in a forward hospital. B. Closure of com- 
pounding wound at reparative surgery. A long posteromedial relaxing incision per- 
mitted the use of a sliding flap and thus permitted closure without tension. The defect 
created by the relaxing incision has been covered with a split-thickness graft. C. 
Healed wounds 2 weeks after reparative surgery. Note that the take on the skin graft 
is about 95 percent. Sound wound healing followed soon afterward. This casualty 
could be rehabilitated for duty in the theater of operations, which was a rather unusual 
result in compound fractures of the bones of the leg and one which would have been 
impossible except under the regimen of reparative surgery. (This patient was managed 
by Capt. George H. Marcy, MC, 23d General Hospital.) 
AFIP C-44-216, C-44-286 
sequestra that could not be prevented surgically, the outcome had to be ac- 
cepted as the inevitable result of injury. In these cases, failure of wound 
healing was attributable to the presence of retained dead tissue and not to 
bacterial infection per se. MANAGEMENT, COMPOUND BATTLE FRACTURES 
113 
AFIP C-44-273 
Figure 41.—Management of compound comminuted fracture of shaft of femur by balanced- 
suspension skeletal traction; sequestration of denuded bone not covered by soft parts. 
The anterolateral wound compounding the femoral fracture was extensive, and the 
considerable muscle loss left the femoral fragments exposed for several inches. Reduc- 
tion of the fracture was carried out in a general hospital shortly after the patient was 
received, but reparative surgery was omitted. A. Anteroposterior and lateral roentgeno- 
grams showing fracture of femoral shaft in traction just before reduction in a general 
hospital. B. Anteroposterior and lateral roentgenograms showing healed fracture with 
massive sequestrum formation, 68 days after wounding. C. Wound of thigh 78 days 
after wounding. Note continued drainage and lack of healing. 
The sequestra were eventually removed, and dependent drainage was established, under 
penicillin protection, but skin grafting was necessary before wound healing was eventually 
achieved. In this case, early reparative surgery, with closure of the wound over the exposed 
bone, might have prevented sequestration of the femoral fragments. Wound healing and 
fracture healing were finally achieved, after delayed reparative surgery. (The case was 
managed at the 21st General Hospital in January 1944, before the program of reparative 
surgery of compound fractures had become theaterwide.) 
The program of reparative surgery proved again that in the management 
of combat-incurred compound fractures there is no substitute for surgery. 
Blood and penicillin were essential adjuvants, but the whole program was based 
upon the concept that the bacterial flora in an open war wound is of minor 114 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 42.—Management of compound fracture of upper third of right tibia by staged 
surgery and modified closed plaster technique. A. Anteroposterior and lateral roent- 
genograms showing defect in upper third of tibia following initial surgery. B. Large 
compounding wound of soft tissues, with several stellate extensions, shown in operating 
room in general hospital just before reparative surgery. C. Suture of extensions of 
wound, so as to cover all exposed cortical bone. The remaining defect was left open, 
and the modified closed plaster regimen was instituted. When the sutures were removed, 
12 days after the reparative operation, through a large window in the cast, the stellate 
incisions were found well healed. 
AFIP C-44-225 
The remaining defect was loosely packed with fine-mesh gauze, and the window w7as 
replaced in the cast and secured with several turns of plaster bandage. The next dressing 
was set for the period at which the cast would be changed, 4 to 6 wreeks after the first 
dressing, probably after the soldier had been transferred to the Zone of Interior. The 
modified closed plaster method was used in this case because loss of tissue made complete 
closure of the soft-tissue wound impossible. In addition, closure would have been doomed 
to failure because of the underlying dead space caused by the defect in the cancellous bone. 
It was essential, in this injury, that the exposed cortical bone be covered, and this was 
achieved by partial closure. 
importance compared to the pathologic process itself. By the end of World 
W ar II, this concept of the management of combat-incurred wounds had been 
generally accepted, and the spotlight of attention had been focused where it 
belonged; that is, upon their surgical management. CHAPTER V 
Regional Compound Fractures 
Part I. Compound Fractures of the Humerus, Radius, 
and Ulna 1 
GENERAL CONSIDERATIONS 
Compound fractures of the bones of the upper extremity were frequent, 
as is shown by the experience of two general hospitals which functioned in the 
Mediterranean theater. These bones were injured in 992 (34.1 percent) of 
the 2,911 compound fractures treated at the 45th General Hospital during 
1944, and in 685 (37.1 percent) of the 1,844 compound fractures treated at the 
21st General Hospital over the same period. When the 332 fractures of bones 
of the hand are excluded, composite figures for the two hospitals show that the 
bones of the arm and forearm were involved in 1,098 (23.1 percent) of all the 
compound fractures treated in them during 1944. Of these injuries, 322 were 
compound fractures of the humerus, and 338 were compound fractures of the 
radius, ulna, or both bones. 
Compound fractures of the long bones of the upper extremity offered a 
peculiarly attractive field for the application of the principles and procedures 
of reparative surgery. They are therefore discussed in considerable detail. 
The management of injuries of the hand is not considered in this volume. 
These injuries are discussed in detail in the volume on hand surgery. 
PROBLEMS OF MANAGEAIENT 
Certain special problems of management presented themselves in com- 
pound fractures of the upper extremity: 
1. The major objective of the management of all wounds of the arm and 
forearm, including all compound fractures, was maximum restoration of the 
function of the hand. This function varies from the finer precision movements 
to grasping with strength. It was therefore essential, in addition to repair of 
the bony framework and skin covering, that the integrity of muscle, tendon, 
and nerve be restored, as nearly as possible, to its original state or that it be 
otherwise compensated for, and that early motion, particularly of the fingers, 
1 Data for this section were collected by Maj. Joe M. Parker, MC, and Capt. Francis R. Crouch, MC, 21st General 
Hospital; Capt. John W. Rovane, MC, 300th General Hospital: Maj. William R. Ferguson, MC, Capt. Robert B. Gott- 
schalk, MC, and Capt. James H. Flynn, MC, 33d General Hospital: and Lt. Col. George A. Duncan, MC, 45th General 
Hospital. 
115 116 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
be instituted, to minimize fixation of joints, muscles, and tendons. The 
overwhelming importance of function of the hand always had to borne in mind, 
therefore, when the management of compound fractures and other injuries of 
the arm and forearm was determined upon. 
2. A severed nerve in the arm or forearm or a severed tendon or tendons 
in the forearm was sometimes of greater importance than the associated com- 
pound fracture or fractures. In the staging of reparative-surgery procedures, 
however, the repair of nerves and tendons was postponed until the wound 
had healed and there had been optimal restoration of the bony framework 
(fig. 39). Nerves and tendons could then safely be repaired through a healed 
wound. These operations were functions of hospitals in the United States. The 
necessities of concurrent injuries therefore sometimes determined the method 
of fracture management and sometimes dictated the plastic procedures which 
might be necessary to accomplish wound healing in injuries of the upper 
extremity. 
3. Bone loss with resulting partial or segmental defects was not infre- 
quent, particularly in the humerus, and called for special methods of fracture 
management (figs. 43 and 44; also figs. 37 and 38). 
4. Immobilization of the upper extremity is difficult, a circumstance which 
made maintenance of reduction of certain fractures, particularly those of the 
humerus and of both bones of the forearm, correspondingly difficult. 
5. In spite of the serious problems of management presented by compound 
battle-incurred fractures of the upper extremity, the favorable factors on the 
whole outweighed the unfavorable. The richly vascularized muscular sleeve 
about the whole circumference of the arm and upper forearm predisposed to 
rapid healing of both wounds and fractures and to minimal infection. Similarly, 
except in the lower forearm, there is a paucity of dense fascia and tendons and 
therefore an absence of tissues with poor blood supply and a correspondingly 
limited resistance to infection. The well-developed muscular sleeve just 
described facilitated the coverage and revascularization of bones denuded at 
wounding and further denuded at surger}r. Dead space was readily obliter- 
ated, and adequate drainage could be secured with equal ease. Maintenance 
of full bone length in this region was relatively unimportant from the stand- 
point of future function. Finally, bone and nerve surgery could be performed 
at the same operation or in stages, according to the necessities of the special case. 
GENERAL PRINCIPLES OF MANAGEMENT 
Unless serious associated injuries required longer stays in evacuation hos- 
pitals, soldiers with wounds of the upper extremity usually reached general 
hospitals within 2 to 4 days after initial wound surgery. Since blood loss was 
considerably less severe than in compound fractures of the femur and of the 
bones of the leg, little time had to be spent in elaborate preoperative prepara- 
tion. Transfusions in the amount of 500 to 1,000 cc. usuallv restored the REGIONAL COMPOUND FRACTURES 
117 
hematocrit reading to the 40 regarded as optimal before reparative surgery. 
Most casualties therefore reached the operating room by the 7th day after 
wounding and seldom later than the 10th day. This meant that practically 
all surgery could be done within the optimum period. In a series of 147 com- 
pound fractures of the humerus, for instance, to be reported later in this chapter 
(p. 130), reparative surgery was done on an average of 6.5 days after wounding. 
A study of peripheral-nerve funct ion was part of the preoperative survey in 
wounds of the arm and forearm, but final appraisal was made in the operating 
room, after the cast had been removed and before anesthesia was begun. The 
status of nerve function could thus be determined with absolute certainty 
when the extremities were unhampered by supporting casts or dressings. 
Wound management.—Wound management in compound fractures of the 
upper extremity followed the general principles of reparative surgery. The 
wound was widely exposed, so that inspection to the depths was possible and 
the fracture could be fully visualized. Any residual devitalized tissue was 
excised. Small, totally separated fragments of bone were removed. The 
decision as to fracture management was made, and internal fixation, if it was 
the method selected, was carried out. 
Whenever possible, the wound was closed by accurate approximation of 
the soft parts, to achieve obliteration of dead space, coverage of denuded bone, 
or protection of nerves and blood vessels from possible damage by bone frag- 
ments. Buried cotton sutures were employed in one hospital during the last 
6 months of the war. Drainage was employed routinely in the first days of the 
reparative-surgery program. Later, it was provided only on specific indica- 
tions, which existed in perhaps 70 percent of all cases. 
When incomplete initial surgery had resulted in a clinically dirty wound, 
so that extensive additional excisional surgery was required, closure was usually 
postponed for several days, to be certain that the wound was clean. Whenever 
possible in these circumstances, the bone was covered by muscle, in an effort to 
effect as rapid revascularization of the bone as possible. 
Splinting.—The general principles of splinting were applied in immobiliza- 
tion of the extremity after reparative surgery. All plaster casts, including 
hanging casts, were trimmed at the proximal palmar crease unless specific 
indications existed for immobilization of the fingers. Precise splinting, which 
permitted active motion of the fingers, was provided in associated radial- 
nerve injuries, so as to avoid continuing stretch of the paralyzed muscles and 
yet permit a full range of active motion (fig. 45). It was not considered neces- 
sary to employ special splinting for median- or ulnar-nerve palsies. 
After the early healing phase in compounding wounds of the forearm and 
immediately after reparative surgery in wounds above the elbow, full and 
active finger motion was encouraged as part of routine postoperative manage- 
ment. If nerve, muscle, or tendon injuries prevented full and active motion 
of all the joints of the fingers, the fingers were moved passively many times 
daily, in order to prevent fixation. 118 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP (Cushing GH) P-1505-A-E, 74S 
Figure 43. (See opposite page for legends.) REGIONAL COMPOUND FRACTURES 
119 
AFIP (Cushing GH) P-1505-A-E, 743 
Figure 43.—Management by delayed internal fixation of compound comminuted fracture 
of shaft of right humerus, with segmental loss of bone and laceration of median and 
ulnar nerves. Ligation of the brachial artery and vein was necessary at initial 
wound surgery, at which the severed median nerve was approximated and the ends 
of the severed ulnar nerve were tagged with wire sutures. A. Anteroposterior roent- 
genogram showing compound comminuted fracture of right humerus, before reparative 
surgery. Note bone loss and resulting defect. Totally loose bone fragments were 
removed at the reparative operation. B. Lateral roentgenogram of fracture. C. 
Anteroposterior roentgenogram of fracture after internal fixation with 3 wire sutures, 
23 days after wounding. At this operation, the end of each fragment was squared to 
provide a maximum surface for the bony contact achieved by the fixation procedure. 
The resultant shortening was about 2 inches. The wound was left open for the next 
7 days, then was partially closed by suture and a skin flap was rotated so as to cover 
all denuded bone. D. Lateral roentgenogram showing fracture after internal fixation. 
This view, like the anteroposterior view C, shows the fragments in good contact with each 
other. E. Anteroposterior roentgenogram made in Zone of Interior hospital 3 months 
after wounding. The fracture united promptly, without sequestration or removal of 
metal, and wound healing was also satisfactory. F. Lateral roentgenogram made in 
Zone of Interior hospital. 
In this case, all residual devitalized tissue was excised at wound revision. Twelve days 
later, apposition of the fragments of bone was obtained by surgery on the bone. Eight 
days later, wound closure was accomplished, the open wound having provided drainage in 
the interval between the operations. The aggressive surgical approach prevented almost 
certain nonunion of the fracture, while the procedures undertaken for wound healing made it 
possible to undertake nerve surgery soon after the patient reached the Zone of Interior. 
(This case was managed by Maj. Herbert W. Harris, MC, at the 17th General Hospital.) 120 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP (Cushing GH) P-1504 
Figure 44.—Management by delayed internal fixation of compound comminuted fracture 
of right humerus with segmental loss of bone and laceration of radial nerve. A. Antero- 
posterior roentgenogram of fracture of humerus after approximation of fragments bjr 
two wire sutures at reparative surgery. Note that contact between the fragments is 
only minimal. B. Lateral roentgenogram of fracture shown in view A. C. Lateral 
roentgenogram made in Zone of Interior hospital 8% months after wounding, showing 
nonunion of fracture of humerus. The wounds healed well, but bone grafting was 
necessary to secure union of the fracture. Definitive suture of the radial nerve was 
carried out at the same operation. 
Although the approximation of fragments in this case did not lead to union, the procedure 
employed provided a chance for union to occur and facilitated later reconstructive surgery. 
Without internal fixation, nonunion was inevitable because of the segmental bone loss at 
wounding. (The case was managed at the 21st General Hospital by Maj. Joe M. Parker, 
MC, and Lt. Col. Henry G. Schwartz, MC.) REGIONAL COMPOUND FRACTURES 
121 
AFIP C-44-363, Fd-44-14 
Figure 45.—Splinting for paralysis of radial nerve. A. Hanging cast utilized for reduction 
of fracture of humerus. Note fingers relaxed, in functional position. B. Complete 
flexion of fingers and thumb by power of median- and ulnar-nerve supply. C and D. 
Closeups showing elastic supports to prevent continuing stretch of paralyzed muscles. 
Note discarded plasma tubing, used in preference to the elastic cord which was supplied 
for traction. Tubing is more effective because it stretches more readily. A piece of 
string tied to the plasma tubing passes between the third and fourth fingers and is 
attached to a portion of a tongue depressor. The cuff around the thumb is made of 
adhesive tape. 
COMPOUND FRACTURES OF THE HUMERUS 
The material on compound fractures of the humerus is based on surveys 
from three hospitals, as follows: 
271 compound fractures of the humerus treated at the 21st General 
Hospital in Italy and later in the European Theater of Operations during 1944 
and 1945. 
221 compound fractures of the humerus analyzed from the 1944-45 dis- 
position-board proceedings at the 300th General Hospital in the Mediterranean 
theater. 
147 compound fractures of the humerus treated at the 33d General Hospital 
in 1944 and 1945, during the last 9 months of the war. 122 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Compound fractures of the humerus are most conveniently discussed 
according to the location of the fracture. In the 337 cases from the 300th 
and 33d General Hospitals in which these data were stated, the injuries involved 
the shoulder joint and the proximal end of the humerus in 18 percent, the shaft 
from the surgical neck to the supracondylar level in 65 percent, and the distal 
end and elbow joint in 17 percent. 
Fractures of the Proximal End of the Humerus 
Several particularly important observations, with correspondingly im- 
portant therapeutic implications, were made in compound fractures of the 
proximal end of the humerus with involvement of the shoulder joint. These 
observations included the following: 
Dislocations of the head of the humerus were very frequently associated 
with compound fractures of the head and neck (fig. 46). They were overlooked 
at the initial operation in a large proportion of the cases encountered early in 
the war. In one group of 24 consecutive injuries of the proximal head of the 
humerus with involvement of the shoulder joint, there were 8 associated dis- 
locations. When the frequency of the association was realized, it became com- 
mon practice to obtain stereoscopic roentgenograms of all fractures about the 
shoulder joint before reparative surgery. The dislocation was usually anterior, 
and, if the head of the humerus was split longitudinally, the fracture surface 
was found resting on the anterior lip of the glenoid. Closed reduction was not 
possible in this type of case. Instead, it was necessary to restore the normal 
regional relationships by open operation on the fracture dislocation. 
Concurrent injury to the major nerve trunks was not frequent, but the 
wounds were frequently so located that damage to the axillary nerve seemed 
highly probable. Nothing could be done about such an injury, as this nerve 
is too small to be attacked directly and repair was therefore out of the question. 
It was the general practice, in order to preserve any undamaged nerve supply 
for the deltoid, to employ an anterior approach to the fracture, with reflection 
of the deltoid, and often with utilization of a portion of the compounding 
wound. 
If the head of the humerus was not too badly comminuted, the usual 
procedure was to maintain reduction by 1 or 2 screws or by wire sutures. When 
the comminution was so extensive that reduction was impossible, the dislocated 
head was excised, and the upper end of the shaft of the humerus was placed 
against the glenoid. If enough of the head remained intact to permit partial 
restoration of the cartilaginous relationship of the shoulder, with a decrease 
in the articular surface of the head, observations at operation showed that 
the remnant of the surface of the head glided well through a fair range of motion. 
The end results of this technique are not known. 
When both the head of the humerus and the glenoid process were so 
completely shattered that it was impossible to reorganize any articular mechan- 
ism in the shoulder joint at reparative surgery, the wound was left open because REGIONAL COMPOUND FRACTURES 
123 
the extensive damage to the articular cartilage probably made prolonged 
drainage inevitable. The best plan of management was to immobilize the 
shoulder in plaster in the position of function, in the expectation that spon- 
taneous fusion would occur. 
Fractures of the Shaft of the Humerus 
Compound fractures of the shaft of the humerus included a wide variety 
of injuries. The compounding wounds varied considerably in size, depending 
upon the type and velocity of the missile and the extent of the initial debride- 
ment. Bone injuries ranged from incomplete cortical fractures to avulsions 
of several inches of the shaft. As a rule, the extent of bony damage paralleled 
the extent of soft-tissue damage. 
Wounds in this area were likely to be clinically clean. It was usually 
possible, without undue difficulty or further trauma, (1) to explore them 
adequately and to remove devitalized tags of tissue, totally loose fragments of 
bone, and other foreign material; and (2) to appraise the extent of bone damage 
and determine possible nerve damage. 
After the type of fracture management had been decided upon and internal 
fixation, if it was indicated at this time, had been carried out, the wounds were 
closed by the layer-suture technique. Wound closure was carried out as part 
of reparative surgery in about 70 percent of all fractures of the shaft of the 
humerus. A certain number of the remaining cases were left unsutured because 
the wounds were of small size. The others were closed or grafted at a staged 
procedure. As already noted, it was unusual to find any evidence of infection 
in wounds of this area of the humerus or any considerable amount of retained 
foreign material or necrotic tissue. When these circumstances were encountered, 
the usual secondary excisional surgery was performed, and closure was delayed 
for 5 to 7 days after operation. 
Methods of fracture management in compound injuries of the shaft of the 
humerus depended upon whether or not bone loss had occurred. 
Fractures without bone loss.—In fractures without bone loss, the hanging 
cast was frequently used whenever the patient could be ambulatory (fig. 47). 
It wras replaced by the shoulder spica (fig. 48) in cases of massive soft-tissue 
injury or in cases in which distraction of the humeral fragments had occurred 
or seemed likely to occur. In addition to its advantages from the therapeutic 
standpoint, the hanging cast converted a bed patient into an ambulatory 
patient, permitting him to go to mess and to the latrine and generally to take 
care of himself. These were considerations of no little importance in a busy 
general hospital with limited manpower. Patients w’ere comfortable in the 
cast and quickly learned how to lie down and rise from the bed without assistance 
and without discomfort. During periods of temporary recumbency soon after 
wounding, reduction was maintained by traction, which wras provided by a 
weight extending from a plaster loop at the elbow over a pulley at the foot of 
the bed. Later, the elbow was merely supported by a pillow. 124 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 46. (See opposite page for legends.) 
AFIP 88226, CA-44-346, 88230, 88228, 88229, 92364, 92365 REGIONAL COMPOUND FRACTURES 
125 
If the fracture was in the lower portion of the shaft, alinement was best 
maintained by placing the forearm in complete pronation, as a precaution 
against outward bowing at the fracture site. The cast was made lighter than 
in civilian practice and was never weighted, since badly comminuted battle- 
incurred fractures with associated soft-tissue damage were easily distracted. 
In the early days of the North African campaign, the shoulder spica was 
frequently used for fractures of the shaft of the humerus, and some surgeons 
continued to use it in all cases of this kind. Those who tested the hanging cast, 
however, usually came to prefer it. The spica was difficult to apply satis- 
factorily with the patient recumbent, and, even when it was applied snugly 
with the patient erect, it was not at all unusual, 10 to 14 days later, to find that 
it had become loose and that the fragments were angulated. In a busy over- 
seas theater, a cast which had to be replaced at frequent intervals was open 
to serious objection. United States experiences in civilian practice would 
have suggested a wider wartime use of the shoulder spica. It was widely used 
in the Spanish Civil War, as well as by British surgeons in the North African 
theater. 
It was the general opinion in the Mediterranean theater that the hanging 
cast, in addition to being more comfortable for the patient than the shoulder 
spica, gave better results from the standpoint of bony alinement and main- 
Figurk 46.—Comminuted fracture dislocation of right shoulder, comminuted fracture of 
shaft of humerus, comminuted fractures of both bones of forearm, associated injuries 
of median and radial nerves. A. Anteroposterior roentgenogram in general hospital 
showing fracture dislocation of shoulder and comminuted fracture of shaft of humerus. 
B. Compounding wounds of shoulder and middle third of forearm just before reparative 
surgery. Note exposed tendons in wound of forearm. C. Anteroposterior roentgeno- 
gram of shoulder and upper arm after reconstruction of head of humerus and fixation 
by multiple screws. Extremity is in skeletal traction for comminuted fracture of shaft 
of humerus. D. Compounding wounds after closure at reparative surgery. Note 
proximal and distal extension of wound of shoulder region to permit adequate exposure. 
E. Skeletal traction applied for comminuted fracture of humerus, with wire through 
olecranon, and for comminuted fractures of bones of forearm, with wire through distal 
ends of both bones. F. Anteroposterior view of bones of forearm in skeletal traction. 
Note suture of stainless-steel wire inserted at reparative surgery to hold major fragments 
of radius in apposition. G. Anteroposterior roentgenogram showing united fracture of 
humerus in Zone of Interior 3J4 months after reparative surgery. Note that absorption 
of bone in the head of the humerus has left the proximal ends of the screws projecting 
into the soft tissues. H. Same as view G, after removal of screws. Further union of 
the fracture of the shaft occurred later. I. Range of overhead reach 8 months after 
reparative surgery. J. Range of internal motion at same time. When this photograph 
was made, radial-nerve function had returned, but a median-nerve paralysis was still 
present. Later, spontaneous recovery occurred. The extremely satisfactory result 
achieved in these serious injuries was made possible only by an aggressive surgical 
approach and the employment of a varied armamentarium of procedures at reparative 
surgery. (This patient was managed by Maj. Joe M. Parker, MC, at the 21st General 
Hospital.) 
396961°—57 10 126 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 47.—Hanging cast used for fracture of humerus. A. Cast with patient erect- 
Note plaster loops for sling and for traction in recumbency. Wrist is free, but hand 
is supported by plaster extension. B. Patient recumbent. Traction from loop is 
utilized in this position. Only 4 or 5 pounds are necessary. Note folded towel support- 
ing arm. 
AFIP Fd-45-22 
tenance of the position of the fragment. Instances were recorded in which 
reduction was accomplished satisfactorily by the hanging cast after skeletal 
traction had failed. Many patients were evacuated before any opinion about 
union could be expressed, but results were generally good in the cases held 
long enough for observation. 
The hanging cast was often used for transportation to the Zone of Interior. 
Patients with injuries of the humerus, with or without involvement of the 
shoulder joint, were seldom in condition to travel before the third or fourth 
week after wounding. By this time, the bony fragments were usually beginning 
to unite, and transportation in this type of cast was regarded as entirely proper. 
Fractures with bone loss.—There were two important considerations 
in fractures of the shaft of the humerus with bone loss. The first was the 
amount of bone lost, and the degree of shortening which would result if the 
bone ends were approximated without replacement of the segmental deficit. 
The second was the probability of sound primary healing of sutured soft parts, 
to facilitate bone grafting at an early date. These considerations were neces- 
sarily weighed against each other in deciding whether to accomplish repair 
by internal fixation, to overcome the segmental defect, or by other measures 
in cases of bone loss. 
If shortening did not exceed 3 to 4 cm., good contact of the bone ends 
could usually be attained by means of 1 or 2 wire sutures (fig. 37). Sutures 
were used in preference to plates because they could be inserted with little or 
no periosteal stripping. When they were supplemented by firm external 
splinting, the fracture was well immobilized (figs. 38, 43, and 44). With this 
technique, reparative surgery of the soft tissues was accomplished without REGIONAL COMPOUND FRACTURES 
127 
Figure 48.—Well-applied shoulder spica 
cast for fracture involving shoulder joint. 
If shoulder fusion is anticipated, the degree 
of abduction is debatable. 
AFIP Fd-4.5-20 
difficulty. In the occasional case in which contact of the fragments had been 
particularly satisfactory, a hanging cast was employed. Most often, however, 
a shoulder spica was used. 
If bone loss was so extensive that shortening in excess of 4 cm. would be 
required to obtain contact of fragments, it was considered preferable to ac- 
complish healing of the compounding wound and return the patient to the 
Zone of Interior, with the idea that bony continuity would be restored at a 
later reconstructive operation. This may or may not have been a better plan 
than internal fixation of the fracture with wire sutures to obtain contact of 
the fragments. 
Internal fixation was employed in only a small proportion of the fractures 
of the shaft of the humerus encountered in the Mediterranean theater (p. 199). 
When it was used, plating was usually avoided, for the obvious reason that 
stripping of the periosteum would have introduced fresh trauma and would 
have enhanced the possibility of sequestration. 
In the 271 compound fractures of the humerus analyzed at the 21st 
General Hospital, internal fixation was used 22 times but was accomplished 
by plating only twice; wire sutures were used 15 times and multiple screws 
5 times. In the 147 cases treated at the 33d General Hospital, internal fixation 
was also used 22 times and was accomplished by plating 5 times; wire sutures 
were used 9 times, and sutures and screws were used in combination 8 times. 
Associated nerve injuries.—In all compound fractures of the shaft of 
the humerus, the possibility of an associated nerve injury existed and had to 
be taken into account in the preoperative evaluation of the patient. Radial- 
nerve injuries were by far the most frequent, as the following figures show: 
In the 271 fractures of the humerus treated at the 21st General Hospital, 
there were 108 nerve injuries, including 70 injuries of the radial nerve, 30 of 
the ulnar nerve, and 8 of the median nerve. Injuries of the radial nerve were 
present in half of all fractures of the middle third of the shaft. 128 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
In the 147 fractures treated at the 33d General Hospital, there were 
66 nerve injuries, including 36 injuries of the radial nerve, 20 of the ulnar nerve, 
and 10 of the median nerve. 
Radial-nerve injuries were thus present in 25.4 percent of these two series 
(106 of 418 cases), ulnar-nerve injuries were present in 11.9 percent (50 cases), 
and median-nerve injuries were present in 4.3 percent (18 cases). 
Because nerve injuries are treated in detail in the neurosurgical volume 
of the clinical history of World War II, only brief mention need be made of 
them here. The important considerations in nerve injuries were that (1) the 
possibility of the injury be borne in mind i?i the preoperative survey, as has 
already been emphasized, and (2) that, when clinical paralysis was present, 
the necessity for exposure of the nerve at operation be considered. The pre- 
operative estimate, as a practical matter, was made on the basis of demonstrable 
motor and sensory deficits. 
Combined nerve and bone surgery proved so successful when it was tried 
tentatively that during the last 9 months of the war it became common prac- 
tice at reparative surgery to expose the involved trunks in all instances of 
peripheral-nerve palsy, to permit precise determination of the damage, unless— 
1. A sufficiently detailed note on the record showed that the nerve had 
been visualized intact at initial surgery. 
2. The location of the wound and of the fracture made it anatomically 
unlikely that the nerve had been injured. In such cases, a diagnosis of nerve 
injury was sometimes made, but returning function usually became evident in 
2 to 3 weeks. This happened in seven cases, for instance, at the 21st General 
Hospital. 
The status of the nerve was usually determined by inspection after it had 
been exposed, though in some cases an injection of physiologic salt solution 
was employed as an aid in determination of intraneural continuity. If the 
nerve was found severed or so severely traumatized that, although it was 
intact, physiologic interruption had evidently occurred, the extent of the 
damage was evaluated, and the possibility of approximating the nerve ends 
after resection of ttie damaged portion was determined. The technique of 
fracture management was often influenced by this decision. 
If the divided nerve ends could apparently be brought together without 
tension, internal fixation, even if plating was necessary, was sometimes em- 
ployed, so that staged nerve repair could be carried out as promptly as possible. 
Of the 22 internal-fixation operations performed at the 21st General Hospital, 
an associated nerve injury and the desirability of early repair were the indi- 
cations in 15 (fig. 39). 
If comminution precluded fixation of the fractured bone, 1 cm. or more 
of the length of the arm was often deliberately sacrificed by removal of loose 
fragments, in order to accomplish stable internal fixation and permit nerve 
repair to be undertaken within the optimal period of 3 weeks after wounding. 
If a nerve deficit existed, a section of the fractured shaft of the humerus, REGIONAL COMPOUND FRACTURES 
129 
sometimes up to 4 cm., was excised, so that the ends of the damaged nerve 
could be brought together. 
Definitive nerve suture was never performed at the first operation of 
reparative surgery. Nerve surgery at this operation never went beyond the 
loose approximation of the ends of the nerve by a single suture, and even this 
procedure was by no means the rule. Definitive repair wras undertaken at a 
later date, through a healed wound. What could be accomplished at the staged 
nerve operation, however, often depended upon what had been done about 
the fracture at reparative surgery. 
In view of the very poor results which were being reported after nerve 
grafting in the Zone of Interior and the relatively or actually good results being 
achieved by the combined procedure described, this new and radical approach 
to fractures of the shaft of the humerus associated with nerve injuries was 
regarded as fully justified. Obviously, the close cooperation of orthopedic 
surgeons and neurosurgeons was essential for the best results. 
The majority of the combined procedures in this series were undertaken 
in injuries of the radial nerve. Relatively few were undertaken for injuries of 
the median and ulnar nerves, which, though probably of greater importance 
functionally, were less frequent. 
Fractures of the Distal Portion of the Humerus 
In fractures of the distal portion of the humerus involving the elbow joint, 
the extent of the injury again determined the technique to be employed. 
Fractures of the condyles, if they were not too greatly comminuted, were 
reduced as anatomically as possible and were often fixed internally, to facilitate 
early motion. This was a consideration of the utmost importance in the restora- 
tion of function. 
T-fractures. with separation of the condyles, were often held in reduction 
by two screws or by a combination of wire sutures and screws. This area of 
the humerus, fortunately, usually tolerates without difficulty the manipulation 
and stripping of the periosteum necessary for accurate reduction of the frag- 
ments. It was occasionally necessary to shift Haps of skin in order to close the 
tissues over exposed bones or joints. One case was observed in which a thick 
flap of skin was utilized to seal the elbow joint, which was preserved with 
only this covering. 
Markedly comminuted fractures about the elbow, with destruction of the 
condyles of the humerus and the upper ends of the radius and ulna, permitted 
little choice in fracture management. The technique employed depended upon 
the condition of the compounding wound. Clean wounds of the elbows with 
marked comminution wrere treated by delayed closure. At one hospital, if 
infection was present, resection of the elbow joint was sometimes performed. 
The wound was closed with drainage or was left open and closed at a later 
operation. The flail elbows which resulted from these operations did not seem 
to be satisfactory while the natients remained under observation and were 130 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
probably no more satisfactory later. The value of this procedure, therefore, 
was debatable except as a means of controlling severe infection and avoiding 
amputation. 
Fractures of the lower end of the humerus were associated with more ulnar- 
and with fewer radial-nerve lesions than fractures of the shaft. Wounds charac- 
terized by avulsion of the medial epicondyle were so frequently accompanied 
by ulnar-nerve paralysis that accurate appraisal of possible nerve damage was 
a routine step in their management. 
Results of Reparative Surgery 
As in all compound fractures, the compilation of end results was impossible 
overseas in fractures of the humerus. The great majority of patients were 
transferred to the Zone of Interior before complete wound healing or complete 
union of the fracture had occurred. There was, however, general agreement 
in the theater that, in terms of wound healing and in the maintenance of satis- 
factory reduction of fractures until union was in progress, the reparative sur- 
gery of compound fractures of the humerus had produced excellent results. 
In many cases, wound healing was complete within 3 weeks of wounding, and 
in many others it was complete at this time except for small areas of granula- 
tion. It appeared that, if the plastic and other procedures necessary to achieve 
skin coverage had been correctly performed, only sequestrating bone retarded 
wound healing. 
An analysis of the 147 cases treated at the 33d General Hospital2 provides 
support for these generalizations. They were classified as follows; 
27 cases with massive soft-tissue destruction and, in most instances, severe 
bone comminution (group A). 
69 cases with moderate soft-tissue damage and severe comminution of 
bone (group B). 
51 cases with minimal soft-tissue damage and minimal comminution of 
bone (group C). 
Treatment was regarded as successful in these cases if the wound was 
completely healed or if only small areas of healthy granulation tissue were 
present, so that the fracture site was well sealed off . Fracture management was 
regarded as successful if adequate apposition and alinement of fragments were 
maintained until union had occurred or until the patient was transferred to 
the Zone of Interior. Management was regarded as unsuccessful (1) if the 
fracture site was not sealed off and there was a sinus or opening wound leading 
to it and (2) if satisfactory reduction of the fracture was not maintained under 
the circumstances just described. Classification of results as unsuccessful be- 
cause of a persisting sinus to bone set rather rigid qualifications for wound 
healing, particularly in comminuted fractures, in which many bone fragments 
are partially denuded at wounding and therefore are potential sequestra. The 
2 A total of 151 cases were treated at the 33d General Hospital, but 4 cases were omitted from the analysis, 2 in which 
amputation was necessary because of circulatory gangrene, and 2 others in which no followup could be secured. REGIONAL COMPOUND FRACTURES 
131 
data available in the series of compound fractures of the humerus analyzed 
from the 33d General Hospital (tables 4, 5, and 6) deserve certain brief comments. 
The results were tabulated from the standpoint of wound revision as the 
first step of reparative surgery because they improved as time passed and 
revision of the wound became more complete. Early in the experience, the 
depths of the wound, including the fracture site, were not routinely exposed. 
Table 4.—Residts in relation to procedure and wound healing in 147 compound fractures of 
the humerus treated at the 33d General Hospital 1944~4& 
Procedure 
Successful1 
Unsuccessful1 
Group 
A 
Group 
B 
Group 
C 
Total 
Group 
A 
Group 
B 
Group 
C 
Total 
Wound re'vision: 
Complete _ _ _ 
Incomplete _ _ 
22 
51 
10 
29 
18 
102 
28 
4 
1 
2 
5 
1 
6 
7 
T otal 
22 
61 
47 
2 130 
5 
7 
1 
13 
Technique of closure: 
Suture 
18 
4 
59 
1 
2 
47 
124 
5 
5 
4 
6 
1 
11 
Partial suture 
3 
1 
1 
2 
Total . * 
22 
62 
50 
134 
5 
7 
1 
13 
1 See text, p. 130, for code. 
2 The details of wound revision were unknown in 4 cases. 
Table 5.—Results in relation to technique and status of fracture in 147 compound fractures of 
the humerus treated at the 33d General Hospital 1944~45 
Technique 
Successful1 
Unsuccessful1 
Group 
A 
Group 
B 
Group 
C 
Total 
Group 
A 
Group 
B 
Group 
C 
Total 
6 
12 
1 
6 
2 1 
24 
23 
2 
11 
2 
11 
27 
9 
4 
41 
62 
12 
21 
3 
4 
3 
4 
3 
Other plaster immobilization 
Internal fixation and plaster 
1 
1 
Total 
26 
62 
51 
139 
1 
7 
8 
1 See text, p. 130, for code. 
2 While it is known that union was delayed in this case, reduction was adequate. 132 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Table 6 .—Results in relation to wound healing and status of fracture in 147 compound fractures 
of the humerus treated at the 33d General Hospital 1944~45 
Results 1 
Group A 
Group B 
Group C 
Total 
Successful wound healing and fracture management. 
Successful wound healing, unsuccessful fracture 
management 
22 
57 
5 
50 
129 
5 
10 
Unsuccessful wound healing, successful fracture 
management 
4 
5 
1 
Unsuccessful wound healing and fracture manage- 
ment _ _ 
1 
2 
3 
Total - _ _ _ _ 
27 
69 
51 
147 
1 See text, p. 130, for code. 
Totally detached bone fragments and dead tissue were therefore left in situ 
in many cases. At this time, revision was limited to the trimming of tags of 
devitalized tissue along the wound edge. Later, the importance of insuring 
that the wound was free of all devitalized tissue before repair was undertaken 
became generally recognized. It then became routine to expose the depths 
of the wound by gentle retraction, evacuate old blood clot, and excise necrotic 
tissue and bone fragments totally devoid of soft-tissue attachment. Consider- 
ably better results were produced under this new policy (table 4). 
In 5 of 13 wounds in which healing was classified as unsatisfactory, a 
typical osteomyelitis was present, of the type frequently seen in battle-incurred 
fractures and always characterized by heavy drainage and rather extensive 
sequestration. Union is known to have occurred in some of these cases in 
spite of these unfavorable circumstances. 
Some information is available from other hospitals to supplement the 
material presented in these tables from the 33d General Hospital. It is known, 
for instance, that in 112 of the 128 compound fractures treated while the 21st 
General Hospital was functioning in the hospital center at Naples, the wounds 
were completely healed or almost completely healed when the patients were 
evacuated to the Zone of Interior. 
In 116 cases managed at the 300th General Hospital, later information 
showed that, when the patients were considered ready for evacuation to the 
United States 90 to 120 days after wounding, complete healing had occurred 
in 94 cases, and in 11 others, while there were some areas of granulation, there 
was no opening to the fracture site. In nine cases, there were sinuses to the 
bone, and there were two instances of osteomyelitis, in both of which the frac- 
ture site was infected and sequestration was occurring. 
Since the combined bone-nerve reparative regimen placed emphasis on 
early wound healing, so that nerve suture might be performed through a clean 
surgical approach within 3 to 4 weeks after healing, information concerning REGIONAL COMPOUND FRACTURES 
133 
this point is of interest. In the 116 cases for which information is available 
in the series from the 300th General Hospital, 30 of the wounds (26 percent) 
were healed within 3 weeks, and 41 others (35 percent) within a total of 4 weeks. 
Sixty-one percent of the wounds were thus healed within the optimal time for 
nerve suture. Eight other wounds were healed within 5 weeks, but no infor- 
mation is available for the remaining cases. 
COMPOUND FRACTURES OF THE RADIUS AND ULNA 
The statistical material on compound fractures of the bones of the forearm 
is based on the following surveys: 
243 compound fractures—112 of the radius, 97 of the ulna, and 34 of both 
bones observed at the 21st General Hospital in Italy and later in Europe during 
late 1944 and 1945. 
272 compound fractures—113 of the radius, 107 of the ulna, and 52 of 
both bones, analyzed from the 1944-45 disposition-board proceedings at the 
300th General Hospital in the Mediterranean theater. 
319 compound fractures—136 of the radius, 124 of the ulna, and 59 of 
both bones, treated at the 45th General Hospital. Both the 1944 and 1945 ad- 
missions are included in this series. 
This makes a total of 834 compound fractures of the bones of the forearm— 
361 of the radius, 328 of the ulna, and 145 of both bones. Not all data are 
available in all series. 
Wound management in compound fractures of the bones of the forearm 
followed the principles generally employed in reparative surgery. The tech- 
nique varied, for anatomic reasons, according to the portion of the forearm in 
which the fracture was located. Although the structures of the upper half of 
the forearm are more tendinous than those of the upper arm, no special diffi- 
culties were usually encountered in that area. As the wrist is approached, 
muscle is replaced by fascia and tendon, both of which are structures with 
little power to resist infection, because of their poor blood supply. For these 
reasons, wounds in this area were sometimes necrotic and sloughing when the 
patients reached the general hospital. Closure could not be considered in 
such cases until after further exicisional surgery, and closure frequently 
required split-thickness skin grafts or sliding or advancement of skin flaps. 
Fracture management.—Fractures of a single bone usually presented no 
problem in fracture management, for, just as in fractures of a single bone of the 
leg, the intact bone served as a splint for the fractured bone, and displacement 
was seldom significant. Procedures to achieve reduction were necessary only 
in fractures about the joints and in an occasional instance of narrowing of the 
interosseous space. In the 209 compound fractures of the radius or of the ulna 
observed at the 21st General Hospital, cast immobilization, with no effort at 
further reduction, was all that was necessary in 190. This was a typical ex- 
perience. 134 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Fractures involving the olecranon process required anatomic reduction 
and fixation to restore joint congruity. Wire-suture fixation was often useful. 
Fractures of the head of the radius were best managed by excision of the 
comminuted fragments. This procedure removed a potential nidus of infection 
and eliminated a handicap to future function of the elbow. 
Fractures of both bones of the forearm in the upper third often presented 
problems in the maintenance of reduction (fig. 49). When soft tissue was 
available for early wound healing, it was often a good plan to place a long plate 
on the ulna, to serve as a strut for the comminuted fragments, as well as to 
maintain length and alinement in the injured bones. This was not always 
possible, however. The subcutaneous position of the ulna often created difficul- 
ties in wound healing when only skin was available for coverage of the bone and 
metal. In spite of these problems, repair of soft parts of the upper forearm 
was usually successful if excisional surgery was complete and soft-tissue loss 
was not excessive. 
If the contour of the fracture permitted rigid stabilization of both bones 
and if soft parts for adequate coverage were available, stabilization by multiple 
screws or plates was often useful. This procedure accomplished anatomic 
reduction, avoided encroachment of the bones on the interosseous space, and 
permitted earlier pronation and supination. 
In comminuted fractures of both bones without bone loss, skeletal traction 
with a wire through the distal ends was occasionally used to accomplish adequate 
reduction. 
In comminuted fractures of both bones with bone loss, internal fixation, 
usually by wire sutures, was used to approximate the fragments. Comminuted 
fragments of one bone were occasionally removed to permit approximation of 
the fractured ends of the other. As a rule, however, this was not advisable 
because of the successes attained in bridging defects with bone grafts at recon- 
structive surgery. 
In the distal portion of the forearm, because of the relatively superficial 
position of the bones, internal fixation by plating was performed only on special 
indications (fig. 50). It was essential that sufficient soft tissue be available for 
closure. 
Combined bone-nerve injuries.—Peripheral-nerve injury was almost as 
common in wounds of the forearm as in wounds of the arm. In the 243 fractures 
observed at the 21st General Hospital, the radial nerve was injured 28 times, the 
ulnar 32 times, and the median 25 times, a total incidence of more than a third. 
Nerve lesions in the forearm were more often incomplete than in similar lesions 
in the upper arm. 
All 28 of the radial injuries just mentioned occurred in the upper forearm, 
in which combined nerve and bone operations are likely to be technically 
difficult if not entirely impractical. In these cases, approximation of the nerve 
ends was frequently of less importance because the principal deficit could be 
overcome later by some reconstructive procedure at the wrist, usually a tendon 
transplant or a fusion operation. Repair of the median and ulnar nerves was, REGIONAL COMPOUND FRACTURES 
135 
U. S. Army photos 
Figure 49.—Unsuccessful management of compound comminuted fracture of upper third 
of right radius (head) and ulna (just distal to coronoid process). Anteroposterior and 
lateral roentgenograms of fractures after incomplete manipulative reduction at reparative 
surgery in general hospital. Note angulation of ulna and loose fragments of radius. 
The fracture united in this position, and 6 months after wounding rotation was almost 
nil and elbow motion was limited to 10° to 15°. 
In this case, the wound healed satisfactorily, but osteotomy was eventually necessary to 
correct the malunion of the ulnar fracture. If the loose fragments of the upper radius had 
been removed and the ulna plated in good alinement at reparative surgery, prompt healing 
could have been anticipated, for skin and soft parts were available for a satisfactory wound 
closure. This procedure would have permitted reasonably early elbow motion and would 
probably have produced an improvement in the end result. 
however, a matter of paramount importance, and in this series from the 21st 
General Hospital the bony structure was deliberately shortened five times, and 
the fractures were plated to facilitate later nerve suture. None of the bone 
defects thus created exceeded 3 cm. 
Nerve and tendon operations in the lower forearm were always performed 
in the Zone of Interior. 
Results.—Although no statistical data were available on the results accom- 
plished in reparative surgery of compound fractures of the forearm, it was 
generally acknowledged that neither the healing of compounding wounds nor 
the reduction of fractures was as satisfactory as corresponding results in com- 
pound fractures of the humerus. For this, there were a number of explanations, 
including the exposed position of fracture sites in the ulna, the abundance of 
poorly vascularized fascial and tendinous structures in the distal portion of the 
forearm, and the paucity of well-vascularized soft tissue in this area. 136 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP (O’Reilly GH) 4071-4074 
Figure 50.—Management of compound comminuted fracture of distal third of left radius 
and ulna by delayed internal fixation. Reparative surgery, 11 days after wounding, 
consisted only of manipulative reduction of the fractures and partial wound closure. 
The wound healed only in part, and necrotic bone presented through an opening in it. 
A. Anteroposterior and lateral roentgenograms of fractures of radius and ulna 1 month 
after unsuccessful manipulative reduction. Note poor alinement of fractures and de- 
struction of bone. B. Anteroposterior roentgenogram showing same fractures 3]i months 
after wounding and 5 weeks after they had been plated in reduction. Apposition and 
alinement are now good. The shortening from necrosis and bone loss was about 3 
inches. C. Lateral roentgenogram taken at same time as view B. D. Anteroposterior 
and lateral roentgenograms 6 months after fractures had been plated. Removal of 
sequestra and metal was necessary to accomplish wound healing. 
In this case, failure to achieve adequate reduction and wound healing after the first 
operation of reparative surgery indicated the necessity for additional surgery long before it 
was performed. In spite of the delay, however, and the infection, correct reparative surgery 
was eventually responsible for an excellent result. (This case was managed at the 300th 
General Hospital by Maj. Spencer A. Collom, Jr., MC.) REGIONAL COMPOUND FRACTURES 
137 
Although results in compound fractures of the forearm were not as good as 
those obtained in similar injuries of the upper arm, later results were known to 
be far superior to those obtained before the program of reparative surgery 
was introduced in the Mediterranean theater. It is known, for instance, that 
84 of the 319 soldiers treated at the 45th General Hospital (approximately 26 
percent) were returned to duty within the 90- to 120-day holding period in this 
theater. These are excellent results, and there is no reason to believe that they 
were not generally duplicated. 
CONCLUSIONS 
As this limited analysis has shown, the objectives of reparative surgery in 
compound fractures of the humerus and the bones of the forearm (minimal 
infection, optimal fracture reduction, early wound healing, maximal functional 
recovery) were apparently achieved in a large proportion of these injuries. In 
many of the casualties, the additional reconstructive surgery which would have 
been necessary under the old plan of management was not necessary under the 
new plan. In other cases, the reconstructive phase of surgery was expedited, 
and the necessity for multiple operations was decreased. The mission of over- 
seas surgery was thus largely accomplished in battle-incurred compound frac- 
tures of the upper extremity managed in the Mediterranean Theater of Opera- 
tions. 
Part II. Compound Fractures of the Femur 
GENERAL CONSIDERATIONS 
According to the machine records of the Mediterranean Theater of Opera- 
tions as they were available for examination in July and August 1945, fractures 
of the femur made up 12.7 percent of the principal diagnoses of battle fractures 
at the time of dispositions by the various general hospitals in the theater. This 
is in general agreement with the experience of the 45th General Hospital in the 
year 1944, which can be assumed to be representative. In that year, fractures 
of the femur accounted for 11.3 percent of all compound fractures managed on 
the orthopedic section of this hospital. When only compound fractures of the 
extremities were considered, the incidence increased to 12.6 percent. When 
fractures of the bones of the hand and the foot were excluded, the incidence of 
compound fractures of the femur rose to 19.2 percent. 
In World War II, just as in World War I, a battle-incurred compound 
fracture of the femur was properly regarded as one of the most serious skeletal 
injuries which a soldier could sustain. In World War I, there were 971 deaths 
3 The statistical data in this section were collected by Capt. John J. Modlin, MC, Maj. Joe M. Parker, MC, and Capt. 
Russell J. Crider, MC, 21st General Hospital; Col. Francis J. Cox, MC, 24th General Hospital; Maj. William R. Ferguson, 
MC, 33d General Hospital: Maj. Irvin Cahen, MC, 64th General Hospital; Maj. Spencer A. Collom, Jr., MC, and Maj. 
William M. Ewing, MC, 300th General Hospital; Maj. Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, MC, 
23d General Hospital; and Lt. Col. George A. Duncan, MC, 45th General Hospital. 138 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
(25.2 percent) in the 3,850 recorded femoral fractures.4 These fractures con- 
stituted 23.6 percent of all recorded battle fractures (16,339). In a study made 
in Fifth U. S. Army mobile hospitals in 1945, 114 of the 1,450 deaths (including 
deaths on arrival) (7.9 percent) were attributed to compound fractures of the 
lower extremity. It seems fair to assume that the great majority of these in- 
juries were fractures of the femur. The World War II figures do not include 
traumatic amputations of the thigh, which may have been included in the 
figures for World War I. 
Compound fractures of the femur furnished major problems in both forward 
and fixed hospitals. Considerable time and effort were required for their man- 
agement; in view of their frequency, this was a very practical consideration in 
overseas hospitals. In forward hospitals, even when experienced surgeons were 
in charge, 2 hours was regarded as acceptable operating time for initial surgery, 
counting from the time the wounded man was placed on the operating table until 
the transportation spica was applied. 
Large amounts of blood had usually been lost in compound fractures of the 
femur, and shock was correspondingly severe. Massive transfusions were neces- 
sary for resuscitation in evacuation hospitals, as well as for protection during 
initial wound surgery. In 100 consecutive compound fractures of the femur 
managed at the 16th Evacuation Hospital, 28 patients required from 1,500 to 
2,000 cc. of whole blood before and during the operative procedure (p. 68). 
Large quantities of blood were also required in preparation of these patients 
for reparative surgery at general hospitals. In 50 casualties received at the 23d 
General Hospital from evacuation hospitals on the Anzio beachhead, the 
hematocrit reading was under 30 in 38 cases. In another group of 242 casualties 
received at the 21st General Hospital, the great majority had to be given 2,000 
cc. or more of blood before the hematocrit reached 40, the desirable preoperative 
minimum. Fifty-three casualties treated at the 300th General Hospital re- 
quired an average amount of 1,900 cc. of blood during the preoperative and post- 
operative periods. 
Even in civilian practice, simple fractures of the femur may be difficult to 
manage. Battle fractures were often severely comminuted and were compli- 
cated by one or more large compounding wounds. If infection had become 
established, additional problems were introduced. Erosion of a femoral artery 
was always a possibility in such cases, and amputation occasionally had to be 
considered for lifesaving reasons. Battle fractures, therefore, presented exceed- 
ingly difficult problems of management. Even seasoned ward surgeons were 
overtaxed and exhausted by the long hours of work required later in the care of 
these patients on the wards. Carelessness in any regard could result in loss of 
reduction or in retardation or failure of wound healing. 
The wards devoted to fractures of the femur, with their forests of Balkan 
frames and their mazes of splints, ropes, pulleys, and weights, were, however, 
among the most interesting in the hospital. Fractures of the femur were of 
4 Walker, John B.: End Results, Fractures of Long Bones. In The Medical Department of the United States Army 
in the World War. Washington; Government Printing Office, 1927, vol. XI, pt. 1, pp. 491-547. REGIONAL COMPOUND FRACTURES 
139 
special interest for another reason: this was the one type of fracture held long 
enough in a theater of operations to permit evaluation of the union of the frac- 
ture and healing of the compounding wound. 
SURVEY OF RESULTS, SPRING, 1944 
Balanced-suspension skeletal traction was from the beginning the standard 
method of management of femoral fractures in the general and station hospitals 
of the Mediterranean theater. In a few instances, only a plaster hip spica was 
used, but this was unusual. 
The results obtained by these techniques during 1943 and the first months of 
1944, although relatively satisfactory, were regarded as less than optimum in 
many instances. Adequate reduction was usually secured with skeletal trac- 
tion, but it was frequently not ideal, and the alinement obtained in fractures of 
both the upper and lower third of the femur often left much to be desired. While 
healing of the compounding wounds by granulation eventually occurred in the 
majority of cases, the process was undesirably slow and often was attended with 
heavy scar formation. The incidence of deep-seated abscesses in the posterior 
fascial planes was not unduly high, though it increased early in 1944, during the 
attacks on Cassino and at the Anzio beachhead. It was generally observed that 
infection was most frequent when the fracture had not been reduced or well 
immobilized or had been distracted and when repeated manipulations had been 
undertaken to correct these errors. It was often difficult to maintain reduction 
while the necessary dressing of large compounding wounds was carried out. 
The location, magnitude, and condition of these wounds complicated the man- 
agement of the fracture and played a part in the establishment of infection. 
During April and May 1944, a survey of fractures of the femur was con- 
ducted in six general hospitals and in a station hospital which was then serving 
as a general hospital in the Naples area, in order to appraise the results of the 
methods of management employed before the regimen of reparative surgery had 
been instituted. All of the soldiers studied had been wounded at least 50 clays 
earlier, during the mountain and beachhead fighting in Italy in January, Feb- 
ruary, and March. They had been cared for under relatively adverse conditions, 
in overcrowded field and evacuation hospitals which were exposed to enemy 
artillery fire, including that of the “Anzio Annie” railroad gun. Many had been 
evacuated over water. They had then been treated in crowded general hospitals, 
some of which were staffed by surgeons relatively inexperienced in military sur- 
gery. During this period, the incidence of clostridial myositis reached its 
height in the Mediterranean theater, and the hazard of this complication was 
added to the other problems of fractures ol the femur. 
A total of 235 patients with fractures of the femur was included in the 
survey. Three (1.3 percent) died after admission to general hospitals, and 
amputation was required in two other cases (0.85 percent). 
In the remaining 230 cases, adequate reduction had usually been achieved, 
though the position was not optimal in certain subtrochanteric fractures, 140 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
fractures of the distal third, and fractures characterized by loss of bone sub- 
stance. In some cases, the use of the flexed knee position and of tight popliteal 
slings for fractures of the lower third of the femur had given rise to such com- 
plications as skin irritations; thrombophlebitis; and inability to extend the 
knee after the fracture had united, because of prolonged stretch of the quad- 
riceps muscle. On the whole, the methods employed had not been conducive 
to early, maximum return of motion in the knee joint. This was partly be- 
cause of prolonged knee flexion, partly because of heavy scarring in the thigh, 
and partly because quadriceps and knee exercises had been inadequate. 
Forty-two cases (17.9 percent of the total 235 cases) were either infected 
at the time of the survey or had been considered infected between the 30th 
and 50th days after wounding. This number included three cases complicated 
by clostridial myositis, which in each instance had appeared soon after the 
patients reached the general hospital. Criteria of infection were purulent 
exudate draining copiously from the fracture site; purulent collections in fascial 
planes; or daily temperature elevations, usually to 101° F. or over, with malaise, 
anemia, and other evidences of toxemia. At the time of the survey, sinuses to 
the fracture site were present in 23 cases. 
In each of the 42 infected cases, the infectious process had been managed 
by apparently adequate drainage. The fact that sinuses to the fracture site 
were present in only 23 cases 50 days or more after wounding was taken to 
mean that in the 19 other cases infection had been controlled and that the fracture 
site had been sealed off by the healing process. Unfortunately, no data were 
collected on the number of completely healed wounds, chiefly because the 
objective of the survey was an investigation (1) of the incidence of infection 
involving fracture sites and (2) of the sequelae of infection. 
The survey of these 235 compound fractures of the femur led to the 
following conclusions: 
1. In the light of the severity of these battle-incurred injuries, it was 
scarcely to be expected that the proportion of either deaths or amputations 
could be materially reduced below the present levels. 
2. The incidence of infection was relatively low, as was the incidence of 
sinuses to the bones, but further improvement in both respects seemed possible. 
3. Better reduction in so-called problem fractures seemed possible of 
achievement, as well as faster healing of compounding wounds, with minimal 
scar formation. 
4. Improvement in the range of knee motion and in quadriceps-muscle 
tone seemed possible if more active attention were devoted to both points. 
SOURCE MATERIAL 
The observations in the remainder of this chapter were either made per- 
sonally or were derived from reports submitted by the chiefs of orthopedic 
sections of various general hospitals in Italy, as follows: 
164 compound fractures of the femur treated at the 24th and 64th General REGIONAL COMPOUND FRACTURES 
141 
Hospitals, plus 535 additional cases studied from the proceedings of disposition 
boards on file in the Office of the Surgeon. This is a total of 699 cases (series A). 
482 compound fractures of the femur treated at the 21st, 33d, and 300th 
General Hospitals (series B). 
Not all data were available in all cases. 
High-explosive shells and mine fragments accounted for the injury in 464 
of the 699 cases in series A. Small-arms lire accounted for 222 cases (32 per- 
cent), and accidental causes for the remainder. The proportion of injuries 
attributable to small-arms fire in this combined series is somewhat higher than 
the proportion estimated for battle wounds in general. 
The location of the femoral fracture in the 1,181 cases making up series 
A and B was the proximal third in 331 cases (28 percent), the middle third in 
466 cases (39 percent), and the distal third in 384 cases (33 percent). There 
was thus no great variation in the involvement of the various levels of the bone. 
Since it is likely that fractures at the junction of the middle third with the 
upper or the lower segment were classified as fractures of the middle third, the 
chances are that each third of the bone was affected in almost equal degree. 
In the 535 compound fractures of the femoral shaft making up the dis- 
position boards’ material in series A, all but 8 of which were combat incurred, 
there were 41 injuries (7.7 percent) to the sciatic nerve or to the peroneal or 
the tibia! nerve below the bifurcation of the sciatic nerve. This was almost 
precisely the same as the 7.1-percent incidence in 133 compound fractures of 
the shaft included in series B, from the 33d General Hospital. In both series, 
some of the nerve injuries were incomplete. 
THE PROGRAM OF REPARATIVE SURGERY 
In spite of the usual severity of their wounds and the frequent necessity 
for a somewhat prolonged stay in forward hospitals after initial wound surgery, 
soldiers with fractures of the femur generally reached fixed hospitals in the 
rear within 5 or 6 days after wounding. Those with associated injuries of the 
abdomen, chest, or head usually did not become transportable as soon. The 
great majority of these patients, in spite of the intensive preoperative prepara- 
tion necessary, could usually he submitted to reparative surgery before the 10th 
day after wounding (the so-called golden period). In one group of 168 cases, 
for instance, 57 patients (34 percent) underwent reparative surgery on or be- 
fore the 7th day after wounding, and only 11.6 percent were not operated on 
until after the 10th day. 
Anatomic conditions and the conditions of the battle-incurred fracture 
and the compounding wound were both favorable and unfavorable for the 
application of the program of reparative surgery to the management of com- 
pound fractures of the femur. Favorable factors were as follows: 
1. The regional anatomy was generally favorable, there being a large 
amount of highly vascularized soft tissue in this region and only a small amount 
of easily exposed fascial and tendinous tissue. Fascia lata could therefore be 
396961°—57 11 142 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
partly excised without seriously affecting function. The heavy soft tissue of 
the thigh aided in the obliteration of the dead space by pressure dressings. 
Dependent drainage could be surgically established through posterior fascial 
planes if a posterior wound was not available. 
2. Loss of bone creating a complete segmental defect was uncommon in 
compound fractures of the femur. When there was partial bone loss, frag- 
ments of bone and periosteum left in situ appeared to have excellent powers of 
regeneration. 
3. If internal fixation was indicated, it was facilitated by the size of the 
femur, while the depth of the location of the bone made it certain that denuded 
bone and metal would be well covered by soft parts. 
4. Plastic procedures designed to accomplish wound healing were facilitated 
by the abundant, loose skin of the thigh. 
Against these favorable factors were the following unfavorable circum- 
stances ; 
1. Missiles frequently followed paths through the thigh that, because of 
difficulties of operative position and approach, made them relatively inaccessi- 
ble. Anatomic considerations made deep exposure of the thigh difficult. As 
a result, even after what seemed adequate initial surgery, some devitalized 
tissue almost invariably remained in the wound. 
2. The extensive intermuscular fascial planes of the posterior thigh per- 
mitted proximal gravitation of purulent exudate. 
3. Although immobilization was essential in the management of the 
femoral fracture, it prejudiced the ultimate range of knee motion. Knee 
function is an important criterion in the evaluation of end results, and from this 
standpoint the results achieved in femoral fractures were sometimes less than 
optimal. 
TECHNICAL CONSIDERATIONS 
The surgery of battle-incurred compound fractures of the femur followed 
closely the general pattern for the reparative surgery of compound fractures 
(p. 83). With the soldier anesthetized, the transportation splinting provided 
by the forward hospital after initial surgery (usually a 1% hip spica but occa- 
sionally a Tobruk splint) was removed in the operating room. A Kirschner 
wire was inserted in the lower femur or proximal tibia, its location being deter- 
mined by the level of the fracture and the site of the wounds. The extremity 
was then placed in the 90-90-90 position (fig. 51). This operative position, 
developed by Maj. Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, 
MC, at the 23d General Hospital, was invaluable for reparative surgery of 
battle fractures of the femur. It permitted free circumferential access to the 
thigh and also provided adjustable balanced skeletal traction as an aid to 
operative reduction of the fracture. 
The depths of the wound and the fracture sites were exposed by gentle 
retraction. Old blood clot, residual devitalized tissue, and totally free bone 
fragments were removed. REGIONAL COMPOUND FRACTURES 
143 
AFIP CC-44-50 
Figure 51.—Suspension traction in 90-90-90 position for operation on com- 
pound fracture of femur. Kirschner wire shown in upper tibia may also 
be placed in lower femur. If skeletal traction is not feasible the same 
position may be maintained by the use of slings under the leg. The 
90-90-90 position is an excellent operative position for reparative surgery 
in injuries of the thigh and femur, since it provides full circumferential 
access to the part. 
A study of the fracture contour by direct vision, together with a study of 
the roentgenograms, determined whether some form of internal fixation should 
be employed or whether skeletal traction alone should be depended upon to 
achieve reduction of the fracture. 
Internal Fixation 
The contour of only a minority of the fractures of the femur permitted the 
effective use of internal fixation. In the majority of cases, therefore, balanced- 
suspension skeletal traction was the method employed for fracture reduction 
(figs. 33 and 35). When internal fixation was applicable, it was performed 
through the compounding wound only if adequate access to the fracture site 
was permitted (figs. 31 and 35). The standard anterolateral approach wTas 
sometimes used but, more frequently, the posterolateral fascial plane was 
selected (figs. 52 and 34). This plane was considered advantageous because 
it gave excellent exposure of the shaft of the femur and it could be used for 
dependent drainage. Moreover, the trauma of the operative procedure was 
posterior to the bone, and the products of the resulting devitalized tissue were 
therefore easily drained away. 144 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 52.—Management of compound oblique fracture of upper third of right femur by 
delayed internal fixation, with staged closure of wounds. This patient received initial 
surgery 7% hours after wounding, but reparative surgery in the general hospital was 
delayed until 19 days after wounding because he was afebrile and because of the heavy 
load of casualties, many of whom required both initial and reparative surgery. A. Ap- 
pearance of old compounding wound at reparative surgery 19 days after wounding. 
B. Appearance of limb at completion of reparative surgery. The old compounding 
wound has been excised. Internal fixation by multiple screws was carried out through 
the posterolateral surgical incision. Both wounds were left open. C. Roentgenograms 
before and after internal fixation. The preoperative roentgenograms were made soon 
after initial surgery, 19 days before the second operation, and do not demonstrate the 
shortening (1*4 inches) which was evident at reparative surgery and which was the 
indication for internal fixation. D. Partial closure of wounds 7 days after reparative 
surgery. Each wound has been drained separately; these are not through-and-through 
drains. E. Appearance of wounds 6 weeks after wounding and 3 weeks after partial 
staged closure. Although both are almost completely healed at this time, drainage 
later recurred from the compounding (lateral) wound. 
AFIP Fd-446, Fd-44-65 REGIONAL COMPOUND FRACTURES 
145 
AFIP 3773, 3772, 3809, 3810, 3808, 3807 
Figure 52—Continued. F. Anteroposterior roentgenogram showing united fracture 6 
months after wounding. Note absorption about two lower screws. G. Lateral roent- 
genogram taken at same time as view F. Note sequestrum. H. Anteroposterior 
roentgenogram after removal of metal and sequestra 8 months after wounding. I. 
Lateral roentgenogram taken at same time as view H. In this view, the defect from 
sequestration on the posterior surface of the femur is clearly shown. J. Solidly healed 
wounds 4 weeks after removal of metal and sequestrum. K. Range of knee motion 9 
months after wounding. The reparative surgery performed on this patient, although 
unavoidably delayed, followed eminently sound principles. If traction alone had been 
employed, shortening would almost certainly have resulted. The trauma of internal 
fixation and the creation of additional devitalized tissue at the first operation of repara- 
tive surgery were sound indications for provision of drainage through the two open 
wounds and for their staged closure. The prompt healing which followed removal of 
the metal and sequestra was typical of many cases of this kind. (The case was managed 
by Lt. Col. Roderick E. Begg, MC, and Capt. John E. Manning, MC, at the 46th 
General Hospital.) 146 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The objections to the periosteal stripping necessary in internal fixation were 
well recognized. On the other hand, the highly vascularized muscular bundles 
surrounding the femur favored the early reattachment of soft parts to the 
denuded bone, and there was little hesitancy in performing the stripping 
required when internal fixation appeared to be useful. Multiple screws were 
employed in the relatively few fractures with an obliquity permitting stable 
fixation (figs. 31 and 35). In a larger group, plating, often augmented by 
additional screws, provided stable fixation (fig. 39). A stabilized internal 
fixation was considered advantageous for a number of reasons: (1) Optimal 
reduction of the fracture was assured; (2) subsequent wound care was facil- 
itated; (3) earlier, intensive exercises for the knee joint were possible; and (4) 
the patient could be transported to the Zone of Interior at an early date, 
without fear of loss of apposition or of alinement of the fracture. Condylar 
fractures of the femur were preferably fixed internally to restore joint con- 
gruity and to maintain reduction during early joint exercises (fig. 53). The 
advantages offered by a stabilizing internal fixation thus appeared to out- 
weigh the disadvantages of additional trauma within the wound and the neces- 
sary denudation of bone. 
In severely comminuted fractures, the judicious use of wire sutures allowed 
major fragments to be held in apposition. This type of fixation was particularly 
applicable in fractures with partial loss of substance. It was also valuable in 
some cases of established infection, in which it was recognized that periosteal 
stripping should be restricted. The following experiences proved these points; 
Capt. John J. Modlin, MC, at the 21st General Hospital, used wire-suture 
fixation in 33 of a series of 138 fractures of the femoral shaft. In this particular 
experience, the indications were broadened because of a heavy flow of casualties 
that made it impossible to render all of the necessary attention to details re- 
quired for the management of fractures of the femur in balanced skeletal 
traction. The wire sutures insured apposition of the fragments, and, even 
though the balanced-suspension skeletal traction could not be adequately 
adjusted during the first few days after operation to obtain good alinement, it 
was possible to correct the alinement later. Had apposition of the fragments 
not been maintained by the wire suture, it is doubtful that late reduction 
would have been possible. 
Maj. Irvin Cahen, MC, 64th General Hospital, reported that internal fixation 
was used as part of the first reparative operation in 14 of a series of 79 battle 
fractures of the femur. The fixation was obtained by plating in 8 cases, by 
multiple screws in 4, and by wire sutures in 2. 
In a followup study on delayed internal fixation of battle fractures in the 
Zone of Interior made by the theater consultant in orthopedic surgery (p. 189), 
it was found that the procedure had been performed at the first operation of 
reparative surgery in 93 (64 percent) of 146 fractures of the femur managed 
by this method. The fixation in this group was by plating in 41 cases (44 
percent), by multiple screws in 39 (42 percent), and by wire sutures in 13 (14 REGIONAL COMPOUND FRACTURES 
147 
U. S. Army photos 
Figure 53.—Internal fixation of displaced fracture of medial femoral condyle. A and B. 
Anteroposterior and lateral views of region of knee made in evacuation hospital. Note 
separation and rotation of medial femoral condyle. C and D. Similar views, 4 months 
later, showing fracture united in excellent position after internal fixation on 10th day 
after wounding. Note perfect preservation of contour of articular surface of lower end 
of femur. Fractures which disturb the relationship of articular surfaces of major 
joints, as in this injury, require that the fragments be maintained in precise reduction, 
and internal fixation, performed through the compounding wound at the first operation 
of reparative surgery, has a definite field of usefulness. (This patient was managed by 
Lt. Col. George A. Duncan, MC, and Maj. Benjamin W. Rawles, Jr., MC, at the 45th 
General Hospital.) 148 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
percent). The remaining fixations were performed after adequate reduction 
had not been achieved by skeletal traction. 
Wound Management 
After the method for maintaining fracture reduction had been determined 
and internal fixation, if it had been chosen, had been effected, drainage of 
residual dead space and wound closure were undertaken. Suture of the 
compounding and operative wounds was performed to the extent that was 
surgically feasible and was compatible with adequate drainage (figs. 31, 33, 34, 
and 35). These wounds were not sutured with the major objective of protec- 
tion of exposed bone. The objectives of wound closure in compound fractures 
of the femur were early wound healing and minimal scar formation, both of 
which have a beneficial effect on future function. 
Drainage.—It was considered important that some opening, preferably 
dependent, remain in the wound in most cases to provide a route of egress 
for the products of possible decomposition of residual devitalized tissue or 
blood clot. The necrotizing effect of purulent exudate deep in the thigh could 
thus be avoided. Only very occasionally was drainage omitted. 
If posterior wounds were present, they were used for drainage. Otherwise, 
the posterolateral fascial plane between the biceps femoris and the vastus 
lateralis was freely incised (figs. 52, 30, 34, and 35). This plane served well 
for drainage of compound fractures between the level of the base of the tro- 
chanter and the level just distal to the junction of the middle and lower thirds 
of the femur. In high fractures involving the trochanteric region, it was nec- 
essary to sever a portion of the gluteus maximus if dependent drainage was 
to be obtained and the hazard of a pocket of purulent exudate beneath this 
muscle was to be avoided. 
Dependent drainage in the distal third of the thigh was difficult unless a 
posterior wound was present. Maj. Herbert W. Harris, MC, at the 17th 
General Hospital, reported some success with a posterolateral incision supple- 
mented by a medial incision anterior to the hamstring muscles. Col. Francis 
J. Cox, MC, at the 24th General Hospital, considered drainage absolutely 
essential and established it in all cases. In his technique, the linea aspera was 
incised, so that there was free communication between a medial thigh space 
and the posterolateral fascial plane. Maj. Newton C. Mead, MC, at the 12th 
General Hospital, preferred direct posterior drainage through a channel passing 
between the hamstring groups to drainage through the posterolateral fascial 
plane. Fingertip dissection was used from the fracture site to the posterior 
skin, which was then incised. Damage to the sciatic nerve was thus avoided. 
In Mead’s experience, this method was effective and was not attended by 
complications. 
A posterolateral fasciotomy used for internal fixation was frequently 
left unsutured for a few days, in order to provide the free drainage permitted 
by an open wound. REGIONAL COMPOUND FRACTURES 
149 
While adequate drainage was considered indicated and important in all 
these injuries, it was of paramount importance in the presence of dirty wounds 
and established infection. If considerable dead tissue had been found (and 
excised) wound closure was postponed. In these cases, suture was often 
performed several days later, when the wounds were clinically clean. 
Postoperative Management 
The great majority of the patients with fractured femurs were placed 
in balanced-suspension skeletal traction immediately upon their return to the 
ward. This was true even of those whose fractures were stabilized in reduction 
by internal fixation, in order to facilitate the wound care and to permit an 
intensive program of knee-joint exercises. The Kirschner wire used in main- 
taining the operative position in the operating room usually sufficed for traction 
on the ward. If a different location appeared desirable, a new wire was inserted 
immediately. The theoretical objections to the location of the wire in either 
the lower femur or the tibia were disregarded, and the site was chosen that 
appeared to be the most effective for reduction of the fracture. In general, 
the lower femur was the location for the wire in fractures of the upper half 
of the bone and the tibia for fractures of the lower half. 
An important early development in the reparative surgery of compound 
fractures of the femur was the introduction of two-wire or double skeletal 
traction for fractures of the distal third of the femur (fig. 54). The tibial 
wire for longitudinal traction was supplemented by a femoral wire for vertical 
traction, which served to lift the ever-troublesome distal fragment into aline- 
ment. This simple method, developed by Captain Modlin and Major Cahen, 
at separate hospitals, went far to solve the problem presented by lower-third 
femoral fractures. 
Table 7 shows the location of the wires for traction in 613 compound 
fractures of the femur. These data do not include cases in which skeletal 
traction was used after internal fixation. 
Table 7.—Location of Kirschner wire for skeletal traction in 613 compound fractures of femur 
Source 
Proximal 
(femur) 
Distal 
(tibia) 
Femur 
and 
tibia 1 
Total 
21st General Hospital 
62 
88 
45 
195 
64th General Hospital 
16 
16 
12 
44 
Proceedings, disposition boards 2 
134 
205 
35 
374 
Total 
212 
309 
92 
613 
Percentage _ 
34. 6 
50. 4 
15. 0 
100. 0 
1 Two-wire technique. 
2 From files, Office of the Surgeon, Mediterranean Theater of Operations. 150 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 54.—Diagrammatic showing of two-wire skeletal traction 
for battle fracture of femur. A. Deformity on admission to fixed 
hospital. B. Incomplete reduction in skeletal traction with wire 
in tibial tubercle. C. Adequate reduction after additional wire 
has been inserted in lower femoral fragment and vertical lift 
has been secured. 
AFIP CB-44-55 
Technique of balanced-suspension skeletal traction.-—Four methods of 
balanced-suspension skeletal traction for fractures of the femur were used in 
the Mediterranean theater. Each offered certain advantages and disad- 
vantages. It was considered desirable that flexion of the knee be held to 15° 
or 20° in order to avoid continuing stretch on the quadriceps muscle, prevent 
fixation of the ligaments of the knee joint while the joint was in flexion, and 
facilitate quadriceps-setting exercises. The degree of flexion of the knee was 
therefore an important consideration in the selection of the method of balanced- 
suspension skeletal traction. 
The four techniques of balanced-suspension skeletal traction included— 
1. The Army half-ring splint with Pierson attachment (fig. 55). This 
method was applicable to fractures of the shaft requiring the pressure of a sling 
posteriorly as an aid in the maintenance of reduction. It was the preferable 
method of splinting for two-wire traction for fractures of the lower third of 
the femur. An outstanding advantage was that it permitted active and pas- 
sive knee motion with little or no strain at the fracture site. The principal REGIONAL COMPOUND FRACTURES 
151 
AFIP CC-44-48 
Figure 55.—Balanced-suspension skeletal traction by means of half-ring 
leg splint and Pierson attachment. Note balance as patient raises himself 
for bedpan. Knee flexion shown is more than advisable. 
disadvantages of the method were pressure of the ring on wounds high in the 
thigh and the inaccessibility of posterior wounds for necessary dressings. The 
pressure of the ring posteriorly could be avoided by placing it anteriorly. 
Major Mead made effective use of this modification of the method in fractures 
of the upper third of the femur with posterior wounds. Pressure of the ring 
on the anterior superior spine of the ilium was prevented by increasing the 
weight lifting the upper end of the splint. Access to posterior wounds was 
easier but still awkward. 
2. The Navy (Joldersma) method (fig. 56). This method was excellent 
for fractures of the upper third of the femur and could be used for the majority 
in the upper half. After the development of two-wire traction, it was used 
for some fractures of the lower third. The application of the original setup 
was cumbersome, but the modifications by Captain Modlin (fig. 57) and Major 
Albert O. Linch, MC (fig. 58), were excellent simplifications. The principal 
advantages offered by the Navy method of splinting were ready access to all 
surfaces of the thigh for subsequent wound care, the ease of nursing care, and 
the comfort experienced by the patient. 
The great disadvantage of the Navy method was that it did not permit 
knee-joint exercises. Therefore, after sufficient healing of the wound and for- 
mation of so-called chewing-gum callus formation at the fracture site, this 
method was preferably replaced by the Army half-ring splint with Pierson 
attachment. 152 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 56.—Navy traction for fracture of femur. A. The canvas sling around the posterior 
thigh is a standard part of the equipment supplied with a Balkan frame. A weight of 
only 3 or 4 pounds is sufficient to support the thigh. The excellent balance between the 
traction and the leg suspension maintains alinement, and elevation of the foot of the 
bed provides countertraction against the weight of the body. B. Details of leg suspension 
in Navy traction shown in view A. Canton flannel is applied over sheet wadding, each turn 
overlapping all but about one-quarter inch of the preceding turn. Internal or external 
rotation of the lower femoral fragment is obtained, in Navy parlance, by moving the 
pins “inboard” or “outboard.” The string, which is of smooth material, glides easily 
through the safety pins and rings on the crossboard. Note the excellent functional 
position of the foot. 
3. The 90-90-90 method (fig. 59). This method, developed by Maj. 
Benjamin E. Obletz, MC, and Maj. Joseph D. Godfrey, MC, at the 23d Gen- 
eral Hospital, and mentioned as an excellent operative position (p. 142), was 
sometimes used for fractures of the upper third of the femur. Its principal 
advantage was that, like the Navy method, it provided access to wounds high 
in the posterior thigh. Its outstanding disadvantage was the prolonged flexion 
of the knee to 90°. There was also danger of distraction. As a technique of 
balanced-suspension skeletal traction for compound fractures of the femur, the 
90-90-90 method had only a limited application. When it was used, it was 
preferably replaced by a conventional method after 2 or 3 weeks. As a rule, 
an orthopedic section did not use both the Navy method and 90-90-90 (ver- 
tical) traction, since the Navy setup appeared to offer all the advantages of 
the 90-90-90 method without its disadvantages. 
4. Russell traction. This method, which was used very occasionally for 
fractures of the upper third of the femur, offered no advantages over those 
already described. 
Captain Modlin and Capt. Russell J. Crider, MC, at the 21st General 
Hospital, in a series of 185 compound fractures of the femur, employed the 
Army half-ring splint with Pierson attachment in 107 cases (58 percent) and 
the Navy method in the remaining 78 cases (42 percent). Major Cahen, in REGIONAL COMPOUND FRACTURES 
153 
Figure 57.—Modlin modification of Navy 
traction for fracture of femur. Both the 
application and the removal of the whole 
setup are facilitated by the use of the 
canvas sling, and the patient is also kept 
more comfortable. Note the plasma tub- 
ing, extending from the clevis to the foot 
support, which maintains the foot at a 
right angle but still permits active 
motion in the ankle. 
AFIP C-44-363 
a smaller group of 45 fractures, used the former method in 26 cases, the latter 
in 17, and Russell traction in 2 cases. 
Quadriceps exercises and knee motion.—The early, definitive reduction 
of fractures of the femur after balanced traction was instituted was considered 
important in the prevention of deformity and sepsis. Repeated manipulations 
of the fractures and major adjustments of the traction setup were traumatizing 
to tissue and prejudicial to healing of the wounds. Quadriceps exercises and 
a program for knee motion were desirable as soon as the wounds had healed 
sufficiently and fracture reduction would not be disturbed. In internally 
stabilized fractures, these objectives could be accomplished about 10 or 12 
days after the operation. In fractures managed entirely by skeletal traction, 
exercises and movement were usually postponed until about 3 or 4 weeks after 
repair of the wound. 
Ideal program.—An ideal program for the management of femoral frac- 
tures in skeletal traction, developed by Captain Modlin at the 21st General 
Hospital in Naples, was as follows: 
The anesthesia provided for the surgery of the fracture and wound was 
continued on the ward while the balanced-suspension skeletal traction was set 
up. The fracture was manipulated into apposition and alinement, and the 
traction apparatus was adjusted to maintain the correct position. Roentgeno- 
grams were made immediately. If they showed that adequate reduction had 
not been achieved, the fracture was remanipulated, and the apparatus was ad- 
justed again. Adequate reduction was usually achieved by these procedures, 
but additional roentgenograms were made the following day, and, if needed, 
further adjustments of the traction apparatus were made. This routine was 
followed daily, if necessary, until satisfactory reduction had been achieved. 
Thereafter, each traction setup was inspected carefully several times each 
week, and checkup roentgenograms were made every 7 to 10 days. 
The patients were all placed on a high-protein, high-caloric diet. The 
hemoglobin, plasma-protein, and hematocrit values were checked at intervals 154 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 58.—Linch modification of Navy traction for 
fracture of femur. The cumbersome board and string of 
the original technique are replaced by multiple pulleys. 
A light metal splint can be substituted for the leather 
support. 
AFIP Fd-44-12 
of 3 or 4 days, and blood-replacement therapy was employed to correct 
deficits. 
A supervised program of quadriceps and knee bending exercises was begun 
at the earliest practical time. This was usually about 3 weeks after wounding. 
The physical therapists attached to the hospital visited the femur ward 3 times 
weekly to supervise the program, but exercise periods were conducted daily 
under the observation of the ward nurses. Competitive exercises among the 
soldiers with femoral fractures were helpful in stimulating interest. 
This regimen was observed to pay dividends in excellent fracture reduc- 
tions, minimal infection, and good knee motion. 
Duration of traction.—Skeletal traction for fractures of the femur was 
preferably maintained until after clinical stability had become evident and 
there was roentgenologic evidence of bony union of the fracture or, in the 
exceptional case, until hope of union in the theater had been abandoned. The 
usual time in traction for compound fractures of the upper and middle thirds 
of the femur was about 10 or 11 weeks, although when casualties were heavy 
the time in traction sometimes had to be shortened. Fractures in the lower 
third of the femur appeared to unite rapidly and usually required only 6 to 8 
weeks in traction. The longer period was considered absolutely necessary in 
fractures above this level, to avoid late angulation. The late weeks of traction 
were utilized to improve the range of knee motion. 
When sufficient union of the fracture had occurred to permit the discon- 
tinuance of the traction, a 1 % plaster hip spica extending only to the iliac 
crests was applied as transportation splinting for the transfer to the Zone of REGIONAL COMPOUND FRACTURES 
155 
U. S. Army photos 
Figure 59.—Skeletal traction by 90-90-90 suspension method for fracture of left femur. 
A. Traction applied. B. Same as view A. Note ease of access to high posterior 
wound of thigh. This position, because of its possible adverse effect on the knee, 
should not be maintained for more than 2 or 3 weeks. 
Interior. A followup study in the Zone of Interior in 1945 (p. 189) revealed 
instances of fractures of the femur which had been removed from traction 
before firm union and which had bowed during transportation in the cast. 
Several of these fractures had become fixed in angulation during that period. 
These observations were added evidence that a hip spica will not prevent 
angulation of a fracture of the femur and that a period of 10 to 12 weeks in 
traction is required for the majority of these injuries if the optimal result is 
to be achieved. 
Captain Modlin and Captain Crider at the 21st General Hospital reported 
that in 177 compound fractures of the femur observed at that hospital the 
average duration of skeletal traction was 12 weeks. Maj. William R. Ferguson, 
MC, at the 33d General Hospital, reported an average traction time of 90 days 
in 140 fractures. In the 535 fractures of the femur studied from the proceed- 
ings of disposition boards on file in the Office of the Surgeon, Mediterranean 
Theater of Operations, the average time in traction was only 8.6 weeks. It is 
known, however, that traction was prematurely discontinued in many of these 
cases because of the stress of heavy casualty loads. 
Other methods of fracture management.—A small but definite number of 
fractures of the femoral shaft were not adequately reduced in skeletal trac- 
tion. In these cases, if it appeared that satisfactory apposition and aline- 
ment could be achieved by an open reduction and internal fixation, the neces- 
sary surgery was carried out. Faulty reduction of the fractures was not 
accepted if it could be prevented by open reduction and internal fixation. 
Either the old compounding wound was reopened or a separate operative 
incision was made. The internal fixation and the subsequent management 
of the soft-part wound conformed to the basic principles already described. 
Ideally, of course, the compounding wounds were healed by the time 
that operative intervention for the unreduced fracture had been selected, so 156 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
that the operative procedure was carried out not on a fracture that was still 
compound but, in a restricted sense, on a simple fracture. The hazard of 
infection was therefore minimal. The unreduced fracture was, however, 
likely to be associated with an unhealed, draining compounding wound or 
wounds, and not infrequently definite wound infection was present. As a 
result, the majority of late internal fixations of fractures of the femur were 
performed in the presence of unhealed wounds. In the 146 internally fixed 
compound fractures of the femur surveyed in the Zone of Interior (p. 194), 
53 (36.3 percent) were performed at a secondary operation of reparative 
surgery. The compounding wounds were recorded as healed at the time of 
the fixation in only 5 cases (3.4 percent). They were unhealed in the remaining 
48 cases. 
Two other methods of managing these major skeletal injuries were used 
infrequently. One was immobilization in a plaster cast, the other, external 
fixation. 
Plaster hip spicas (usually the 1% spica, though in one hospital a complete 
double spica was used) were employed in a few selected cases in which appo- 
sition and alinement were excellent on admission. Bone loss, in which dis- 
traction of fragments was feared if traction were employed, formed another 
indication for the application of a plaster hip spica. Several surgeons in the 
theater preferred the hip spica for fractures associated with a well-drained 
established infection. Occasionally, heavy casualties and a demand for hos- 
pital beds influenced the adoption of the plaster spica as the method of frac- 
ture management because it permitted early transfer to the Zone of Interior. 
In spite of the usefulness of the plaster hip spica in occasional special 
cases, observations over the theater led to the conclusion that balanced- 
suspension skeletal traction, with or without internal fixation, was the prefer- 
able method of management in the overwhelming majority of compound 
fractures of the femur. 
External skeletal fixation was not a popular method. In the series 
analyzed, it was employed only 19 times (table 8). 
Distribution of Methods of Fracture Management 
Table 8 shows the methods of fracture management used in the several 
series forming the basis of this study. Although skeletal traction was em- 
ployed after the great majority of internal fixations, the data for this technique 
include only cases in which skeletal traction was used without internal fixation. 
Table 9 shows the type of metallic internal fixation employed in 284 cases 
in these series. The 21st General Hospital series is unusual in that 40 of 74 
internal fixations of fractures of the femur (54 percent) were performed with 
wire sutures. This relatively high incidence has already been explained (p. 
146). The 24th General Hospital also employed wire-suture fixation in a high 
percentage of cases. REGIONAL COMPOUND FRACTURES 
157 
Table 8.—Selection of methods of fracture management in 1,063 compound fractures of 
femoral shaft 
Source 
Skeletal 
traction 
Internal 
fixation 
Plaster 
cast only 
Russell 
traction 
External 
skeletal 
fixation 
Total 
21st General Hospital 
152 
74 
226 
24th General Hospital - 
48 
27 
4 
1 
80 
33d General Hospital 
112 
22 
9 
143 
64th General Hospital 
43 
34 
2 
79 
Proceedings, disposition boards 
325 
149 
52 
9 
535 
Total - _ . , 
680 
306 
56 
2 
19 
1. 063 
Percentage, 
64 
28. 8 
5. 2 
. 2 
1. 8 
100 
1 From flies, Office of the Surgeon, Mediterranean Theater of Operations. 
Table 9.— Techniques of internal fixation in 28 fractures of femoral shaft 
Source 
Plates 
Multiple 
screws 
Wire 
sutures 
Total 
21st General Hospital 
12 
22 
40 
74 
24th General Hospital 
6 
8 
13 
27 
64th General Hospital 
15 
13 
6 
34 
Proceedings, disposition boards 1 
87 
42 
20 
149 
Total 
120 
85 
79 
284 
Percentage.. _ .. 
42. 3 
29. 9 
27. 8 
100 
1 From files, Office of the Surgeon, Mediterranean Theater of Operations. 
APPRAISAL OF RESULTS 
Casualties with fractures of the femur remained in general hospitals a 
sufficiently long time to allow an appraisal of wound healing (table 10) and, 
usually, of union of the fracture. Even patients treated by stabilizing inter- 
nal fixation of the fractures remained for several weeks, and traction for those 
treated by other methods was continued for 8 to 12 weeks. A fairly long 
term appraisal of results was possible. Important data on the results achieved 
from the viewpoint of an overseas theater concerned the deaths, amputations, 
healed wounds, wounds healed except for small granulated areas without sinus 
formation to bone, sinuses to bone, infected fractures, and the quality of 
fracture reductions. 
3969G10—57 12 158 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Table 10.—Appraisal of wound healing in 825 compound fractures of femoral shaft at time 
of disposition 
Status of wounds 
Source 
Healed 
Healed 
except for 
small 
granulat- 
ing areas 
Sinus for- 
mation to 
bone 
Infected 
fracture 
sites 
Total 
21st General Hospital (experience in Italy 
only) 
29 
23 
22 
5 
79 
33d General Hospital 
70 
37 
22 
4 
133 
64th General Hospital 
52 
14 
12 
78 
Proceedings, disposition boards 1 
249 
219 
50 
17 
535 
T otal 
400 
293 
106 
26 
825 
Percentage 
48. 5 
35. 5 
12. 9 
3. 1 
100 
1 From flies, Office of the Surgeon, Mediterranean Theater of Operations. 
In September 1944, a survey was made in seven general hospitals in Naples 
and Home to gather data on the results achieved in compound fractures of the 
femur after the institution of the so-called reparative triad; that is, penicillin, 
blood replacement, and precise surgery. The evaluation was made on each 
patient by the chief of the orthopedic section of the hospital, after overseas 
management had been completed and transfer to the Zone of Interior was 
imminent. 
Data secured in the 277 cases of compound fractures of the femoral shaft 
reported in this survey follow: 
Number Percent 
Deaths 2 0. 7 
Amputations (exclusive of those caused by damage 
of major vessels at wounding) 2 . 7 
Infection at some period more than 30 days after 
wounding (as evidenced by fever and purulent 
drainage from fracture site) 35 12. 6 
Sinus formation to fracture site at time of dis- 
position 29 10. 5 
A comparison of these data with those gathered on a similar group before 
the advent of penicillin, full blood replacement in the fixed hospital, and 
reparative surgery (p. 139) revealed no appreciable change in the incidence of 
deaths and amputations. The incidence of persistent sinus formation was 
about the same in each group. There was, however, a smaller proportion of 
infected fractures at some period 30 days after wounding (12.6 percent against 
17.9 percent). REGIONAL COMPOUND FRACTURES 
159 
Persistent sinuses were undoubtedly indicative of sequestrum formation 
and were not necessarily a criterion of failure of management. In severely 
comminuted fractures, with many partially denuded fragments, some sequestra- 
tion was often inevitable. During the survey in the Zone of Interior in early 
1945 (p. 191), it was repeatedly observed that sound wound healing followed 
removal of sequestra, provided that reasonably healthy soft tissues were 
available. Therefore, while sequestration was undesirable, its development 
did not necessarily prejudice the end result. 
An accurate appraisal of the quality of reduction of the fractures of the 
femoral shaft in the series studied was not possible. It is known that ade- 
quate reduction was achieved in the great majority of all cases. Improve- 
ments in techniques of skeletal traction and the use of an aggressive surgical 
approach, combined with internal fixation if it was thought advantageous, 
prevented malposition and malalinement. The concept of the management of 
these injuries was that (1) the fractures should be reduced and maintained 
in reduction by whatever means were required; (2) that this objective could 
be reached without endangering life or limb; and (3) that wound healing 
would seldom be retarded but, if it were, that the end result, as measured by 
the function of the extremity, would still be greatly improved. Inadequate 
fracture reduction was therefore seldom accepted, and the statement that 
fractures of the femur were usually adequately reduced is regarded as justified. 
Data concerning the healing of the wounds in these series have been 
compiled in table 10. Healing in wounds with small granulating areas was 
considered satisfactory; there was no opening to the fracture site in these 
cases, and healing processes had converted the compound fracture into a 
simple fracture. It is known that many wounds in which granulating areas 
were recorded on disposition in the theater were healed when the transporta- 
tion plaster hip spicas were removed in named general hospitals in the Zone 
of Interior. Infected wounds presented profuse, purulent drainage from the 
fracture site. These fractures were usually those associated with severe dam- 
age and loss of soft tissue. The heavy drainage probably indicated relatively 
heavy sequestration. Nonunion of the fracture was not necessarily present. 
CONCLUSIONS 
The regimen of reparative surgery as applied to battle-incurred fractures 
of the femur in the Mediterranean theater and as evaluated overseas produced 
minimal sepsis, improved reduction of fractures, earlier wound healing with 
minimal scarring, and improved quadriceps power and range of knee motion 
without increased morbidity or mortality. Morbidity, in fact, appeared to 
have decreased. The final appraisal of the end results could be made only 
in the Zone of Interior, after the function of the extremity had been resumed. 
It is believed, however, that the regimen paid rich dividends in the prevention 
of deformity and the functional restoration of these severely wounded 
extremities. 160 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Part III. Compound Fractures of the Tibia and Fibula5 
Although results in certain compound fractures were reasonably satis- 
factory when the program of reparative surgery was introduced in the Medi- 
terranean theater in the spring of 1944, fractures of the tibia and fibula were 
not included in the group. The management of the fractures of one bone 
(the tibia or the fibula) seldom offered difficulties. The management of 
fractures of both the tibia and the fibula constituted a major problem, which 
cried aloud for solution, and it is fortunate that both bones were injured in 
not more than a quarter of all wounds of the leg. 
The results being obtained in the theater in the spring of 1944 in fractures 
of the tibia and fibula did not meet the standards considered desirable and 
possible in the overseas management of these injuries. For this failure, there 
were a number of reasons: 
1. When manipulation and traction, correctly applied, had failed to 
achieve adequate reduction, the failure was frequently accepted as the best 
that could be achieved under the circumstances because operative interference 
was considered too hazardous. The fear of infection was easy to understand, 
for there had been a fairly high incidence of locally necrotizing wound infection 
in wounds involving these fracture sites. 
2. Wound discharges often pooled in dead spaces about unreduced fractures 
of the tibia. 
3. Even when healing by granulation proceeded at a rate accepted as 
normal, it was a slow process and was always attended with scar formation, 
often of massive degree. 
4. When tibial cortex was left exposed, in the expectation that it would 
be covered by granulations, sequestration almost invariably resulted. 
THE REPARATIVE-SURGERY PROGRAM 
Compound fractures of the tibia and fibula therefore seemed, at least at 
first glance, to offer a peculiarly fertile field for the application of the new pro- 
gram of reparative surgery. Its components—surgical closure of compound- 
ing wounds; adequate reduction of fractures, by surgical measures if necessary; 
and dependent drainage of residual dead space—were all designed’to overcome 
the chief failures of the earlier, nonoperative plan of management, with healing 
by granulation. The situation, however, was not as hopeful as it seemed. 
All the factors which were so favorable to the program in fractures of the femur 
were unfavorable in fractures of the tibia and fibula because—- 
1. Injuries of these bones were frequently associated with a significant 
degree of bone loss. This fact accounted for delays in union and for many 
s The statistical material in this section was provided by Maj. William R. Ferguson, MC, and Capt. Robert B. 
Oottschalk, MC, 33d General Hospital; Lt. Col. George A. Duncan, MC, Maj. R. D. Butterworth, MC, Maj. Benjamin 
W. Rawles, Jr., MC, and Capt. Beverly B. Clary, MC, 45th General Hospital: Maj. Joe M. Parker, MC, and Capt. 
Francis R. Crouch, MC, 21st General Hospital; and Maj. Otto E. Autofrance, MC, 6th General Hospital. REGIONAL COMPOUND FRACTURES 
161 
instances of nonunion and was a serious consideration in an extremity in 
which full weight bearing and almost full length are essential for normal gait. 
2. Many difficulties lay in the way of obtaining and maintaining reduc- 
tion and fracture union in an extremity in which excellent alinement is almost 
essential for normal gait. In civilian practice, delayed union or nonunion is 
not infrequent in fractures of the bones of the leg. 
3. The large anteromedial surface of the tibia lies just under the subcu- 
taneous tissue. As a result, the cortex was often exposed at wounding. Since 
there are no highly vascularized tissues in this area—even the covering skin is 
thin and light—closure of compounding wounds located over the anteromedial 
surface of the tibia was always difficult. In addition, there was frequently a 
significant loss of tissue at wounding, so that closure without tension was 
often impossible. 
4. Posterior dependent drainage of residual dead space was always difficult 
to obtain in this area unless there was a large compounding posterior wound. 
5. The type of combined bone and nerve surgery which gave such ex- 
cellent results in compound fractures associated with nerve injuries in the 
upper extremity was not practical in the leg. Fortunately, the incidence of 
these combined injuries, while somewhat greater than in compound fractures 
of the femur, was considerably less than in compound fractures of the shaft 
of the humerus. 
These unfavorable factors, while they did not prevent the full utilization of 
the program of reparative surgery in compound fractures of the bones of the 
leg, obviously handicapped it before it was instituted. 
ANALYSIS OF CASES, 1944-45 
The observations in this chapter, in addition to the personal observations, 
are based on the following collected data: 
347 fractures of the tibia, fibula, or both bones treated from June 1944 
through May 1945 at the 33d General Hospital. 
638 fractures of the tibia, fibula, or both bones treated at the 45th General 
Hospital during 1944. 
279 fractures of the tibia or the tibia and fibula treated at the 21st General 
Hospital during the last 6 months of its operation. 
219 fractures of the tibia, fibula, or both bones treated at the 6th General 
Hospital from July through December 1944. 
654 fractures of the tibia, fibula, or both bones studied from the proceed- 
ings of disposition boards in the Office of the Surgeon, Mediterranean Theater 
of Operations, and filed after 1 May 1944. 
Practically all of these 2,137 fractures were managed after the reparative- 
surgery program became effective throughout the theater in the spring of 1944. 
As usual, not all desired data were available in all series. 
All the hospitals from which material was procured functioned in the Medi- 
terranean theater. The material from the 21st General Hospital, which served 
as one of the supporting hospitals in the invasion of southern France, also 162 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
covers the period after December 1944, at which time it came under the Chief 
Surgeon, European Theater of Operations. 
Fractures of the bones of the leg were the most frequent fractures encoun- 
tered in the Mediterranean theater. The 638 cases handled at the 45th General 
Hospital during 1944 may be taken as representative. These cases represented 
21 percent of all compound fractures and 24 percent of all compound fractures 
of the extremities admitted during this period. When fractures of the bones 
of the hand and foot are excluded from the calculations, the proportion rises to 
37 percent. Fractures of the bones of the leg also represented 4.6 percent of 
all battle injuries treated at the 6th General Hospital from July through 
December 1944. 
The most detailed information on the causes of compound fractures of 
the tibia and fibula was available from the 654 cases studied in disposition- 
board proceedings. Details were available for 506 battle injuries and for 116 
injuries classified as nonbattle, as follows: 
High-explosive shell fragments from artillery, mortars, mines, or grenades 
accounted for 345 of the 506 battle injuries (68.2 percent). Small-arms fire 
accounted for the remaining 161 cases. 
The 116 nonbattle injuries constituted 18.6 percent of the total series (622 
cases) in which this information was available. The largest group of fractures, 
71 (61.2 percent), were caused by vehicular accidents. Falls accounted for 17 
cases (14.7 percent), injuries from falling objects for 13 (11.2 percent), and air- 
plane crashes during training for 11 (9.5 percent). Explosions accounted for 
3 cases and a railroad accident for the remaining case. 
Information as to the site of the fracture was available in 1,855 of the 
2,137 cases analyzed in this chapter. The tibia alone was fractured in 819 
instances (44.1 percent), the fibula alone in 523 (28.2 percent), and both bones 
in 513 (27.7 percent). 
Information as to the presence or absence of associated nerve injuries was 
complete in 481 of the 498 cases from the 21st and 6th General Hospitals. In 
this group, there were 13 injuries of the tibia! nerve and 47 of the peroneal 
nerve, a combined total of 60 injuries (12.5 percent). This percentage is to be 
compared with 7.7 percent in combined injuries in compound fractures of the 
femur (p. 141) and 41.6 percent in compound fractures of the humerus (p. 128). 
WOUND MANAGEMENT 
Detailed data are not available on the preoperative management of pa- 
tients with compound fractures of the bones of the leg in the general hospitals 
of the Mediterranean theater. It is known, however, that they were usually 
received in these fixed hospitals by the fifth or sixth day after wounding unless 
concurrent injuries required a longer stay in forward hospitals. They had 
usually received one or more transfusions of whole blood in forward areas, but 
additional transfusions were usually required, in the amount of 1,000 to 2,000 REGIONAL COMPOUND FRACTURES 
163 
cc., before hematocrit readings reached the minimum level (40) regarded as 
safe for surgery. 
In the absence of specially unfavorable circumstances, the reparative 
operation could usually be undertaken well before the 10th day after wounding. 
In 100 consecutive cases treated at the 33d General Hospital, the average was 
6 days. In 297 cases studied in disposition-board proceedings, the average 
was 8.5 days. 
Management of the wound in compound fractures of the tibia and fibula 
presented certain special problems. The first had to do with bone fragments. 
Completely detached fragments of cortical bone were frequently found free in 
the large marrow cavity of the tibia. Because they were potential sequestra, 
their removal was imperative. Sharp, projecting ledges of bone were removed 
by rongeur. 
The second problem had to do with wound closure. Loss of tissue was 
frequent. Even when the skin edges could be brought together without 
tension, healing was often prejudiced by dead space, which was usually present 
and which often could not be obliterated or effectively drained. In the early 
days of the reparative-surgery program, wound closure was often made more 
difficult by the use, in forward hospitals, of longitudinal incisions, with a long 
transverse axis, through the center of the combat wound. The crucial type 
of defect which resulted was almost impossible to close satisfactorily. Eventu- 
ally, surgeons in forward hospitals recognized this difficulty and thereafter 
converted such wounds into a modified Z by the use of proximal and distal 
incisions made from opposite corners. Closure was greatly simplified when 
such an incision was used at initial wound surgery. 
It required discriminating judgment in many cases to decide to close the 
wound, perhaps with the aid of relaxing incisions or the advancement of flaps 
(figs. 36 and 40), or to leave it partially or completely open, in the expectation 
that the defect would heal by granulation (fig. 42). The importance of cover- 
ing all denuded cortical bone, and preferably the entire fracture site, with 
soft parts was well recognized and was a major objective of wound closure in 
compound fractures, but deliberate acceptance of the closed plaster technique, 
with healing by granulation, was sometimes the wiser choice when there was 
extensive loss of soft tissue or when dead space was present that could not be 
obliterated. 
Even if closure was considered safe, drainage was always necessary in 
wounds of the leg because some residual dead space was invariably present 
and deep abscess formation was always a possibility if drains were not used. 
It was found best to provide drainage by soft rubber tissue or fine-mesh gauze 
and to allow the drain to emerge from the residual dead space through the 
sutured wounds. Attempts at dependent drainage through the posterior com- 
partment of the leg were seldom successful, and the trauma of the incision or 
erosion from the drainage material introduced the risk of damage to regional 
vessels and nerves. When the compounding fractures were anterior, as they 164 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
usually were, the solution of the problem was to keep the patient in the prone 
position for a week or 10 days after wound closure. This position effectively 
prevented puddling of blood and wound exudate in the bony defect. 
When the decision was made to leave the wound partially or completely 
open, the defect was loosely filled with dry, fine-mesh gauze, and the patient 
was nursed in the prone position for a week or 10 days. 
Still another contingency that had to be considered in injuries of the leg 
was how to manage a wound that had required extensive revision at the first 
operation of reparative surgery. In such cases, the best plan was to leave the 
wound open for 5 to 7 days after operation, to take advantage of the good drain- 
age provided by the wide-open incision. In some hospitals, this plan was rou- 
tine in fractures of the tibia and fibula managed by internal fixation. When 
delayed closure was undertaken at the appropriate time, which might be 14 
days or more after wounding, it was usually possible to close the skin edges 
without tension by the use of relaxing incisions or by shifting of flaps of skin. 
The newly created skin defects were usually covered with split-thickness skin 
grafts at the same operation. 
FRACTURE MANAGEMENT 
Fractures of the Tibia or the Fibula 
As has already been stated, fractures of either the tibia or the fibula 
seldom introduced problems of management, particularly when the injury was 
in the fibula. Even when it was in the tibia, plaster immobilization usually 
met the needs of the situation. The majority of United States orthopedic 
surgeons entered upon military duty with the expectation of managing all 
fractures of the tibia and fibula, whether alone or in combination, chiefly by 
plaster. Reports from the Spanish Civil War and reports of British surgeons 
of their experiences earlier in the war supported this point of view. 
All plaster casts on the leg were so applied as to hold the knee and ankle 
joints in physiologic position. The arches of the foot were well molded. Unless 
muscle or nerve injury required support of the toes, the plaster was trimmed 
back to the metatarsal heads, so that full flexion of the toes would be possible. 
A wire or plaster loop incorporated in the cast protected the foot from the pres- 
sure of bed clothing and other trauma. 
Fractures of the fibula.—The management of fractures of the fibula was 
simple unless the external malleolus was destroyed. In many such cases, only 
molding in plaster was possible. Bone loss in the shaft was seldom of signifi- 
cance. Immobilization in plaster was provided for several weeks but was not 
necessarily maintained until bony union was complete. The early removal of 
the cast permitted muscle and joint exercises during the final stages of fracture 
healing and played an important part in reducing the period of disability. 
Compound fractures of the fibula were among the few compound battle 
fractures that allowed the return of soldiers to full duty status in a theater of REGIONAL COMPOUND FRACTURES 
165 
operations. In 155 fractures of the fibula treated at the 45th General Hospital, 
about 40 percent of the soldiers were returned to their original duty status. 
Fractures of the tibia.—Fractures of the tibia in the middle or the upper 
third were usually managed by plaster immobilization, to maintain alinement. 
The intact fibula acted as a strut to secure the normal length. 
Fractures of the lower third of the tibia offered more difficulties. The 
two-pin plaster technique of external skeletal fixation was occasionally employed 
to insure full length and to avoid a varus deformity of the foot. This complica- 
tion usually occurred only in fractures in this location. 
Internal fixation was employed in a few fractures of the upper third of the 
tibia with spread of the condyles or with forward displacement of a fragment to 
which the patellar tendon was attached. It was also used in a few fractures of 
the tibia at other levels. This technique was used in 1.5 percent of 158 fractures 
of the tibia treated at the 33d General Hospital, in 4.3 percent of 277 cases 
treated at the 45th General Hospital, and in 4.7 percent of 277 cases studied 
from disposition-board proceedings. 
When bone loss had created a segmental defect in the tibia, the decision 
had to be made whether (1) to osteotomize and shorten the intact fibula in 
order to secure contact of the tibial fragments or (2) to leave the fibula intact 
in the expectation that the bony defect in the tibia could be repaired by grafting 
at reconstructive surgery (fig. 60). In a number of cases, the fibula was short- 
ened. A number of other cases were observed in which it was thought that it 
would have been well to use this technique, since the shortening of the extremity 
would not have exceeded an inch. Another advantage of this technique was 
that deliberate shortening of the extremity sometimes permitted better approxi- 
mation of the soft tissues. On the other hand, reports from Zone of Interior 
hospitals indicated that a high proportion of bone-grafting operations for seg- 
mental defects of the tibia were successful. In cases in which shortening would 
have exceeded an inch, it was therefore the general policy to permit the fibula 
to remain intact in expectation of later bone grafting. 
Fractures of the Tibia and Fibula 
Manipulative reduction with plaster immobilization was sufficient for the 
management of many fractures of both bones of the leg. If the fractures were 
severely comminuted, this often meant the acceptance of about a centimeter 
of shortening. The method presented one definite pitfall—late angulation 
within the cast, which could occur after edema had disappeared, atrophy of 
muscle and fatty tissue had ensued, and the cast had ceased to be a snug fit. 
Fractures of both the tibia and fibula with segmental defects resulting 
from loss of bone at wounding or surgery provided a major problem. Unless 
shortening would be excessive, it was usually desirable to achieve contact of 
the bony fragments. When, however, the defect exceeded an inch or at the 
most an inch and a half, it was usually preferable to allow it to persist, in an 
effort to maintain tibial length. Damage to soft parts, which was usually 166 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
U. S. Army photo 
Figure 60.—Anteroposterior and lateral roentgenograms 
showing fracture of right tibia with segmental loss of 
1 to Vi inches of bone. The fibula was intact. Union 
of the tibia was finally obtained after years of hos- 
pitalization spent in staged plastic procedures on the 
soft tissues, including split-thickness skin grafting fol- 
lowed by pedicle grafting, and two bone-grafting 
procedures. 
severe, further complicated the issue. The difficulties of wound management, 
the persisting dead space created by the bony defect, the prejudicial effect of 
the dead space on wound healing, and the limitation of function to be expected 
in an extremity that had been so severely damaged, all had to be weighed in 
the decision whether to shorten the extremity, maintain length mechanically, 
or, in the occasional case, amputate the limb. When, as just noted, informa- 
tion reached the theater that bridging bone grafts were proving very successful 
in the Zone of Interior, the scales were usually weighted in favor of preservation 
of length in the borderline cases in which amputation did not appear to be 
indicated, and the technique most applicable to the particular case was selected. 
Techniques of fracture management.—In addition to plaster alone, four 
other methods of fracture management were employed in the Mediterranean 
theater in compound fractures of the tibia and fibula (tables 11 and 12): 
1. Skeletal traction in a cast was employed effectively in a number of 
hospitals. The usual plaster immobilization was supplemented by traction 
obtained by means of a wire or pin inserted in the os calcis and incorporated REGIONAL COMPOUND FRACTURES 
167 
into the cast (figs. 61 and 62). When traction was maintained for about 6 
weeks, the risk of late angulation, which has just been mentioned, was greatly 
reduced. Stability frequently developed during this period, and apposition 
Table 11.—Fracture management in 622 compound fractures of tibia and tibia and fibula1 
Fractures 
Technique 
Tibia cases 
Tibia and 
fibula cases 
Total cases 
Cast 
277 
167 
444 
Cast traction 
2 
45 
47 
Two-pin fixation in cast _ 
1 
11 
12 
Internal fixation tibia _ 
13 
80 
93 
Plating 
2 (6) 
(5) 
(2) 
(59) 
(20) 
(1) 
9 
(65) 
(25) 
(3) 
9 
Screws _ . _ _ 
Wire 
Plating fibula 
External fixation 
2 
11 
13 
Amputation 
4 
4 
Total _ _ 
295 
327 
622 
1 Data were secured from proceedings of disposition boards on file in the Office of the Surgeon, Mediterranean Theater 
of Operations. The technique was not stated in 32 other cases studied. 
2 Figures in parentheses are subtotals. 
Table 12.—Fracture management in relation to level of tibial injury in 621 compound fractures 
of tibia and tibia and fibula 1 
Level of tibial fracture 
Technique 
Proximal 
third 
Mid 
third 
Distal 
third 
Total 
Cast 
143 
146 
154 
443 
Cast traction _ 
11 
9 
27 
47 
Two-pin fixation in cast 
2 
6 
4 
12 
Internal fixation tibia 
11 
48 
34 
93 
Plating 
2 (4) 
(36) 
(25) 
(65) 
Screws __ 
(7) 
(ID 
(7) 
(25) 
Wire 
(1) 
2 
(2) 
(3) 
9 
Plating fibula 
2 
5 
External fixation. _____ 
1 
11 
1 
13 
Amputation 
1 
3 
4 
Total _ _ 
171 
222 
228 
621 
i Data were secured from proceedings of disposition boards on file in the Office of the Surgeon, Mediterranean Theater 
of Operations. The level of the tibial fracture was not stated in 33 other cases studied. 
2 Figures in parentheses are subtotals. 168 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 61.—Skeletal traction in cast for fractures of both bones of leg. A. Application of 
cast. Constant traction is exerted on musculature of leg through Kirschner wire by 
means of muslin bandage or rope tied to bow on wire and passed around hips of assistant, 
who leans backward. The fracture has been reduced by manipulation. The plaster 
cast is well padded from the fracture site upward. Ideally, reduction is obtained by 
manipulation and traction at the time the cast is applied and is maintained by traction. 
Note functional position of foot. B. Traction with patient recumbent. Cast has 
been wedged for alinement. C. Traction with patient on right side. 
AFIP 54-3045 REGIONAL COMPOUND FRACTURES 
169 
U. S. Amy photos 
Figure 62.—Roentgenologic results of skeletal traction in cast. A and B. Anteroposterior 
and lateral views of fractures of both bones of right leg at junction of upper and middle 
thirds before and after skeletal traction in cast. Note length and alinement obtained 
by this method, which also aids in obtaining apposition, though manipulative reduction 
is also important in all but grossly comminuted fractures. C and D. Same views of 
fractures of both bones of right leg at junction of middle and lower thirds. 170 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
was well maintained. Traction supplement of the plaster technique should 
probably have been employed more frequently than it was. In a number of 
instances observed in the Zone of Interior in the spring of 1945, late angulation 
had occurred in both bones of the leg when only plaster immobilization was 
used. Roentgenograms made shortly before evacuation had showed the 
fractures to be well reduced, and the angulation had apparently occurred in 
the 3 to 4 weeks occupied by transfer over water and to the Zone of Interior 
hospital after landing. In some instances, the angulation had become fixed, 
and manual correction was not possible. 
2. Two-pin stabilization in plaster involved merely the addition of pins 
to the plaster technique. This method was enthusiastically employed at one 
hospital in the theater but had a very limited use in other hospitals. It was 
chiefly employed in fractures with segmental defects in which it was desired 
that almost full length be maintained. The majority of surgeons preferred not 
to employ this technique in the absence of very specific indications. They did 
not regard it as effective in maintaining reduction, and they realized the hazards 
of persistent distraction, breakage of pins, and infection, which were associated 
with it. 
3. External skeletal fixation, of which the two-pin plaster technique is 
really a modification, was steadily gaining in favor in the closing days of the 
war as an acceptable method of managing severely comminuted fractures of the 
tibia and fibula, including those with bone loss (p. 207). In several hospitals, 
the half pins were inserted in the major fragments as the first step of fracture 
management at the reparative operation. Then, while the fracture site was 
exposed, reduction was accomplished under direct vision, and the stabilizing 
bars were locked to maintain it. Finally, a long leg plaster cast, in which the 
apparatus was incorporated, was applied. The cast held the foot in correct 
position and increased the stability of the reduction. 
4. It had been hoped, when the program of reparative surgery was intro- 
duced in the Mediterranean theater in the spring of 1944, that the problems 
of management of fractures of both bones of the leg would be solved in large 
measure by the use of internal fixation. This hope was only partly realized 
(figs. 63, 64, 65, 32, and 36). In the majority of injuries, comminution was too 
severe to make the technique feasible, while periosteal stripping in a region of 
poorly vascularized soft tissue continued to be hazardous, in spite of penicillin 
protection and refinements of surgical technique. Fractures in which coverage 
of denuded bone was difficult were usually unsuitable for management by this 
technique. In spite of these objections, the judicious application of plates, 
screws, or wire sutures in selected cases, particularly those in which it was 
possible to cover exposed bone and metal by healthy soft parts, resulted in 
improved and often stabilized reductions. 
Wires sutures permitted major fragments to be held in approximation and 
insured some degree of apposition. Fixation by this method and by screws 
was considered less hazardous than plating, but plating was not infrequently 
utilized, in spite of the added risk, to obtain the benefit of better stabilization. REGIONAL COMPOUND FRACTURES 
171 
Figure 63.—Management of compound comminuted fractures of lower third of right tibia 
and fibula by delayed internal fixation of tibia. Ligation of the posterior tibial artery 
was necessary at initial surgery. A. Appearance of wound after reparative surgery 
9 days after wounding. The wound has been only partly closed, to provide for drainage 
after internal fixation of the tibia by plating, on the indication of bone loss at the site 
of the fracture in the fibula. B. Preoperative and postoperative roentgenograms show- 
ing loss of bone at fracture site before reparative surgery and position of fractures after 
plating of tibia. C. Range of ankle motion 13 months after wounding. Anteropos- 
terior and rotated anteroposterior roentgenograms showed fractures solidly united and 
in good alinement 12 months after wounding. Removal of metal and several small 
sequestra was necessary for satisfactory wound healing. 
The elective choice of internal fixation by plating was justified in this case because of 
(1) the difficulties ordinarily experienced in fractures of the lower third of the tibia and (2) 
the availability of soft parts to cover the denuded bone. The end result was excellent. 
(The case was managed at the 21st General Hospital by Maj. Newton C. Mead, MC, and 
Capt. Francis R. Crouch, MC.) 
AFIP C-44-290 
Toward the end of the war, it began to be recognized that it was a better plan 
to stage the procedures: Wound healing was accomplished as promptly as 
possible, and then, if adequate reduction had not been attained, plating was 
carried out through a surgical incision. A certain number of fractures, however, 
continued to present such combined problems of fracture reduction and wound ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
172 
Figure 64.—Management of compound comminuted fractures of middle third of left tibia 
and fibula by delayed internal fixation. A. Roentgenograms made at evacuation 
hospital shortly after wounding. B. Roentgenograms made at general hospital after 
stabilization of fracture of tibia by a long plate and an additional transfixion screw. 
These roentgenograms reveal a second fracture, located more distally, not seen on the 
original films (view A). A few days later, this fracture was fixed in reduction by two 
screws. The wound, which had been closed at both the original and the second operation, 
did not heal. C. Roentgenograms made in Zone of Interior hospital, 3}i months 
after wounding. Note nonunion of fractures and massive sequestration. At this time, 
the wound was gaping down to the plate. D. Roentgenograms made 6 weeks later, 
after removal of sequestra and metal. Wound healing was obtained after this operation. 
Note loss of bone by sequestration. 
Lovell GH 27243 
This case clearly illustrates the hazards of plating of the tibia. The advantages offered 
by this technique when it is used before wound healing has occurred do not justify the risks 
entailed. In this case, wound healing did not occur and there was massive sequestration 
of the bone which had been denuded at operation. REGIONAL COMPOUND FRACTURES 
173 
management that early plating through the compounding wound seemed 
justified, in spite of the risk involved. 
Internal fixation of the fibula (figs. 66 and 67) was employed in several 
hospitals when a transverse or oblique fracture of that bone was associated 
with a comminuted fracture of the tibia. Plating, in effect, converted the 
combined fractures into a fracture of only the tibia; the stabilized fibula acted 
as a strut, maintaining tibial length and holding the tibial fragments in adequate 
reduction. Both metal and bone were easily covered by soft tissue, and wound 
healing was seldom a problem. Plating was usually accomplished through a 
separate surgical incision. After operation, the limb was put up in a long leg 
plaster cast. 
This technique was used in 9 of 179 fractures of both bones of the leg 
treated at the 45th General Hospital. In 4 cases, the indication was a large 
segmental defect of the tibia, for which it was expected that a bridging bone 
graft would later be employed. In the other 5 cases, adequate reduction of 
the tibia was not possible by other methods. The fixation in 7 of the 9 cases 
was accomplished through the compounding wound. 
The surgeons at this particular hospital believed that the simplicity and 
minimal hazard of this technique, combined with the feasibility of early trans- 
portability to the Zone of Interior with no fear of loss of reduction, made 
plating of the fibula the method of choice for combined fractures of the tibia 
and fibula whenever the contour of the fibular fracture permitted its use. 
Other surgeons, with somewhat less enthusiasm, accepted the concept that 
this technique had a limited application in the management of fractures of 
both bones of the leg. 
EVALUATION OF RESULTS 
Evaluation of the results of reparative surgery of compound fractures of 
the bones of the leg was necessarily limited to observation of the status of 
healing of the wounds and of reduction of fractures at the time of disposition. 
A soldier with a compound fracture of the fibula could be returned to duty in a 
fair proportion of cases. A soldier with a compound fracture of the tibia was 
unlikely to be of further military usefulness and was usually a candidate for 
early transfer to the Zone of Interior. Transfer was effected as soon as repara- 
tive management of the wound had been completed and it was reasonably 
certain that reduction would not be lost in transit. It was sometimes effected 
earlier than was desirable because heavy influxes of casualties demanded bed 
space in the theater. 
The consensus throughout the theater was that on the whole, because of 
the handicaps attendant upon the management of these fractures (p. 160), the 
results were inferior to those accomplished in compound fractures of the femur 
and of the bones of the upper extremity. It was generally agreed, however, 
that they were far superior to the results which had been accomplished before 
396961°—57 13 174 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 65. (See opposite page for legends.) 
Schick GH 8793 REGIONAL COMPOUND FRACTURES 
175 
the introduction of the reparative-surgery program. Necrotizing wound 
infection had become infrequent. Fracture reduction was improved. Com- 
plete wound healing was obtained in a large number of cases. In other cases, 
in which healing was incomplete, the size of the defects left to heal by granula- 
tion had been greatly reduced. 
A high incidence of sequestration was considered almost inevitable in 
comminuted fractures of the tibia. When it occurred, sinuses formed and 
wound healing was not accomplished. Removal of the sequestra was recog- 
nized as a function of reconstructive surgery in the Zone of Interior. It was 
performed only on special indications, and in correspondingly few cases, in 
the Mediterranean theater. It was generally believed that, in most of these 
cases, satisfactory healing of the wounds would occur after removal of dead 
bone, provided that sufficient healthy soft tissue was available in the area. 
In the 279 fractures of the tibia or the tibia and fibula which were treated 
at the 21st General Hospital, the tibia was fractured in 191 cases and the tibia 
and fibula in 88. The proximal third of the bone was involved in 81 cases and 
the distal third in 55; the knee joint was involved in 53 of the former group and 
the ankle joint in 12 of the latter. One hundred and ninety of the wounds 
were clinically clean on admission. In the remaining 69 cases in which this 
information was available, the wound contained necrotic tissue, and there was 
a heavy exudate. 
Details of wound management were available in 270 cases in this series. 
Complete suture without drainage was carried out in 81 cases, partial suture or 
suture with drainage in 143 cases, and suture with skin graft in 7 cases. Thirty 
wounds were left open. Amputation was necessary in 9 cases, in 1 instance 
Figure 65.—Management of compound comminuted fractures of right tibia and fibula by 
internal fixation of tibia; bilateral compound comminuted fractures of right os calcis 
and talus. A. Anteroposterior roentgenogram made in general hospital several days 
after wounding, showing fractures of tibia and fibula. B. Lateral roentgenogram, same. 
C. Anteroposterior roentgenogram showing fractures of bones of leg after internal 
fixation of tibia by plating through the compounding wound, which was closed. D. 
Lateral roentgenogram, same. E. Anteroposterior roentgenogram after removal of 
metal and sequestra in Zone of Interior hospital. Wound healing did not occur until 
after this procedure. The fracture is united, but heavy sequestration has reduced 
the strength of the bone. F. Lateral roentgenogram made at same time as view E. 
G. Roentgenogram showing severe distortion of bones of heel shortly after wounding. 
This roentgenogram is to be compared with view F, in which the destruction in these 
bones 6 months after wounding is well demonstrated. 
As this case is viewed in retrospect, the severe trauma to the right foot and leg might 
well have been considered a justification for amputation in all echelons. Perhaps the fact 
that the trauma was bilateral was regarded by the surgeon as a contraindication. Since 
traction was not possible, the choice of internal fixation probably seemed justified. On the 
other hand, plating of the tibia is always hazardous because of the necessary periosteal 
stripping and the resulting denudation of bone, for coverage of which highly vascularized 
soft parts are not available in this area. The ever-present possibility of massive sequestra- 
tion such as occurred in this case would seem to indicate that nonplating methods are 
preferable in such injuries. 176 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 66.—Management of severely comminuted fracture of right tibia, with nearly 
transverse fracture of fibula, by plating of fibula. A. Anteroposterior and lateral 
roentgenograms of bones of leg made at general hospital. At reparative surgery 
7 days after wounding, the fibula was stabilized by plating and thus served as a strut 
for the tibia, the fragments of which were maintained in apposition and alinement. 
At the same operation, a large wound over the medial aspect of the leg was partly closed, 
and the remaining defect was loosel}r packed. Two and a half weeks later, with the 
plated fibula as an aid in maintaining reduction of the tibia, the unhealed portion of 
the wound was successfully covered with a split-thickness graft. B and C. Anteropos- 
terior and lateral views made in general hospital in Zone of Interior several months 
later. Fracture is firmly united. D. Frontal view of leg showing healed wounds with 
extensive loss of soft tissues. E. Medial view. (This patient was managed by 
Maj. Herbert W. Harris, MC, and Capt. Edwin L. Mollin, MC, at the 17th General 
Hospital.) 
AFIP (Mayo GH) 876-4, 6, 5, 1, 3 REGIONAL COMPOUND FRACTURES 
177 
Figure 67.—Management of transverse fracture of left fibula and comminuted fracture of 
tibia, with loss of bone, by plating of fibular fracture. A. Anteroposterior and lateral 
roentgenograms before reparative surgery. B. Same as view A, with patient still on 
operating table, after plating of fibula. Without benefit of plaster immobilization, the 
tibia is now held at almost full length and in almost perfect alinement. C. Compound- 
ing wound of tibia 16 days after suture at reparative surgery. Note complete healing. 
D. Healed operative incision used for plating of fibula, soundly healed after same 
lapse of time. (This patient was managed by Maj. Joe M. Parker, MC, and Capt. 
Francis R. Crouch, MC, at the 21st General Hospital.) 
AFIP C A—44-522 178 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
because of a knee-joint infection and clostridial myositis complicating a severe 
fracture of the upper end of the tibia. In the remaining cases, the amputation 
was performed for circulatory causes. 
Methods of fracture management could be ascertained in 264 cases, 
including 9 cases in which the fracture was incomplete and immobilization 
was not required. The remaining cases were treated by plaster-cast immobili- 
zation in 206, in 22 of which both bones were fractured; by cast traction in 23 
cases, in all of which both bones were fractured; and by internal fixation in 26 
(14 by screws, 9 by wire, and 3 by both techniques). 
The status of the wound when the patients were evacuated was unknown 
in 100 cases in this series, because of the tactical necessity for speedy evacuation. 
In 40 of the remaining 170 cases (23.5 percent), the wounds were completely 
healed. In another 49 cases (28.8 percent), the wounds were healing, and there 
was no opening to the bone. In 59 cases (34.7 percent), in all of which the 
closed plaster technique had been used, the fracture site was exposed, but the 
wound was clean and healing appeared to be in progress. In the other 22 
cases, the wound was not healed, and both bone and soft tissue were frankly 
infected. 
Results accomplished overseas were also studied in a series of fractures 
of the tibia (132) and of the tibia and the fibula (80) treated at the 33d General 
Hospital. These 212 fractures were classified into three groups (table 13) on 
the basis of severity of damage to the soft tissue and bone, as follows: 
Group A.—Extensive damage to soft tissue, and, usually, severe comminu- 
tion of bone. In many cases there had been loss of soft tissue or of bone at 
wounding. 
Group B.—Moderate soft-tissue damage, severe comminution of bone. 
Group C.—Slight damage to soft tissues, little or no comminution of bone. 
Results were classified as successful or unsuccessful from the standpoint 
of wound management and fracture management. Wound management was 
Table 13.—Severity of injury in relation to location of fracture in 132 compound fractures of 
the tibia and 80 of the tibia and fibula 1 
Location 
Severity of injury 
Group A Group B \ Group C 
Total 
Proximal third 
26 
20 
16 
62 
Mid third - _ _ _ .. _ 
36 
20 
5 
61 
Distal thirds. _ _ 
43 
22 
15 
80 
Not stated - 
3 
3 
3 
9 
T otal 
108 
65 
39 
212 
1 These cases were managed at the 33d General Hospital. REGIONAL COMPOUND FRACTURES 
179 
regarded as successful when the wound was either completely healed or com- 
pletely healed except for small areas of healthy granulation tissue, with the 
fracture site well sealed off. Management was regarded as unsuccessful when 
there was an open, draining wound or a sinus leading to the fracture site. These 
criteria were exacting, since in highly comminuted battle fractures sinuses usu- 
ally led only to sequestra’s forming from fragments of bone partially denuded 
at wounding. Leaving these fragments in situ also introduced this possibility. 
Wound healing had not been achieved in these cases, however, and they were 
considered instances of unsuccessful wound management. 
Fracture management was considered successful when the fragments were 
held in adequate apposition, length, and alinement for the special bone injury. 
It was considered unsuccessful when reduction was inadequate. 
By these criteria (tables 14, 15, and 16), wound healing was considered 
successful in 167 of these 212 compound fractures of the tibia and fibula. 
Fracture management was successful in 207 cases. When the criteria of success 
are combined, 166 cases were successful from the standpoint of wound healing 
and fracture management, and only 4 were unsuccessful from both aspects. 
Table 14.—Results in relation to severity of injury and technique of wound management in 132 
compound fractures of the tibia and 80 of the tibia and fibula 1 
Technique 
Successful 
Unsuccessful 
Group A 
Group B 
Group C 
Total 
Group A 
Group B 
Group C 
Total 
Revision: 
Complete 
72 
47 
21 
140 
13 
4 
17 
Incomplete 
3 
8 
16 
27 
20 
6 
2 
28 
Total 
75 
55 
37 
167 
33 
10 
2 
45 
Suture: 
Complete 
45 
41 
30 
116 
3 
5 
8 
Partial. 
16 
8 
3 
27 
20 
2 
2 
24 
No suture 2_ 
14 
6 
4 
24 
10 
3 
13 
T otal.. 
75 
55 
37 
167 
33 
10 
2 
45 
1 These cases were managed at the 33d General Hospital. 
2 Closed plaster technique. 
Early in the reparative-surgical program, the depths of the wound, includ- 
ing the fracture site, were not routinely exposed, and there is no doubt that 
totally detached fragments of bone and tags of dead tissue were left in situ. 
As experience increased, it was increasingly appreciated that the entire wound 
must be freed of dead tissue. The improved wound healing in the cases in which 180 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
additional debridement was carried out (89 percent, against 49 percent in the 
cases not completely explored) furnished substantiating evidence of this funda- 
mental principle of reparative surgery. 
Table 15.—Results in relation to severity of injury and technique of fracture management in 
132 compound fractures of the tibia and 80 of the tibia and fibula 1 
Technique 
Successful 
Unsuccessful 
Group A 
Group B 
Group C 
Total 
Group A 
Group B Group C 
Total 
Plaster cast 
92 
61 
37 
190 
3 
1 
4 
Internal fixation 
10 
2 
2 
14 
1 
1 
External fixation 
2 
1 
3 
Total 
104 
64 
39 
207 
4 
1 
5 
1 These cases were managed at the 33d General Hospital. 
Table 16.—Combined results of wound and fracture management in relation to severity of 
injury in 132 compound fractures of the tibia and 80 of the tibia and fibula 1 
Results 
Severity of Injury 
Total 
Group A Group B 
Group C 
Wound and fracture management successful 
Only wound management successful 
75 
54 
1 
10 
37 
166 
1 
41 
4 
Only fracture management successful 
Wound and fracture management unsuccessful 
29 
4 
2 
Total 
108 
65 
39 
212 
1 These eases were managed at the 33d General Hospital. 
Part IV. Compound Fractures of the Foot 
All hospitals in the Mediterranean Theater of Operations had frequent 
admissions for compound fractures of the bones of the foot. At first glance, 
this fact might seem to violate the axiom that the proportion of injuries in any 
given area of the body bears a general relation to the proportion of body surface 
which the area represents. Although the foot constitutes a relatively small 
portion of the lower limb and an absolutely small part of the total body surface, 
admissions for compound fractures of the bones of the foot made up from 18 REGIONAL COMPOUND FRACTURES 
181 
to 20 percent of all compound fractures managed in general hospitals. At the 
45th General Hospital, for instance, during 1944, the 565 compound fractures 
of the bones of the foot represented 19.3 percent of all compound fractures 
treated during that year. The os calcis was injured in 101 cases, the tarsals in 
146, the metatarsals in 224, and the bones of the toes in 94. The explanation 
of the large numbers of fractures of the foot was chiefly the extensive and 
extremely effective use of land mines by German troops. 
On the surface, it would not seem that compound fractures of bones of 
the foot would be of great significance. They are not inherently lethal, it is 
true, but they account for an enormous amount of disability, even when they 
are of minor severity, and, when they are extensive, they may permanently 
destroy a soldier’s military usefulness. At the best, a man with a compound 
fracture of a bone of the foot, unless only a smaller toe was involved, could not 
be expected to return to duty within the theater holding period of 90 to 120 
days. As a result, most patients with such injuries had to be evacuated to 
the Zone of Interior. It is perfectly fair to say that if an enemy could succeed 
in producing compound fractures of bones of the foot in most of their opponents, 
a very large expenditure of medical service would be required for their manage- 
ment and only an insignificant number of the soldiers could return to fight again. 
Of the compound fractures which affected only a single toe, a fair pro- 
portion were the result of self-inflicted gunshot wounds. The battle-incurred 
injuries varied all the way from relatively simple fractures to completely dis- 
organized fractures of the tarsus, with massive soft-tissue compounding wounds. 
Injuries of this type were most often caused by land mines. 
WOUND MANAGEMENT 
Initial surgery in wounds of the foot was conducted according to the 
general principles of debridement as far as the regional anatomy permitted. 
Usually, all that could be done was to remove large foreign bodies and obviously 
dead tissue. 
The anatomy of the foot, unfortunately, also militated against all but the 
most limited application of the program of reparative surgery, for a number of 
reasons: Some degree of tension is normal in the skin of the foot, particularly 
on the plantar surface. For this reason, the swelling which ordinarily occurs 
in the tissues after wounding and initial surgery is of more significance in the 
foot than in most other areas. Finally, the soft tissues of the foot possess 
generally inferior qualities of healing, even when there has been no great loss 
of tissue, and in many of these injuries the loss had been considerable. 
As a result of these considerations, delayed primary closure of wounds 
of the foot, even when tissue loss had been small, was usually limited to occa- 
sional wounds of the dorsal surface. It was seldom possible to close wounds on 
the plantar surface. The best that could be done, in most cases, was to place a 
few sutures in the angles of the wound, cover exposed cortical bones and 
tendons, and accept healing by granulation. 182 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The fact that most wounds could not be closed did not, of course, contra- 
indicate the routine performance of other steps of the reparative operation. 
Grossly displaced and rotated fragments of bone could often be replaced 
manually in their normal position at this time. 
The wounds were dressed with fine-mesh gauze, preferably impregnated 
with vaseline or some water-soluble ointment, to promote drainage from the 
depths of the wound. Dry gauze, which was preferred in other locations, was 
less satisfactory when it was used in wounds of the foot. 
FRACTURE MANAGEMENT 
Manipulation under full vision, as just noted, was a simple and effective 
method of management of many fractures of the foot. It was usually effective 
in fractures of bones of the small toes, with immobilization maintained by 
dressings. It was also sometimes useful in bones of the great toe, but fractures 
in this area required special management because this toe is essential for 
locomotion, and residual disability is highly undesirable. 
Banjo traction was the preferred method of management when the 
proximal phalanx of the great toe was comminuted and fragments were over- 
riding or when there was significant displacement of a major fragment, par- 
ticularly a fragment which included a portion of an articular surface. A small 
Kirschner wire was introduced into the distal phalanx of the toe from the dorsal 
to the plantar surface, passing through the toenail. A boot cast extending to 
the metatarsal heads was then applied to hold the foot at 90° in neutral version. 
A heavy loop of wire was incorporated in the cast, and traction was accom- 
plished by rubber bands extending from it to the Kirschner wire. This simple 
method permitted access to compounding wounds for dressings and at the same 
time minimized the deformity caused by the fracture. 
Fractures of the metatarsal bones had to be prevented from uniting in 
dorsal angulation. If this were permitted, the metatarsal heads would be 
excessively prominent in the ball of the foot, and callus formation and pain on 
walking would be inevitable. Healing of all metatarsals in full length and in as 
nearly perfect alinement as possible was necessary for the heads of these bones 
to continue to serve as points of weight bearing. These results could be 
accomplished in most fractures of the metatarsals by simple manipulative 
molding and immobilization in a boot cast. If any significant degree of 
shortening was present after manipulation or if it was impossible to maintain 
proper alinement, banjo traction was instituted through one or more of the 
toes by the technique just described. 
Fractures of the tarsus could be managed only by manipulative molding 
and immobilization in a boot cast. In this type of injury, the healing of the 
compounding wound was of greater concern than the management of the 
fracture, and the reduction of the fracture had to be conducted with this 
consideration in mind. REGIONAL COMPOUND FRACTURES 
183 
Compound fractures of the tarsus, especially when the os calcis was in- 
volved, were a source of prolonged disability. Functional results were seldom 
optimal and were often actually poor. Although conservatism was ordinarily 
practiced, many orthopedic surgeons, when they reviewed their experience, 
wondered whether this had been the wisest course. They could recall many 
cases of extensive bony disorganization and persistent infection, with con- 
tinuing destruction of bone or loss of weight-bearing skin on the plantar surface 
of the heel, in which conservative measures had been employed but in which 
amputation might have been the wiser course. In some of these cases, amputa- 
tion was eventually performed in the Zone of Interior but only after the soldiers 
had been hospitalized for months and even years. 
The same course of events was sometimes observed in fractures of the 
astragalus. Early amputation in this type of case would have lessened the 
period of disability and saved considerable hospitalization and medical effort 
which, in the end, achieved no results at all. It should be emphasized, of course, 
that amputation was never carried out in a case in which the vascular supply 
to the distal portion of the foot appeared adequate and in which there was a 
reasonable chance of preserving a functioning, weight-bearing extremity. 
POSTOPERATIVE MANAGEMENT 
Postoperative management in compound fractures of the bones of the foot 
treated in plaster after reparative surgery required bed rest, with the injured 
extremity elevated, for at least 7 to 10 days, to reduce edema of the foot and 
toes, prevent infection, and promote wound healing. When this plan was 
followed, the edema originally present subsided promptly, often to such a 
degree that a new plaster boot had to be applied. 
Since the majority of these casualties were of no immediate military use- 
fulness, they were usually evacuated to the Zone of Interior as soon as possible 
after reparative surgery. This was, as a rule, within 2 to 3 weeks after wound- 
ing. A snug boot cast was adequate for transportation splinting. CHAPTER VI 
Delayed Internal Fixation of Compound Battle 
Fractures—A Followup Study in the Zone 
of Interior 
During the first 16 months’ experience in the Mediterranean Theater of 
Operations, manipulative reduction followed by immobilization in a plaster 
cast or continuous skeletal traction proved satisfactory, or reasonably satis- 
factory, methods of management for a major portion of the combat-incurred 
fractures. Inadequate reduction, however, was by no means infrequent. It 
was particularly common in fractures involving the condylar and articulating 
portions of the large joints, fractures of both bones of the forearm and both 
bones of the leg, fractures in which loss of bone had caused segmental defects 
without contact of fragments, and fractures accompanied by massive loss of 
soft tissue. Even though the position obtained by repeated efforts at manipu- 
lative reduction or continuous skeletal traction had often not been satisfactory 
in these groups of injuries, inadequate reduction was accepted because of the 
fear that operative intervention would incite systemic infection or at least a 
severe wound infection with prolonged osteomyelitis. 
For these reasons, delayed internal fixation of compound battle fractures 
was seldom performed during this period. On occasion, when adequate reduc- 
tion had not been achieved by nonoperative methods, open reduction and inter- 
nal fixation were performed, even though the wound wras unhealed. The results 
were encouraging in a small series at one hospital, but in another series, at a 
different hospital, they w'ere poor. A study of these cases and of sporadic 
cases treated in this way in other hospitals did not produce evidence that 
would warrant recommendation or approval of the procedure. 
Even though it was realized that there would be a place for delayed internal 
fixation in the management of problem fractures once wound management 
was better understood, its use in the Mediterranean theater was forbidden by 
directive in November 1943. Section IV of Circular Letter No. 48, issued 
18 November 1943 from the Office of the Surgeon, Headquarters, North African 
Theater of Operations, read as follows; 
IV. DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF COM- 
POUND FRACTURES WITH OR WITHOUT SECONDARY SUTURE OF WOUND. 
1. This procedure is still under trial with reference to indications, hazards, and incidence 
of serious complications. Its use is restricted to special groups authorized to assume the 
responsibility as a special study. 
185 186 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
At this time, there were no groups in the theater authorized to make such 
studies. For one thing, further investigation of the problem and further 
experience in wound management as a whole were necessary before internal 
fixation could be considered an advisable technique. For another, it was 
thought desirable to wait to test the technique until adequate supplies of peni- 
cillin were available, as a safeguard against invasive infection. 
The use of delayed internal fixation in the Mediterranean Theater of 
Operations as a part of the reparative surgery of compound fractures began in 
March and April 1944, during the hectic days of Anzio and Cassino. Its use 
was first permitted in the 300th, 23d, and 21st General Hospitals, in which 
penicillin therapy had been made available as an adjuvant to an aggressive 
surgical program. The patients treated by internal fixation fell into two groups, 
as follows: (1) Those with unreduced fractures and unhealed wounds, who had 
previously been treated unsuccessfully by other methods; and (2) those recently 
admitted from evacuation hospitals after initial wound surgery, with no 
previous attempts at reduction of the fractures. The progress of each of these 
patients was followed carefully and, when necessary, the theater holding period 
was abrogated to permit prolonged observation, in an effort to assure that later 
recommendations concerning the use of internal fixation would be soundly based. 
The results of the initial test of delayed internal fixation as they were 
observed in the spring of 1944 were extremely satisfactory. Moreover, when 
the first 14 cases so treated were studied later in the Zone of Interior, it was 
found that in 10 instances the fractures had united and the wounds had healed 
without removal of the metal. The final results were equally satisfactory in 
the other four cases, although it had been necessary, in order to expedite healing 
of the wounds, to remove the metal and sequestra. The results were particu- 
larly impressive in seven in which established wound infection had been present 
when stabilization of the fracture was undertaken. 
The immediate results as obtained in the 300th, 23d, and 21st General 
Hospitals by the use of delayed internal fixation warranted its recommendation, 
on specific indications, as part of the program of reparative surgery of compound 
fractures. It was pointed out, however, that the use of this technique was 
not, in itself, an objective of the program. The measures designed to obviate 
infection and achieve wound healing included (1) the excision of dead tissue as 
part of revision of wounds in general hospitals; (2) the closure of compounding 
wounds, especially to cover denuded bone; and (3) adequate drainage of residual 
dead space or of unexcisable bits of devitalized tissue. All these measures 
were of greater importance in the program than internal fixation of fractures. 
Internal fixation would have been doomed to failure if the other essential sur- 
gery had been ignored. 
Internal fixation was neither advisable nor feasible in the majority of com- 
pound battle fractures because of severe comminution. The fractures which 
would permit its use were in the minority. Internal fixation was therefore 
reserved for specific indications, as will be pointed out shortly (p. 190). DELAYED INTERNAL FIXATION 
187 
TECHNICAL CONSIDERATIONS 
Internal fixation was frequently used at the first operation of reparative 
surgery, but it was also employed later, after other methods had failed. It 
was often used at the first reparative operation (1) in fractures about the joints, 
to secure anatomic replacement of the articular surfaces; (2) in fractures of 
the long bones located deep in muscle tissue, particularly fractures of the 
femoral shaft or upper radius; (3) in fractures which experience had shown 
were difficult to hold in reduction by other means, such as fractures of the olec- 
ranon process associated with massive soft-tissue loss; and (4) in fractures 
in which there had been segmental loss of bone and in which contact of the 
fragments could not otherwise be secured. 
Internal fixation was accomplished in three ways, as follows: (1) By 
standard plating, (2) by multiple screws, and (3) by wire sutures. Slotted 
plates and intramedullary pins were postwar developments. The only type of 
metal available in overseas hospitals was 18-8 chrome-nickel stainless steel. 
Fixation by multiple screws (2 or more) was often particularly useful in oblique 
fractures. This technique required little or no additional periosteal stripping 
and was therefore associated with minimal trauma. When the fracture could 
not be stabilized rigidly because of comminution, one or more wire sutures 
were used to hold major fragments in apposition. They could usually be placed 
without additional stripping of the periosteum. 
Intimate contact of the bony fragments was essential for sound union and 
was regarded as of such importance that in occasional cases, in order to secure 
it, the extremity was deliberately shortened, to overcome segmental loss and 
permit approximation of the fragments. The same plan was sometimes adopted 
when there were deficits of nerve trunks or muscles without segmental loss of 
bone. Removal of bony fragments permitted approximation of nerve or 
muscle bundles in these injuries and was undertaken with the idea of accomplish- 
ing maximum functional restoration of the whole extremity rather than merely 
achieving a united fracture. 
Although the operation was sometimes performed through the compound- 
ing wound, this technique had two disadvantages: (1) The metal was placed 
on bone which was usually devoid of periosteum. (2) It was also placed at the 
bottom of dead space created by the excision of devitalized muscle. It was 
therefore usually better, especially when a plate was applied, to utilize a 
separate surgical incision, which permitted coverage of the bone and metal by 
periosteum and soft parts. 
The routine procedure for the management of these casualties in a fixed 
hospital must be clearly understood. Every patient was prepared for repara- 
tive surgery, usually 5 to 10 days after wounding. He was anesthetized in the 
operating room, where the plaster cast and dressing applied after initial surgery 
were removed. The extremity was cleansed, prepared, and draped. The 
operating room was set up for any surgery which might be indicated on a com- 
pound fracture. 188 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The wound was then thoroughly visualized by gentle retraction. All 
residual dead tissue was excised, and the depths of the wound were cleansed 
of old blood clot. The fracture site was exposed. In the great majority of 
cases, reduction was attempted by traction or manipulation, but internal 
fixation could be employed at this time, as part of the first procedure of repar- 
ative surgery, if its advantages were evident, as, for instance, in condylar 
fractures of joints, oblique fractures of long bones which were easily reducible, 
or segmental defects due to bone loss. Wound closure, usually with drainage, 
completed this stage of reparative surgery. 
If later roentgenograms showed that adequate reduction had not been 
achieved by traction or manipulation and if the contour of the fracture per- 
mitted, internal fixation could be performed at another operation, perhaps 
after wound healing. 
Delayed internal fixation was not reserved for the ideal case. On the 
contrary, it was frequently employed in compound fractures that were major 
problems under any plan of management, as, for instance, an avulsion of the 
soft parts of the arm which exposed the shaft of the humerus for several inches 
or a grossly displaced, infected fracture of the femur, with a huge soft-part 
wound, 66 days after surgery. These are situations hardly included in the 
realm of reparative surgery. 
SURVEY OF RESULTS 
After the program of reparative surgery of compound fractures, including 
internal fixation on special indications, had been extended to all general 
hospitals in the Mediterranean theater, the results of this procedure were 
closely checked. In the majority of cases, they were regarded as satisfactory. 
The incidence of wound infection had apparently not been increased. Drainage 
had usually not been prolonged. Ultimate scar formation was expected to be 
less. Fracture reduction was certainly improved. There seemed, therefore, 
every reason to hope that there would be considerable improvement in both 
anatomic and functional end results in the fractures in which this method was 
employed. 
One disturbing fact was that, in spite of frequent warnings to the contrary, 
a few surgeons in the theater had accomplished internal fixation by plating in a 
relatively large number of fractures of the tibia. The consultant in orthopedic 
surgery had repeatedly pointed out that anatomic conditions in this area do 
not permit satisfactory coverage of the denuded bone by vascular soft parts. 
The risk of massive sequestration after the application of a plate had also been 
emphasized. This was particularly true because of the stripping of the perios- 
teum necessary when the plate was applied to the anteromedial surface of the 
bone. The surgeons who, despite these warnings, attempted to manage frac- 
tures of the tibia by plating often found that they had created for themselves 
major problems in closure of the wound, even when fixation had been carried 
out through a separate surgical incision. Results observed in the Mediter- DELAYED INTERNAL FIXATION 
189 
ranean Theater of Operations in the management of compound fractures of the 
tibia by internal fixation were far less satisfactory than the results achieved 
by this method in fractures of any other long bone. 
On the whole, the results observed in cases in which internal fixation had 
been used seemed highly satisfactory when the patients were examined before 
evacuation to the Zone of Interior. The results, in fact, seemed particularly 
good when they were evaluated in the light of the problems which had to be 
solved in these cases. Overseas observation, however, did not settle the ques- 
tion of end results. For that, investigation in the Zone of Interior was neces- 
sary. Previous attempts to secure followup data had not been successful. The 
Surgeon, Mediterranean Theater of Operations, therefore requested that the 
consultant in orthopedic surgery for the theater be ordered to the United States, 
to carry out, among other observations, a survey of casualties with compound 
fractures who had been treated in the Mediterranean theater by delayed 
internal fixation and who were then in Zone of Interior hospitals. This survey 
was carried out in the spring of 1945, with the cooperation and assistance of the 
Surgical Consultants Division, Office of The Surgeon General. 
Materials and Methods 
The survey was conducted in 24 general hospitals in the United States 
between 16 March and 26 April 1945. The 332 fractures surveyed had been 
managed in 18 general hospitals in the Mediterranean theater, by approximately 
50 orthopedic surgeons. The material thus represented a cross section of the 
battle experience and surgical proficiency of the theater. The majority of the 
patients had undergone operations in which delayed internal fixation had been 
performed between 4 June 1944, the date of the fall of Rome, and 1 November 
1944, the date of the approximate conclusion of the fighting on the Gothic Line. 
Two hundred and ninety-five case reports, representing three hundred 
fractures, were assembled as follows: 
1. From personal examination of patients still hospitalized or still required 
to report for observation to outpatient clinics. 
2. From a study of records of patients still hospitalized but presently 
absent on furlough or pass. 
3. From a study of the records of patients who had been referred to con- 
valescent hospitals, returned to duty, or given a Certificate of Disability 
discharge. 
In each instance, the total record was studied, from wounding to the date 
of the investigation, and all roentgenograms were examined. The case reports 
made up as a result of these investigations included, as far as possible, the 
following data: The precise diagnosis of the bone injury; the diagnoses of 
associated injuries which might have influenced fracture management; an 
appraisal of the indication for internal fixation; the type of fixation (plate, 
screw, wire suture); the time interval between wounding and fixation; the 
396961°—57 14 190 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
status of the wound at the time the fixation operation was performed; the 
surgical approach to the fracture (through the compounding wound or through 
a separate surgical incision); the presence of wound infection at the time of 
tiie fixation operation; the presence of associated nerve injuries; the results 
achieved from the standpoint of wound healing and bony union; the time at 
which wound healing and bony union were achieved in relation to the time of 
the fixation operation; and whether removal of metal and sequestra had been 
necessary. 
Another group of 32 patients consisted of soldiers who had been demo- 
bilized, were in convalescent hospitals which were not visited, or had been 
returned to duty. Their status indicated, with reasonable assurance, that 
their wounds were healed and their fractures united, which meant that optimal 
results had been accomplished. Their records, however, were lacking in 
certain basic data, including the kind of fixation employed and the indication 
on which operation had been done. These cases, therefore, are necessarily 
omitted from some of the tabulated presentation of results. 
The material secured from this survey is presented chiefly in the form of 
tabular data, with special emphasis on the results obtained to the date of the 
investigation in relation to (1) the indications for internal fixation, (2) the 
technique of fixation employed, and (3) the area of injury. Certain other data 
are also discussed. 
No true controls exist for this series. In all the hospitals surveyed, a 
serious effort was made to secure data on comparable cases treated by methods 
other than internal fixation, but the information had not been compiled and 
could not be obtained. A number of patients were observed, however, whose 
results might have been improved if internal fixation had been used to stabilize 
their fractures. In a number of instances of malunion and nonunion in femoral 
fractures studied roentgenologically, the contour of the fractures suggested 
that this technique might have been feasible and might have given better 
results. In a number of fractures of the humerus with segmental defects, it 
was also thought that union might have been achieved if bony apposition had 
been maintained by metallic internal fixation. 
Definition of Terms 
Indications.—Indications for the internal fixations performed in this group 
of fractures were classified as obligate and elective. The terms carry their own 
definitions. 
Obligate indications included the following: 
1. Bone loss which either had produced a segmental defect without contact 
of the fragments (figs. 38 and 43) or was associated with persistent distraction 
of the fragments (figs. 30 and 50). In either event, union could not be expected 
without corrective measures. DELAYED INTERNAL FIXATION 
191 
2. Fractures about the joints, particularly condylar fractures of the knee 
or elbow. Reparative measures were necessary in this type of fracture to 
accomplish joint congruity (fig. 53). 
3. Massive soft-tissue loss which precluded routine measures of closure 
and required staged procedures. Fixation of the fracture was part of the at- 
tempt to achieve wound healing. 
4. Associated nerve injuries which required, for optimum results, early 
stabilization of the fracture, sometimes with deliberate shortening of the bone 
to permit approximation of the severed nerve ends (fig. 39). 
5. Failure to achieve and maintain adequate reduction In' manipulative 
measures or traction (figs. 30 and 50). Malunion, delayed union, or nonunion 
was inevitable in such cases in the absence of corrective measures. 
The operations performed under the last mentioned indication were ob- 
viously performed after failure of other methods of treatment. In all other 
operations done on obligate indications, internal fixation was sometimes per- 
formed at the first operation of reparative surgery and sometimes later, in many 
instances after the wound had healed. 
All indications which were not obligate were regarded as elective. Elective 
operations were carried out at the first procedure of reparative surgery. 
Results.—Results were classified as favorable, unfavorable, and incomplete, 
as follows: 
Favorable.—This catagory was further divided into— 
1. Group A.—In this group of optimum results, the fractures united in 
perfect, or almost perfect, anatomic alinement, and the wounds healed solidly 
and promptly, without sequestration and without removal of the metal used in 
the fixation (figs. 31, 34, 35, and 43). In several fractures of the femur and of 
the tibia, the metal was removed later, either as a prophylactic measure or 
because slight evidences of absorption were detected around the screws. Its 
removal, however, was not necessary to accomplish either wound healing or 
bony union (figs. 30, 36, and 52). 
2. Group B.—In this group, the fractures united promptly in adequate 
reduction, and wound healing occurred satisfactorily after metal and sequestra 
had been removed (figs. 32, 50, and 63). 
Unfavorable.—This category was further divided into—- 
1. Group C.—In this group, union of the fracture occurred promptly but 
with massive sequestration, and metal and large sequestra had to be removed 
before wound healing was obtained (figs. 64 and 65). All cases in the C group 
were fractures of the tibia, a bone in which, as already pointed out, plating is 
always associated with some risk. The massive sequestration which occurred 
threatened bony continuity and introduced the risk of refracture when weight 
bearing was resumed. The risk thus introduced, because of loss of bon}' 
strength, made it necessary to use braces for several months (fig. 65). 
2. Group D.—In this group, wounds healed without sequestration or 
removal of metal, but bony union had not occurred at the time of the survey. 192 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The results are classified as unfavorable for this reason.1 From the standpoint 
of wound healing, management was successful. The fact of nonunion, of course, 
must be evaluated against the chances of the same result if internal fixation had 
not been performed (fig. 44). 
3. Group E.—In this group of fractures, wound healing did not occur, and 
in most instances fracture union was not achieved, until both sequestra and 
metal had been removed. The time required for both wound healing and bony 
union therefore exceeded normal expectancy. 
4. Group F.—In this group, fractures did not unite, and wounds did not 
heal. In several instances, wound healing occurred after removal of metal and 
sequestra, but it was expected that bone-grafting procedures would be necessary 
in all cases to accomplish bony union (fig. 64). As in group D, these results 
must be evaluated against the probability of similarly unsatisfactory results if 
internal fixation had not been employed. 
Incomplete — In these fractures (group G), it was thought that satisfactory 
end results would eventually be secured, as the fractures were well united. 
Wound healing, however, had not occurred at the time of the survey. In some 
instances, plastic procedures on the wound would obviously be necessary, in 
addition to sequestrectomy and removal of metal, before healing could be 
expected to occur. In other instances, it was felt that, if metal and sequestra 
were removed, the same excellent results would follow this secondary procedure 
as had followed it in another group (B) in the series (fig. 52). 
Results in relation to indications for internal fixation are presented for the 
whole series in tables 17 and 18, and for regional injuries in tables 19, 20, 21, 
and 22. 
Results in Relation to Technique 
Results of internal fixation in relation to technique are presented in table 
23. As it shows, plating was used in slightly over half of the 332 compound 
fractures of the long bones included in this survey. The largest proportion of 
entirely satisfactory results (groups A and B) was obtained with multiple screws; 
results were excellent in 82 of 95 such cases. There were 21 absolute failures 
(failure of wound healing and nonunion of the fracture) at the time of the survey 
in the 168 fractures treated by plating, against 4 absolute failures in 69 fractures 
treated by wiring. There were no absolute failures in the 95 fractures fixed 
by screws. There were a number of instances in the unfavorable categories in 
which it was thought that with the passage of time better results than were 
then apparent might be achieved. 
1 This category of results was classified as satisfactory in the original report, on the ground that, although the fracture 
was ununited, the wound was healed and that the chief purpose of the survey was to determine the status of wound healing 
in fractures treated by delayed internal fixation. Because of the possibility of misunderstanding (since an ununited frac- 
ture cannot be considered a satisfactory result), this category of results has been moved to the unsatisfactory group of 
cases, in the exercise of the editorial function. The author of the volume, who conducted the survey, does not regard the 
results achieved as entirely unsatisfactory, since this group of cases demonstrated that the use of delayed internal taxation 
in open or compound fractures due to gunshot wrounds did not cause a high incidence of infection. In the great majority of 
cases, the wound and fracture both healed in due time. It should be remembered that this survey does not represent a 
study of end results but is rather a progress report; in some instances, sufficient time had not elapsed from the date of 
internal fixation to permit final evaluation of either wound healing or fracture healing. [Editor’s note.] DELAYED INTERNAL FIXATION 
Table 17.—Residts of internal fixation performed on obligate indications in 135 compound 
fractures 1 
Fracture 
Favorable 
Unfavorable 
Incomplete 
Total 
A 
B 
C 
D 2 
E 
F 
G 
Humerus 
24 
6 
4 
1 
4 
3 
42 
Radius and ulna 
11 
4 
1 
2 
18 
Femur 
31 
7 
3 
2 
7 
57 
18 
Tibia and fibula 
7 
5 
1 
3 
2 
Total 
73 
22 
9 
3 
16 
12 
135 
1 See text, pp. 191-192, for code of results. 
2 See footnote 1, p. 192. 
Table 18.—Results of internal fixation performed on elective indications in 165 compound 
fractures 1 
Fracture 
Favorable 
Unfavorable 
Incomplete 
Total 
A 
B 
C 
D 2 
E 
F 
o 
Humerus 
17 
2 
2 
21 
Radius and ulna 
6 
1 
1 
1 
9 
Femur 
51 
17 
2 
3 
2 
4 
79 
Tibia and fibula 
27 
10 
8 
2 
6 
3 
56 
Total 
101 
30 
8 
5 
3 
9 
9 
165 
1 See text, pp. 191-192, for code of results. 
2 See footnote 1, p. 192. 
Table 19.—Results of internal fixation in relation to indications in 67 compound fractures 
of humerus 1 
Indications 
Favorable 
Unfavorable 
Incomplete 
Total 
A 
B 
C 
D 2 
E 
F 
Q 
Obligate 
Elective 
24 
17 
4 
6 
2 
4 
1 
4 
3 
2 
42 
21 
4 
Unknown 
Total 
45 
8 
4 
1 
4 
5 
67 
1 See text, pp. 191-192, for code of results. 
s See footnote 1, p. 192. 194 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Table 20.—Results of internal fixation in relation to indications in SI compound fractures 
of radius and ulna 1 
Indications 
Favorable 
Unfavorable 
Incomplete 
Total 
A 
B 
C 
D 2 
E 
F 
G 
Obligate 
11 
6 
4 
4 
1 
1 
1 
2 
1 
18 
9 
4 
Elective 
Unknown 
Total 
21 
5 
2 
3 
31 
1 See text, pp. 191-192, for code of results. 
2 See footnote 1, p. 192. 
Table 21.—Results of internal fixation in relation to indications in lfi6 compound fractures 
of femur 1 
Indications 
Favorable 
Unfavorable 
Incomplete 
T otal 
A 
B 
C 
D 2 
E 
F 
G 
Obligate 
Elective _ 
Unknown 
31 
51 
10 
7 
17 
3 
2 
2 
3 
7 
2 
7 
4 
57 
79 
10 
T ot al 
92 
24 
5 
5 
9 
11 
146 
1 See text, pp. 191-192, for code of results. 
2 See footnote 1, p. 192. 
Table 22.—Results of internal fixation in relation to indications in 88 compound fractures 
of tibia and fibula 1 
Indications 
Favorable 
Unfavorable 
Incomplete 
Total 
A 
B 
C 
D 2 
E 
F 
G 
Obligate 
7 
27 
14 
5 
10 
1 
2 
3 
6 
2 
3 
18 
56 
14 
Elective 
8 
Unknown 
Total 
48 
15 
8 
3 
9 
5 
88 
1 See text, pp. 191-192, for code of results. This table includes 13 fractures in which the fibula was plated. 
2 See footnote 1, p. 192. DELAYED INTERNAL FIXATION 
195 
Table 23.—Composite results of internal fixation in relation to technique and location of fracture 
in 332 compound fractures of long hones 1 
Technique and location 
Favorable 
Unfavorable 
Incomplete 
Total 
A 
B 
C 
D 2 
E 
F 
a 
Plating: 
Humerus 
16 
3 
1 
1 
3 
1 
25 
15 
Radius and ulna _ _ _ _ 
9 
2 
1 
3 
Femur 
41 
12 
2 
5 
5 
72 
Tibia and fibula 3 
16 
10 
6 
1 
8 
2 
43 
13 
Fibula and tibia 3 
10 
1 
2 
T otal 
92 
28 
6 
7 
6 
21 
8 
168 
Screws: 
Humerus 
10 
3 
1 
14 
Radius and ulna 
2 
2 
Femur 
39 
7 
1 
6 
53 
26 
Tibia and fibula 3 
19 
2 
2 
3 
Fibula and tibia 3 
Total _ 
70 
12 
2 
1 
10 
95 
Wire: 
H umerus 
19 
2 
3 
1 
3 
28 
14 
Radius and ulna 
10 
3 
1 
Femur 
12 
5 
2 
2 
21 
Tibia and fibula 3 
3 
2 
1 
6 
Fibula and tibia 3 
Total 
44 
12 
6 
4 
3 
69 
Grand total 
Percentage _ 
206 
62. 1 
52 
15. 7 
8 
2. 4 
14 
4. 2 
6 
1. 8 
25 
7. 5 
21 
6. 3 
332 
100. 00 
1 See text, pp. 191-192, for definition of terms. 
2 See footnote 1, p. 192. 
3 Tibia and fibula—plating of tibia. Fibula and tibia— 
plating of fibula. 
Sequestration was apparently the chief hazard associated with internal 
fixation (fig. 64). It occurred in slightly over a third of the cases surveyed and, 
case for case, seemed more extensive than might have been expected in the 
light of cases in which this procedure had not been used. Experience overseas 
had shown that in the ordinary course of events sequestration was practically 
always limited to areas of bone which had, presumably, been denuded at 
wounding; these areas were increased by the periosteal stripping necessary when 
internal fixation by plating was used. In some cases surveyed in the Zone of 196 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Interior, failure of wound healing was clearly attributable to delay in removal of 
sequestra as well as metal. Since the fractures were well united in all of these 
cases, there seemed no reason for having postponed the secondary surgery which 
was obviously necessary. 
Sequestration was only occasionally massive when screw or wire fixation 
was used. When it occurred with these techniques, it did not seem to interfere 
with union of the fracture. In such cases, it would probably have occurred no 
matter what method of fracture management had been employed. There was 
no doubt, however, of the tendency toward sequestra formation when plating 
was employed. It occurred in 69 of the 168 fractures treated by this technique 
and was sometimes so massive that the resulting bony defect could be com- 
pensated for only by bone grafting. 
Sequestration seemed less likely to occur, particularly when plates were 
used, if the internal fixation was done through a separate incision rather than 
through the compounding wound. It was also thought that wound healing 
occurred more promptly if the operation was performed through a separate 
incision. 
Other Data 
The details of 29 fractures in which internal fixation was performed in the 
presence of established wound infection are presented in table 24. The average 
time from wounding to operation in these cases was 36 days. 
Only 37 nerve injuries were recorded in these 332 fractures, 21 in fractures 
of the humerus, 6 in fractures of the radius and ulna, 9 in fractures of the femur, 
and 1 in a fracture of the tibia and fibula. Only 1 nerve injury in 88 fractures 
of the tibia and fibula seems unlikely; other nerve injuries probably occurred 
and were not recorded. 
Table 24.—Results of internal fixation in 29 compound fractures with established wound 
infection 1 
Fracture 
Favorable 
Unfavorable 
Incomplete 
Total 
A 
B 
C 
D 2 
E 
F 
O 
Humerus 
1 
1 
1 
3 
Radius and ulna 
1 
1 
2 
Femur 
9 
3 
2 
2 
4 
I 
21 
Tibia and fibula 
1 
1 
1 
3 
Total 
10 
4 
1 
3 
2 
6 
3 
29 
1 See text, pp. 191-192, for code of results. 
2 See footnote 1, p. 192. DELAYED INTERNAL FIXATION 
197 
Kefracture, which in each instance involved the femur, occurred 7 times 
in these 332 fractures. In 6 of the 7 refractures, the second fracture occurred 
at a point at which there had been bone loss at the site of the original injury. 
In the seventh refracture, the bone loss had been caused by sequestration. 
In four instances, there was no obvious cause for the second fracture. In two 
instances, the refracture followed falls, and in the remaining instance it followed 
manipulations to secure motion of the knee joint. In spite of the complication 
of the second injury, the end results were good to excellent in all seven refrac- 
tures. 
Generally speaking, although no statistics were collected to prove it, it 
was thought that the range of knee motion following rigid internal fixation 
(that is, by plates and screws) of fractures of the femur, when surgery was 
supplemented by a program designed to achieve maximum functional results, 
exceeded the range achieved in comparable injuries managed by other methods. 
The range of knee motion, however, varied with the level of the fracture. 
Knee motion was excellent in some fractures of the upper half of the femur. 
It was less good in many fractures of the lower half and was particularly 
unsatisfactory in fractures of the lower third. In many cases, the explanation 
of less than satisfactory knee function was failure to institute a program of 
knee motion after the patient reached the Zone of Interior in a hip spica. The 
omission of this program simply failed to capitalize on one of the decided 
advantages of internal fixation. 
It was interesting to observe the results in patients who had come from 
the 21st General Hospital in the Mediterranean theater, which was known to 
have an excellent program of postoperative knee motion in effect on its fracture 
wards. Whether the patients with fractured femurs from this hospital had or 
had not been managed by internal fixation, the range of knee motion, case 
for case, was superior to the range of motion observed in patients from other 
hospitals. 
CONCLUSIONS OF THE SURVEY 
It was concluded from this survey of internal fixation carried out in hos- 
pitals in the Zone of Interior that, when this procedure is used on correct 
indications and is performed by the correct technique, it has a definite, if lim- 
ited, place in the management of battle-incurred compound fractures of the 
long bones in fixed hospitals overseas. The term “correct indications” implies 
that the operation is performed only as an adjuvant measure and within the 
strict limitations of reparative surgery. Failure to institute surgical measures 
to forestall infection and favor wound healing invariably prejudices the results. 
There were no deaths and no amputations in these 332 fractures. The 
overall results were satisfactory to excellent with two groups of exceptions, 
fractures associated with massive soft-tissue loss and fractures of the tibia and 
fibula managed by plating. 198 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
In the light of the results achieved in this series and evident in this survey, 
conclusions concerning the results possible of achievement by delayed internal 
fixation may be stated as follows: 
1. Nonunion can be prevented in fractures with segmental defects or per- 
sistent distraction, as is evidenced by the achievement of bony union in 27 of 
39 such fractures in this series. 
Varying degrees of malunion, delayed union, or nonunion can be prevented 
in many cases in which inadequate reduction was achieved by other measures. 
This is evidenced by the achievement of bony union in good apposition and 
alinement in 64 of 75 such fractures in this series. 
Bony union, with optimal reduction, can be achieved in condylar fractures 
about the knee and elbow. This result was achieved in all 15 such fractures 
in this series. 
The obvious advantages of well-stabilized optimum reduction can be 
achieved in fractures which lend themselves to rigid stabilization, and satis- 
factory wound healing may be achieved in many cases, provided that fixation 
is accomplished by multiple screws, with minimal periosteal stripping. Union 
was accomplished in good position in all 95 fractures thus managed in this 
series. Wound healing was accomplished without sequestration or removal of 
metal in 71 of these fractures and was accomplished after their removal in 
another 14. 
When plating is the method of fixation, bony union and satisfactory 
wound healing must be anticipated in a smaller proportion of cases. In 168 
fractures managed by this technique, bony union was accomplished in 140. 
Wound healing was accomplished without sequestration or removal of metal 
in 99 fractures and was accomplished after their removal in another 34. 
Improved apposition of fragments can sometimes be provided by the use 
of wire sutures, and favorable results may be anticipated in many instances. 
When this technique was used in this series, bony union was accomplished in 
59 of 69 fractures. Wound healing, without sequestration and without removal 
of metal, was accomplished in 50 fractures, and in another 12 the wound healed 
after metal and sequestra were removed. Four fractures in which wire sutures 
were used were absolute failures, and three others were incomplete at the time 
of the survey. 
2. The chief hazard of delayed internal fixation, namely, increased seques- 
tration, may be explained by the periosteal stripping which the procedure 
entails and by its interference with readherence of soft parts to denuded bone. 
Other observations indicate that sequestration of bone in nonfixed battle 
fractures is practically always limited to bone that was probably denuded at 
wounding. Sequestration occurred in a little over a third of the fractures in 
this series, but comparable data in a control series are not available. 
The sequestration which occurred in this series when screw or wire-suture 
fixation was used was seldom massive, did not seem to interfere with union 
of the fracture, and probably would have occurred in many cases if the frac- 
tures had been managed by other methods. DELAYED INTERNAL FIXATION 
199 
Massive sequestration occurred in 41 of the 168 fractures which were 
managed by plating, with retardation of attainment of full strength of the bone. 
In some fractures managed by plating, a massive defect may be created which 
is reparable only by bone grafting. 
3. Unless the fracture contour permits rigid fixation by screws or unless 
wire sutures appear advantageous, it is best to attempt reduction by traction 
or manipulation and strive for early wound healing. When wound healing 
has been accomplished, fixation by plating or some other technique is rela- 
tively safe. Wound healing occurred by this plan in 20 of 21 fractures in this 
series, without sequestration or removal of the metal. 
Excellent results may be expected in fixations of the long bones of the 
upper extremity if severity of bone loss or of the soft-tissue injury does not 
prejudice the chances of union and wound healing. Massive soft-tissue loss 
had occurred in this series in 5 of 7 failures of internal fixation of fractures of 
the upper extremity, and bone loss had occurred in the other 2 fractures. 
Fixations of the femur, performed on correct indications, by means of 
multiple screws or wire sutures and with minimal periosteal stripping, may be 
expected to give excellent results. In this series, there were no failures in frac- 
tures of the femur fixed by screws. Bone loss was responsible for the two 
failures with wire-suture fixation. One of the patients, in addition, had suffered 
a massive loss of soft tissue. The risk of the periosteal stripping necessary when 
plating is employed makes it preferable to delay fixation until after wound 
healing unless the indications and anticipated advantages overshadow the 
hazard. 
Fixation of the tibia by multiple screws or wire suture may be expected 
to give very satisfactory results. Periosteal stripping should be kept to a 
minimum. There were only two unfavorable results in the fractures in this 
series fixed by screws; in both, heavy sequestration occurred. The single 
entirely unfavorable result in the fractures fixed by wire sutures was expected, 
ultimately, to be favorable; only 4 months had elapsed since wounding, and 
it was thought that the fracture would eventually unite. Plating of the tibia 
should be reserved until after wound healing. Eight of the nine failures in 
fixations of the tibia, and six of the eight massive sequestrations, occurred 
after plating of this bone. A more extensive use of wire sutures to maintain 
approximation might have improved results. 
When both tibia and fibula are fractured, plating of the fibula may be a 
useful procedure, and one which is relatively safe. It maintains length and 
alinement, aids in achieving apposition of tibial fragments, and provides some 
degree of immobilization of the fracture of the tibia. 
4. Internal fixation, when used as an adjuvant to the management of 
unreduced, infected compound battle fractures, may aid in the control of 
infection and in achieving the best result which can be obtained in the circum- 
stances. In the 29 infected cases in this series (table 24), bony union was 
achieved in good alinement in 20, and wound healing occurred without further 200 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
sequestration in 13. In 13 additional cases, wound healing occurred after 
removal of sequestra and metal. 
This followup study of 332 compound fractures, all but 13 of which were 
combat incurred, revealed satisfactory to optimal results in 258 cases (77.7 
percent). These 258 fractures illustrate the optimum results which could 
have been achieved. They include 21 fractures in which removal of metal and 
sequestra had not yet been performed but in which excellent results could be 
expected after secondary surgery had been carried out. They do not include 
eight fractures of the femur in which massive sequestration had occurred but 
in which there seemed reason to hope that satisfactory weight-bearing extremi- 
ties would eventually be secured. 
ANALYSIS OF UNFAVORABLE RESULTS 
The 53 fractures classified as unsuccessful fall into 4 groups: 
Eight operations, all performed on elective indications (group C). In 
this group, union of the fracture occurred promptly, but metal and massive 
sequestra had to be removed before wound healing was obtained. All cases in 
this group were fractures of the tibia, in which plating is always associated 
with some risk. The massive sequestration which occurred threatened bony 
continuity and introduced the risk of refracture when weight bearing was re- 
sumed. This risk made it necessary to use braces for several months longer 
than was necessary in the A and B groups. 
Fourteen operations, nine performed on obligate and five on elective indi- 
cations (group D). In this group, union had not occurred at the time of the 
survey, and, for this reason only, the results are classified as unfavorable.2 
From the standpoint of wound healing, the result was successful. The fact of 
nonunion, furthermore, must be evaluated against the chances of the same result 
if internal fixation had not been performed. 
Six operations, three performed on obligate and three on elective indica- 
tions, in which wound healing did not occur and, in most instances, union of the 
fracture was not achieved, until both sequestra and metal were removed (group 
E). The time required for both wound healing and bony union therefore ex- 
ceeded normal expectancy. 
Twenty-five operations, sixteen performed on obligate and nine on elective 
indications, in which fractures did not unite and wounds did not heal (group F). 
The fractures in this group represent the only absolute failures in the series, and, 
even in it, wound healing occurred in several instances after removal of metal 
and sequestra. It was expected, however, that bone-grafting procedures would 
be necessary in all cases to accomplish bony union. As in group D, these results 
must be evaluated against the probability of similarly unsatisfactory results if 
internal fixation had not been employed. 
2 See footnote 1, p. 192. DELAYED INTERNAL FIXATION 
201 
These unfavorable results, to consider the fractures from the separate 
standpoints of wound healing and bony union, include 14 fractures in which 
wound healing occurred but bony union did not; 8 fractures in which bony 
union occurred but wound healing was obtained only after metal and massive 
sequestra were removed (all fractures of the tibia); 6 fractures in which wound 
healing did not occur and bony union was usually not achieved until both 
sequestra and metal were removed; and 25 fractures in which neither union of 
the fractures nor wound healing was accomplished. 
In the 53 unfavorable cases, 19 operations were performed on the femur, 
20 on the tibia and fibula, 9 on the humerus, and 5 on the radius and ulna. 
Twenty-five were performed on elective and twenty-eight on obligate indications. 
Certain of these cases warrant special comment: 
In 2 operations on the femur performed on obligate indications, 1 managed 
by plating and 1 by wiring, the indication was segmental bone loss so extensive 
that nonunion was regarded as probably inevitable by more conservative 
methods. In a third fracture, which was managed by plating, previous manage- 
ment had been unsuccessful. The fracture was double, and the large rotated 
central fragment could not be reduced. When the patient was surveyed, the 
proximal fracture was well united, and it was thought that the distal fracture 
might still unite. In spite of the unsuccessful result in this case, the use of 
internal fixation was regarded as both justified and advantageous. 
In one of the elective operations on the femur, the fracture, which was 
mildly comminuted, was only partly stabilized by screws and wire sutures; 
the operation had been performed in an infected field. The patient had already 
undergone amputation of the foot on this side and amputation of the contra- 
lateral leg for infection. He was observed only 4 months after wounding, and 
it was thought that the fracture might still unite. In another unsatisfactory 
operation, the major fragments of the severely comminuted femur were sutured 
in apposition. The wound was infected, the infection extending into the joint, 
and the fracture site had to be drained by dependent drainage. The failure 
of union in this case could not be attributed to internal fixation. 
In one operation on the tibia and fibula, classified as unfavorable because 
of nonunion although the wound healed promptly, the failure must be charged 
against poor technique; examination of the roentgenograms taken overseas 
showed that the bone had been plated with the fragments distracted. In 
another operation, a 4-inch defect in the tibia had been strutted by plating the 
fibula, in expectation of a later bone-grafting operation. In a third operation, 
nonunion was explained by bone loss and unsatisfactory contact of the 
fragments. 
In three unfavorable operations on the humerus, all managed by wiring, 
there was segmental bone loss. It is interesting that in 10 similar operations 
in the series union was achieved by the same technique. In another operation, 
plating was performed 25 days after wounding, when wound healing was 
complete, because conservative measures of fracture management had failed 
to achieve satisfactory reduction. 202 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Ill a fracture of the bones of the forearm in which internal fixation failed 
to produce union even though the wound healed, the indication for operation 
was bone loss. The ulna was intact, but there was a 1-inch segmental defect 
in the radius. A wire suture was applied to help maintain alinement, without 
any real expectation that union could be accomplished. In another patient, 
with a fracture of the radius and a double fracture of the ulna, the indication 
was elective. A Steinmann pin which had been passed down the medullary 
canal of the ulna had to be removed at the end of 3 weeks, and the radius was 
plated at this time. When the patient was observed in a Zone of Interior 
hospital, neither fracture of the ulna had united and reduction was poor, but 
it was thought possible that union of the radius might still be accomplished. 
In the 25 operations regarded as absolute failures, 16 were performed on 
obligate and 9 on elective indications. The failure in each case must be eval- 
uated in the light of the severity of the problem and the indications for fixation. 
When the 25 fractures are analyzed from this standpoint, the conclusion is 
reached that 2 fractures had been improved by internal fixation; 8 had not been, 
though progress had not been retarded; and 13 (3.9 percent of the 332 fractures 
in the series) had been harmed by the operation. In the two remaining frac- 
tures, a final evaluation from this standpoint was not possible at the time 
the survey was made. 
Editor’s note.—It should be emphasized again, as the author has noted already (p. 191), that fixation of the tibia 
with plates and screws yielded the highest percentage and the greatest number of unfavorable results in the open frac- 
tures treated by internal fixation. Unfortunately, these techniques are the easiest to accomplish. These facts should 
be brought home to every medical officer. Otherwise, the tibia will continue to serve as a boobytrap for the unwary, 
incompletely trained surgeon, with the wounded soldier as the victim. CHAPTER VII 
External Skeletal Fixation of Fractures in the 
Communications Zone1 
The experience with external skeletal fixation in the management of 
battle-incurred compound fractures in the Mediterranean Theater of Operations 
in World War II is of historical interest only. Apparatus for external skeletal 
fixation became available in the theater for certain general hospitals and a 
smaller number of specially authorized station hospitals in the summer and fall 
of 1943. Almost as soon, however, as the method began to be used, it became 
evident that its indiscriminate use in military surgery was attended with 
pitfalls and hazards and that its application must be rigidly restricted. For 
these reasons, it had a very limited use in the Mediterranean theater, and this 
report chiefly concerns the special hospitals in which it was employed. 
The restrictions placed upon the use of external skeletal fixation in combat- 
incurred compound fractures were specified in Circular Letter No. 48, Office 
of the Surgeon, North African Theater of Operations, 18 November 1943.2 
In substance, they were as follows: 
External skeletal fixation is a highly specialized technique of fracture 
management, to be used only in carefully selected cases, only on special indi- 
cations, and only by surgeons trained and experienced in its application. If 
an indication arises for its employment in a hospital whose staff does not include 
a surgeon with these qualifications, the patient must be transferred to a hospital 
in which trained personnel is available. 
Only under emergency conditions may a patient be transferred from one 
hospital to another with apparatus for external skeletal fixation in place. 
If the transfer is not avoidable, he must be assigned to a hospital whose staff 
includes a surgeon trained in its use. Evacuation to the Zone of Interior with 
the apparatus in place is not permissible. If further immobilization is required, 
the patient must be held in an overseas hospital until the pins can be removed 
and more conventional methods of splinting substituted. 
ANALYSIS OF CASES 
Circular Letter No. 48 also provided that the clinical record of each patient 
treated by external skeletal fixation must be forwarded, through channels, to 
the Surgeon, North African Theater of Operations, after treatment had been 
1 Data for this chapter were collected by Maj. Herbert W. Harris, MC, and Capt. Edwin L. Mollin, MC, 17th 
General Hospital. 
2 See appendix, pp. 312-316. 
203 204 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
completed. The record was to cover all details of the case, including the date 
and circumstances of wounding; a complete description of the fracture and of 
the compounding wound if the fracture was compound; the initial treatment; 
the indications for external skeletal fixation; the length of time required to 
apply the apparatus and reduce the fracture; the number of roentgenograms 
required; the date, character, and extent of any distraction observed; the 
occurrence of infection about the pins; other complications; the date of re- 
moval of the apparatus; the subsequent management of the injury; and the 
disposition and end results. 
These instructions, unfortunately, were not universally carried out, and 
the complete data which it had been hoped would be accumulated in the Office 
of the Surgeon therefore did not become available. In an effort to supply the 
deficiency and determine the extent of the usage of external skeletal fixation 
and the results achieved by it, a survey was carried out early in 1945, on the 
orders of the Surgeon, in each of the general and station hospitals in which the 
apparatus had been made available. 
Four of the general hospitals in which provision had been made to employ 
external skeletal fixation treated no cases at all by it. Another hospital used 
the method in a few cases early in 1943 and had such poor results that it 
abandoned the technique entirely. The records were not available for some 
35 cases treated in 2 general and 1 station hospital which left the theater in 
August 1944 to support the invasion of southern France. 
The final report, therefore, covers only 8 general and 2 station hospitals 
and includes only 146 cases, all treated in 1944 and all recorded in sufficient 
detail to permit a reasonably satisfactory analysis. Some 20 other cases 
treated in these hospitals by external skeletal fixation had to be discarded be- 
cause of paucity of data. Representative experiences are presented in tables 
25, 26, and 27. 
After a full year of experience with external skeletal fixation used accord- 
ing to the instructions set forth in Circular Letter No. 48, there was no una- 
nimity of opinion concerning the merits of the technique. The small group 
of surgeons who had seen no place for it in civilian practice had been unwilling 
to give it a trial under military circumstances. Surgeons who had had an 
extensive previous experience with it and had therefore expected that it 
would have a wide application in both simple and compound combat-incurred 
fractures for the most part changed their opinion and restricted or discontin- 
ued its use. On the other hand, a group of surgeons with limited experience 
with the technique in civilian orthopedic practice believed that it offered 
decided advantages in carefully selected cases, and a number of them, as their 
military experience increased, actually broadened the indications. 
Complications.—Drainage from the sites of the pins was fairly frequent 
in these 146 cases but could usually be terminated by removal of the pins. 
Osteomyelitis was reported at the sites of the pins in only two cases in the 
series. In one instance, it developed about a pin far removed from the wound 
and must be considered a primary infection. In the other case, it extended 205 
EXTERNAL SKELETAL FIXATION 
from a severely infected compound fracture of the os calcis to a lower pin in 
the tibia. In both instances, wound healing was obtained after removal of 
dead bone and the institution of drainage. The only other serious complica- 
tion in the series was an abscess which developed about a lower femoral pin; 
it responded promptly to drainage. 
Table 25.—Essential data on 14 jractures treated by external skeletal fixation, 33d General 
Hospital, 1944 
Fracture 
Indication 
Complications 
Results 
Lower third humerus, compound, 
Elective (plated) 
Mild infection about 
Union. 
comminuted. 
Lower third humerus, simple, com- 
Elective - 
pins. 
do 
Do. 
minuted. 
Middle third humerus, compound, 
Comminution, skin grafting 
Do. 
comminuted. 
Delayed union. 
Ulna, compound, comminuted, dis- 
Malposition fragments, both bones. 
Union, stiff elbow. 
location head radius. 
Union. 
Radius and ulna, compound, com- 
Comminution, displacement 
Mild infection about 
minuted. 
Proximal third radius and ulna, com- 
pound, comminuted. 
pins. 
do 
Nonunion. 
Middle third femur, simple, com- 
minuted. 
Elective 
Unknown. 
Proximal third femur, simple, com- 
Comminution, malposition, short- 
Mild infection about 
Do. 
minuted. 
ening. 
pins. 
Do. 
Middle third femur, simple, com- 
Overriding, displacement-, 
do _ 
minuted. 
Early callus at evac- 
do 
uation. 
Unknown. 
Do 
Overriding, displacement 
do 
Middle third femur, compound, com- 
do 
do 
Do. 
minuted. 
do 
Do. 
Do 
Displacement, shortening 
Table 26.—Essential data on 27 fractures treated by external skeletal fixation, 26th General 
Hospital, 1944 
Fracture site 
Cases 
Average dura- 
tion of fixation 
Results 
Union 
Delayed 
union 
Nonunion 
Unknown 
Tibia, fibula 
Number 
1 11 
1 
6 
3 
3 
1 
1 
1 
Days 
68 
18 
81. 2 
49. 6 
52. 8 
27 
Unknown 
52 
3 
1 
3 
2 
2 
1 
3 
3 
1 
Tibia 
2 
1 
1 
Femur 
Humerus 
1 
Radius, ulna 
Radius 
1 
Resection knee joint 
Total - - . 
1 
27 
61. 39 
13 
5 
4 
4 
1 Amputation was required in 1 case, on indications not related to fracture management. 
396961°—57 15 206 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Table 27.—Essential data on 25 fractures treated by external skeletal fixation, 17th General 
Hospital, 1944 
Fracture 
Indication 
Complications 
Results 
Union. 
Do. 
Union, full duty. 
Union. 
Do. 
Nonunion ulna, de- 
layed union radius. 
Union. 
Do. 
Do. 
Do. 
Unknown. 
Union. 
Do. 
Do. 
Union resected knee, 
nonunion tibia. 
Union. 
Do. 
Do. 
Do. 
Do. 
Delayed union.1 
Union. 
Do. 
Do. 
Unknown. 
Maintenance length and allne- 
ment at radial carpal joint. 
Vertical fracture, reduction not 
possible in plaster. 
Do... - 
Radius, wrist, simple, comminuted - 
Radius, ulna, lower third, compound, 
comminuted. 
Irritation (no infec- 
tion). 
Do 
Comminution, bone loss, traction 
failure. 
Comminution, rotation distal 
fragment, to supplement trac- 
tion. 
Osteomyelitis at 
site of pin. 
Femur, distal third, compound, 
comminuted. 
Do 
Do 
Do. 
Rotation distal fragment, to sup- 
plement traction. 
Fixation after resection of knee 
joint. 
do 
Fixation after resection of knee 
joint. 
Femur, compound, comminuted, 
into knee joint. 
Femur, tibia, compound, commi- 
nuted, infected knee joint. 
Femur, lower third into knee joint, 
tibia and fibula, compound, com 
minuted. 
Femur, compound, comminuted, 
tibia and fibula into knee joint. 
Femur, compound, comminuted, 
into knee joint. 
Infection about pin 
in tibia. 
Traction failure in alinement of 
short distal fragment: supple- 
mental to skeletal traction. 
Traction alone failure: supple- 
mental to traction. 
Failure to control distal fragment 
in traction: supplemental to 
traction. 
Mild irritation 
about proximal 
pin. 
Femur, lower third, compound, com- 
minuted. 
Do . 
Bowing fascial 
slough at site of 
pin. 
Femur, proximal third, compound, 
comminuted. 
Femur, supracondylar, compound, 
comminuted. 
Femur, condyles, compound, com- 
minuted. 
Compound dislocation, Infection 
ankle joint. 
Traction failure; supplemental to 
traction. 
To correct rotation distal frag- 
ment: supplemental to traction. 
Fixation after resection of knee 
joint. 
Fixation after resection of ankle 
joint. 
1 After replacement by skeletal traction. 
Comment 
The results of this analysis, together with discussions with the surgeons 
who had used the method, confirmed the opinion that external skeletal fixa- 
tion has only a limited application in the management of combat-incurred EXTERNAL SKELETAL FIXATION 
207 
fractures in overseas hospitals. Under special circumstances, it was thought 
to be a useful adjuvant to standard methods of treatment, and, in certain 
cases it might be the method of choice, but the indications were seldom 
regarded as absolute. 
There were a number of clear-cut contraindications to the use of external 
skeletal fixation in simple fractures in which it might have been the method 
of choice in civilian practice. They included (1) the length of time required 
to insert the pins and reduce the fracture; (2) the exacting care required to 
avoid loss of reduction and to prevent the development of complications 
during healing; and (3) the necessity for holding the patient in the hospital 
in which the pins had been applied until they could be removed. These were 
all matters of real importance in busy military hospitals. 
The application of external skeletal fixation in compound battle fractures 
was similarly limited although under certain circumstances it was thought 
that the time and care which the method required might be compensated for 
by the results that might be achieved. 
The World War II experience suggests that this technique might be 
applicable, in carefully selected cases, in the following situations: 
1. Fractures of long bones with severe comminution and loss of substance. 
Fractures of this kind have always been a problem in military orthopedic 
surgery. Loss of bone at wounding or the necessary removal at operation of 
fragments totally devoid of soft-tissue attachments might leave a partial or 
complete hiatus, sometimes of 2 or 3 inches. In these circumstances, it was 
difficult to maintain apposition of the fragments by plaster or traction, and 
comminution made internal fixation impractical. External skeletal fixation 
permitted stabilization of the fragments in apposition under direct observation. 
There was some loss of length, it is true, but in the upper extremity this is not 
a matter of importance. In the lower extremity, loss of length is serious. 
When it was expected to exceed an inch or an inch and a half it was therefore 
sometimes considered advisable, even if the fragments could have been ap- 
proximated, to brace them apart until wound healing had been obtained, in 
preparation for a bridging bone graft at a later reconstructive operation. 
In this way, shortening could be minimized. External skeletal fixation some- 
times served this purpose very well. It was similarly effective when loss of 
substance had been extensive in an occasional fracture of a single bone in the 
forearm or the leg. 
2. Persisting malalinements of fractures. External skeletal fixation proved 
useful in a few subtrochanteric and supracondylar fractures of the femur in 
which reduction could not be obtained by skeletal traction, presumably because 
of persistent and unopposed muscle tension. An analysis of the cases in- 
cluded in the survey showed that this technique had been the method of choice 
in a number of such fractures after skeletal traction had failed. It was neces- 
sary, however, that additional immobilization be provided by skeletal traction 
or by a hip spica. Stability was lost in a number of cases in which 
this precaution was not observed. 208 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-45-770 
Figure 68.—Management of compound comminuted fracture of left radius, with loss of 
bone substance and median-nerve palsy, by external skeletal fixation. A. Compound 
comminuted fracture of distal third of radius. Note loss of bone substance. B. 
Maintenance of reduction of fracture by external skeletal fixation. 
Five weeks after the fixation apparatus had been applied, the wounds were well healed; 
they had been left open at the original operation and were later closed with the aid of pinch 
skin grafts. The pins were removed 2 months after wounding, after moderate drainage 
had developed about them. Roentgenograms showed only scanty callus at this time, but 
the fracture was in excellent alinement, and the patient had good finger motion except for 
the area affected by median-nerve palsy. 
In this case, external skeletal fixation preserved alinement and bone length while the 
soft tissues were healing. It also allowed motion of the adjacent joints to a much greater 
degree than would have been possible had the extremity merely been immobilized in plaster. 
3. Compound comminuted fractures of the tibia and fibula. In this type 
of fracture both maintenance of reduction and wound healing were frequently 
difficult when the more usual methods of management were employed. In a 
few cases, the fractures could be reduced under full vision and locked in position 
by external skeletal fixation. A reinforcing plaster cast was also used. Some 
surgeons felt that this combined technique produced better results than 
plaster immobilization alone. 
4. Comminuted fractures of both bones of the forearm. For a number of 
reasons, these fractures constituted one of the most difficult problems of mil- 
itary surgery. In a few cases, the difficulty was overcome by the use of ex- 
ternal skeletal fixation, which produced improved apposition and alinement 
of the fragments. EXTERNAL SKELETAL FIXATION 
209 
A FIP C-45-775 
Figure 69.—Management of segmental compound comminuted fractures of proximal third 
of left tibia and fibula by external skeletal traction. A. Roentgenogram of fractures. 
B. External skeletal apparatus in place. 
When the cast was changed 1 month after wounding, the wound was granulating, but 
the crest of the tibia was exposed. Ten days later, all bone was covered with granulating 
tissue, and clinical union was apparent. The pins were removed as soon as the new cast 
had hardened thoroughly. When the cast was again changed at another hospital 30 days 
later, the wound was healed, and the fracture site, although not rigidly solid, felt well fixed. 
In spite of the severity of the injury, length and alinement were preserved in the tibial 
fracture. 
5. Comminuted fractures of the lower radius (fig. 68), in which shortening 
and collapse of the fragments often introduced a number of problems. Ex- 
ternal skeletal fixation was occasionally effective in maintaining length and 
normal joint alinement in both simple and compound fractures with severe 
comminution. A reinforcing cast was neither necessary nor desirable. When 
the apparatus was in place, motion of the fingers and of the thumb was possible. 
The results achieved in this type of injury suggested that external skeletal 
fixation was sometimes the procedure of preference. 
6. Burns or other wounds which required multiple staged operative pro- 
cedures and in which repeated access to the wounds was necessary. Windows 
cut in casts did not always provide the exposure required, and frequent changes 
of cast would have resulted in loss of position of the fracture, while the manipula- 
tions necessary to restore position would have prejudiced the healing of both 
fracture and wound. External skeletal fixation provided maintenance of 
reduction while delayed closure, skin grafts, and other procedures were carried 
out. 
7. Segmental fractures. Segmental fractures (fig. 69) with displaced 
central fragments are usually difficult to reduce. The two such cases included 
in this series, one a fracture of the tibia and fibula and the other a fracture of 
the femur, were both managed successfully by external skeletal fixation. 210 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
8. Resection of the knee and ankle joints (p. 231). In an occasional case 
of this kind, external skeletal fixation resulted in stable approximation of the 
bone surfaces and permitted repeated access to the wound for such procedures 
as were necessary to accomplish wound healing. A reinforcing plaster spica 
was used. 
As this list of indications shows, external skeletal fixation had a limited 
application in the management of battle fractures, its chief use being on a few 
specialized indications or as a supplement to other methods. In the great 
majority of cases, combat-incurred fractures were much better managed by 
other methods, and there was little or no need for apparatus for this method 
in a theater of operations. CHAPTER VIII 
AX ounds of Joints1 
HISTORICAL NOTE 
Pool, who wrote the section on wounds of the joints in the history of the 
United States Medical Department in World War I,2 stated that the evolution 
of the management of these injuries by Allied medical officers fell into three 
well-defined stages: 
1. Debridement; drainage; irrigation with antiseptic solutions; immobilizations. 2. 
Debridement; Carrel-Dakin treatment of the joint; immobilization. 3. Debridement; lav- 
age of the joint with Dakin’s solution or ether; joint suture, with drainage of the joint for 
about 24 hours; immobilization; passive movements and massage in 8 to 10 days. 
According to Pool, the poor results accomplished in joint injuries in the 
early years of World War I could be attributed to— 
* * * an undervaluation, on the part of surgeons, of the resistance to infection which 
the synovial membrane of a joint offers, a failure to comprehend the proper operative pro- 
cedures, and the universal employment of prolonged immobilization. 
Certainly a realization of the importance of the three chief features that 
characterized the final program; namely, debridement, complete closure of the 
joint, and early motion, developed slowly. In the early years of the war, 
surgeons hesitated to close a wounded joint for fear of enclosing a potential 
septic process. Drainage tubes were therefore used freely. In November 
1917, however, the Interallied Surgical Conference, when it met in its third 
session,3 concluded that “complete closing of joint wounds is universally ap- 
proved. ” Early in the war, repeated efforts were made to obtain chemical 
sterilization of the joint cavity by the use of various antiseptic methods and 
solutions, including, somewhat later, the Carrel-Dakin method. Eventually, 
there wTas general agreement that sterilization could not be achieved by these 
methods and that drainage tubes not only failed to drain the joint but also 
caused considerable harm by trauma to the intra-articular structures and by 
inviting secondary infection. Drainage of the compounding wound was, of 
course, an entirely different matter. 
1 The data in this chapter on wounds of the knee joint were collected by Maj. Herbert W. Harris, MC, and Capt. 
Edwin L. Mollin, MC, 17th General Hospital; Maj. Howard B. Shorbe, MC, 70th General Hospital; and Lt. Col. George 
A. Duncan, MC, and Maj. Benjamin W. Rawles, MC, 45th General Hospital. The data on wounds of the hip joint 
were collected by Maj. Spencer A. Collom, Jr., MC, 300th General Hospital. 
2 Pool, Eugene H.: Wounds of Joints. In The Medical Department of the United States Army in the World War. 
Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 317-341. 
3 Conclusions of the Interallied Surgical Conference, 3d session. In The Medical Bulletin, War Medicine, 1917-18, 
vol. I, pp. 77-78. 
211 212 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Finally, immobilization for long periods was the rule in the early days of 
the war. Willems, whose work was done chiefly at La Panne in Belgium, 
provided the principal exception to this position.4 He contended that early, 
active motion was essential in all penetrating wounds of the joint and par- 
ticularly in wounds of the knee joint, regardless of whether or not infection 
was present. He considered early motion, in fact, as especially essential in 
infected wounds of the knee joint, his contention being that by motion purulent 
exudate was “squeezed” out of the recesses of the joint, without the traumatiz- 
ing effect of drainage tubes, while continued motion prevented ankylosis and 
favored full functional restoration. Some of his results were brilliant. Pool 
mentioned the Willems method approvingly but supplied no supporting data. 
In spite of the results Willems was able to achieve, his concepts spread very 
slowly, and the general opinion continued to be that early active motion was 
even more impractical when suppurative arthritis was present than it was in 
uncomplicated penetrating wounds of the knee joint. The theory was generally 
accepted, however, that motion should be begun reasonably early, which 
usually meant within 10 days of injury. 
Resection of joints that were the site of suppurative arthritis following 
penetrating wounds had been practiced in all recorded wars preceding World 
War I, including the War of the Rebellion. In World War I, the French 
used this method extensively. It was sometimes employed as a primary 
prophylactic procedure, to eliminate the risks of infection and subsequent 
generalized sepsis and to avoid the necessity for amputation. In other in- 
stances, it was used as a secondary procedure in joint wounds complicated by 
suppurative arthritis. The high death rate and the high amputation rate 
reported for wounds of the major joints in all previous wars and in the early 
phases of World War I furnished ample rationale for this practice, particularly 
in severely comminuted fractures extending into the joint. The operation, 
however, found little favor with either British or American surgeons in World 
War I, though Pool stated that it had a limited application, to be determined 
by individual indications, in cases of suppurative arthritis not progressing 
satisfactorily under more conservative methods of management. 
The civilian experience with wounds of the joints between World War I 
and World War II is in no sense comparable to military experiences. Neither 
in number nor severity do civilian wounds compare with battle-incurred 
wounds. Furthermore, the suppurative arthritis observed in civilian practice 
is usually bloodborne, in contrast to the predominantly traumatic etiology 
of the variety observed after battle-incurred wounds. 
In peacetime practice, suppurative arthritis continued to be treated 
between the wars by parapatellar drainage or, less often, by posterior drainage, 
combined with immobilization of the part by splints or by plaster casts. The 
Willems method of early mobilization, which some surgeons continued to 
use after World War I, gradually lost favor and was eventually discarded 
4 See footnote 2, p. 211. WOUNDS OF JOINTS 
213 
entirely. Occasional surgeons practiced aspiration of the joint. Others 
advocated a small arthrotomy incision and lavage of the cavity followed by 
complete closure. Sulfonamide therapy, which was introduced shortly before 
World War II began, was thought to be beneficial. 
Both Jolly 5 and Trueta,6 on the basis of their separate experiences in the 
Spanish Civil War, had concluded that the best method of management of 
war wounds of the joints seen in forward hospitals was (1) adequate debride- 
ment and removal of foreign bodies, (2) thorough lavage of the joint cavity, 
(3) suture of the synovial membrane or the capsule, and (4) immobilization of 
the part either in plaster or in a standard splint. There were differences of 
opinion as to how long immobilization should be continued in fixed hospitals, 
but there was general agreement that either passive or active motion should be 
instituted after the danger of suppurative arthritis had passed and as soon as 
the state of the soft-tissue wound permitted it. Joint injuries that were 
essentially compound fractures of the bones entering into the articulation 
were immobilized in the position least undesirable from the standpoint of 
future function, it being accepted that in such cases some residual limitation 
of motion was inevitable. Operation was not regarded as necessary in in- 
stances of perforating bullet wounds; in these cases it was assumed that bone 
damage was minimal. 
In World War II, just as in World War I, joint resection was rather 
extensively practiced by French surgeons, who employed it, as in the earlier 
war, to forestall amputation due to infection in severely damaged joints, as 
well as in suppurative arthritis. Russian and German surgeons also em- 
ployed resection of the joint, but the British seldom resorted to it. 
GENERAL CONSIDERATIONS 
It is surprising, in view of the extreme seriousness of wounds of the joints 
in military surgery, how few directions for their management were provided 
for LTiited States Army medical officers. Technical manual Guides to Therapy 
for Medical Officers (TM 8-210), published 20 March 1942, merely stated 
that wounds of the joints should be treated as compound fractures. The 
item was even less useful than it might have been because the text was not 
indexed. Orthopedic Subjects,7 one of the Military Surgical Manuals pub- 
lished by the Subcommittee on Orthopedic Surgery of the Committee on 
Surgery, Division of Medical Sciences, National Research Council, contains 
less than half a page on the subject: 
If the wound involves a joint, this should be opened widely at the time of the incision 
of the skin and fascia and the joint should be thoroughly explored. Loose fragments of 
5 Jolly, D. W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941. 
6 Trueta, J.: Treatment of War Wounds and Fractures With Special Reference to the Closed Method as Used in 
the War in Spain. New York: Paul B. Hoeber, Inc. 
7 Orthopedic Subjects. Prepared and edited by the Subcommittee on Orthopedic Surgery of the Committee on Sur- 
gery of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals, Philadelphia 
& London: W. B. Saundets Co., 1942. 214 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
bone and any foreign material present in the joint should be removed. Any soiled bone 
exposed in the wound should be excised. The joint may or may not be irrigated with 
physiologic salt solution, depending on the choice of the surgeon. In most instances it is 
possible to clean the joint adequately without irrigation. The wound should then be dried, 
the joint cavity should be sprinkled liberally with one of the sulfonamide drugs and the 
wound should be treated as has been described in the case of fractures not involving joints. 
The vaseline gauze packing should extend down to the joint cavity. In most instances the 
synovial membrane can be closed with fine catgut. In wounds which are not very recent, 
or which are in questionable condition, the joint should be left open. As a rule, no attempt 
should be made to suture the capsule or ligaments exposed in the wound and severed. The 
joint should be immobilized in a plaster-of-paris cast as described previously. 
An accurate record of wounds of the various joints does not exist for World 
War II. This is chiefly because compound fractures adjacent to and involving 
the joints were so often present concurrently. When this happened, the injuries 
were likely to bo recorded as fractures rather than as wounds of the joints. 
Certain corrections, of course, can be read into certain statistics. Thus a 
compound fracture of the femoral condyles necessarily involved the structures 
of the knee joint, just as a compound fracture of the head of the humerus 
necessarily involved the structures of the shoulder joint. These adjustments, 
however, were not possible when the level of the fracture was not stated, as 
it frequently was not, and in these circumstances the record of joint involve- 
ment was permanently lost. 
There was never any question as to the potential seriousness of all wounds 
of the joints in World War II. Any damage, no matter how slight, had to be 
regarded as prejudicial, in some degree, to future function. The injuries varied 
from small penetrating depressions which carried the articular cartilage into 
the underlying cancellous bone to extensive compound comminuted fractures 
of the bone ends making up the joint. Often the damage amounted to com- 
plete destruction of all articular structures. Even if the damage was slight, 
suppurative arthritis was a possibility in every wound of a joint. At the best, 
its development invited ankylosis. At the worst, it endangered the survival 
of the extremity and sometimes the survival of the patient. Every injury 
of a joint had to bo managed with the possibility of these consequences in 
mind. 
Since the overwhelming majority of wounds of the joint were compound 
fractures of the bones entering into the articulation, the management of these 
wounds by United States Army surgeons in World War II, as might have been 
expected, went through the same process of evolution as has been described 
for the management of compound fractures. Since wounds of the knee joint 
are far and away the most important of these injuries, the development of a 
standard policy of management chiefly concerned them and can be most 
conveniently and logically described in connection with them. The manage- 
ment of wounds of the hip joint also introduced certain special considerations 
which are briefly described in a separate section. WOUNDS OF JOINTS 
215 
WOUNDS OF THE KNEE JOINT 
Since the knee joint and the hip joint are the major weight-bearing joints 
of the body, any injury to either joint is serious. A penetrating wound pro- 
duced by a missile usually results in intra-articular damage. The trauma is 
usually sufficient to affect future function to some degree, and each wound 
is a potential instance of suppurative arthritis. Once suppurative arthritis is 
established, the infectious process often endangers both life and limb, and 
fusion of the joint is often the best that can be hoped for. 
Frankau, who wrote the section on gunshot wounds of the joints in the 
official British history of World War I,8 confirmed these generalizations. In 
the first months of the war, he said, the results were “lamentable.” The 
amputation rate for wounds of the knee joint not complicated by fractures 
was 60 percent. It rose to at least 80 percent when a concurrent fracture 
was present. The case fatality rate was always high, though, as methods of 
management improved, it fell to 8 percent. The amputation rate was also 
reduced; it fell from 25 percent in 1916 to 7 percent in 1917. 
In view of the results in World War I, one can understand the point of 
view expressed in Buxton’s 9 report on 273 wounds of the knee joint treated 
in one fixed hospital during the second and third Libyan campaigns in World 
War II; namely, that an incidence of 34.8 percent for suppurative arthritis, 
an amputation rate of 4.4 percent, and a death rate of 1.8 percent could well 
be regarded as “excellent.” Buxton attributed these results to the small 
size of the causative missiles in this series, as well as to the feasibility of early 
operation and the availability of systemic sulfonamide therapy. When, 
however, such results as these are fairly regarded as “excellent,” it is easy to 
see why wounds of the knee joint should be classified among the most serious 
of all battle injuries. 
The majority of wounds of the knee joint in World War II were caused 
by high-explosive shell fragments, including artillery and mortar shells, gre- 
nades, mines, and boobytraps. These missiles were responsible for 222 of the 
271 wounds of the knee joint observed at the 45th General Hospital in the 
Mediterranean theater. Forty-two of the remaining forty-nine injuries were 
caused by bullet wounds, six were noncombat injuries which had occurred in 
traffic accidents, and one injury was incurred in an airplane crash. 
Early Plans of Management (Before February 1944) 
In the early months of United States participation in World War II, 
wounds of the knee joint wrere managed as the judgment and experience of the 
individual medical officer dictated, rather than by theaterwide policies. In 
8 Frankau, C. F. S.; Gunshot Wounds of the Joints. In History of the Great War Based on Official Documents. 
Medical Services Surgery of the War, London: His Majesty’s Stationery Office, 1922, vol. II, pp. 297-325. 
9 Buxton, St. J. D.: Gunshot Wounds of the Knee Joint. Lancet 1:681-684, 20 May 1944. 216 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
the best treated cases, the plan of management included prompt, thorough 
debridement; through lavage of the joint cavity; the introduction of sulfon- 
amide powder into the cavity; closure of the synovial membrane or capsule; 
and immobilization, usually in a long leg plaster cast. If initial surgery had 
been greatly delayed or if frank infection was present when the patient was 
first seen, closure of the synovial membrane was usually omitted, in an attempt 
to provide drainage. If the joint was severely damaged, the wound was 
usually extended and left open for drainage, but at this period in the war 
extensive intra-articular debridement was not performed. Primary resection 
as practiced by the French in this type of injury was not carried out, even 
when the joint had been destroyed. Although this program of management 
was extremely conservative, few secondary amputations seem to have been 
necessary. 
Even in the early days of United States participation in World War II, 
the importance and desirability of complete closure of the joint were fully 
established, though the practice was not extended to infected cases. Once the 
joint was closed, the intra-articular cartilage was protected, the hazard of sec- 
ondary intra-articular infection was obviated, and better subsequent function 
could be hoped for. It was also thought, though no direct proof existed, that 
closure of the joint permitted the presumptive bactericidal properties of the 
synovial fluid to act more effectively. 
When the casualty reached a fixed hospital, the plaster was removed; 
the wound was dressed and again left open for drainage; and immobilization, 
usually by plaster, was reinstituted. It was not until the principles of repara- 
tive surgery had become firmly established that it became customary to suture 
the wounds of the soft part at the second operation, sometime between the 5th 
and 10th days after wounding, as surgical limitations permitted. 
The duration of immobilization varied with the extent of bone damage. 
When it was not extensive, passive and active motion was instituted as promptly 
as it was thought to be safe in the special case. The Willems principle of 
immediate motion was almost never used. The feeling was that the ad- 
vantages of a few days of additional immobilization and rest for the part 
would expedite wound healing and that the advantages of prompt wound 
healing would outweigh any advantages likely to be derived from early forced 
active motion. 
Complications were infrequent when damage to the joint was minimal 
or even moderate, especially in joints without cartilaginous or bony damage. 
Even in these favorable cases, however, it \cas noted at the general hospitals 
that, when closure of the synovial membrane had been omitted, healing was 
frequently slow and there was more impairment of joint function than might 
have been predicted from the degree of initial damage. In other cases of 
minimal or moderate damage, prolonged infection, with slow destruction of 
the joint, sometimes occurred. In such cases, though the joint was doomed, 
open drainage usually prevented the development of toxemia and systemic 
sepsis. Precise figures are not available, but it was recognized that cases of WOUNDS OF JOINTS 
217 
this sort were not infrequent, both in overseas hospitals and in hospitals in the 
United States. 
On the whole, joints operated upon early and thoroughly, with closure 
of the synovial membrane and institution of immobilization, were usually 
free from infection (fig. 70). The term “early,” however, was relative. The 
timelag from w'ounding to initial surgery usually exceeded 12 hours. In one 
typical series of 384 wounds of the knee joint, it averaged 16.5 hours. When 
operation was done so long after wounding, forward-area surgeons in the early 
months of the war, fearful of the consequences of infection in a closed joint, 
frequently assumed that infection might already be present and therefore 
left the joint open for drainage. Observations at the hospitals in the rear 
showed that patients who were treated in this way sometimes did well but 
that in many cases infection wras prolonged and the joint wras completely 
destroyed. These could not be regarded as satisfactory results, even though 
few amputations were necessary and loss of life wras negligible. 
Idie Formative Stages in Development of Standard Concepts of 
Management (March-April 1944) 
In the early spring of 1944, there was a sharp rise in the incidence of 
suppurative arthritis following wounds of the knee joint treated in several 
of the general hospitals in the Naples area. It was possible to trace the cause, 
at least in part, to a wave of surgical conservatism among forward-area sur- 
geons at the Anzio beachhead. Part of this conservatism was apparently 
deliberate. Part of it was to be explained by the extremely difficult combat 
conditions under which forward surgeons were then working. Whatever the 
explanation, the results were the same. In many instances, surgical exposure 
of the joint was inadequate, intra-articular debridement was incomplete, and 
infection in the joint was the consequence. 
The increased incidence of suppurative arthritis in the group of casualties 
just described focused particular attention upon wounds of the knee joint and 
their possible complications. Shortly afterward, as part of the early formative 
stages of the program for the adjuvant use of penicillin in the management 
of battle wounds, a number of wounds of the knee joint with potential infec- 
tion or early established infection were studied in several general hospitals 
in the Naples area. All the wounds had been sustained from a few days to a 
few weeks earlier. Observations made on these 35 cases brought out the 
following facts: 
1. No infection had occurred in cases which had been treated by complete 
initial surgery, closure of the synovial membrane or capsule, and adequate 
immobilization. 
2. Suppurative arthritis of varying degrees of severity, with prolonged 
drainage and slow destruction of the articular surfaces, w as observed in several 
cases in which intra-articular damage at wounding had been only minimal 
to moderate but in which excisional surgery had been inadequate and in which 218 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 70.—Staged management of wound of left knee joint. A and B. Anteroposterior 
and lateral roentgenograms made in evacuation hospital before initial surgery, showing 
damage to lateral condyle of tibia. At initial surgery, the knee joint was opened 
medially and laterally and thorough debridement was performed. The synovial 
membrane and capsule were closed, penicillin solution was instilled into the joint, and 
immobilization was provided by a single hip spica. C and D. Anteroposterior and 
lateral roentgenograms made in fixed hospital 6 days later. The hip spica used as 
transportation splinting is still in place. Aspiration of the joint at this time showed no 
evidence of infection. The soft-part wounds were therefore sutured, and immobiliza- 
tion was continued. E. Appearance of healed wounds 2 weeks after reparative surgery. 
Because the wounds healed promptly, active and passive motion could be instituted 
promptly. F. Range of flexion and extension (90°) 5 weeks after wounding. The 
application of the principles of staged surgical management to this injury prevented 
wound infection and produced a highly satisfactory functional result. 
AFIP CA-45-872 WOUNDS OF JOINTS 
219 
the joints had been left open for drainage. The reaction closely resembled that 
observed in joints destroyed by the missile. 
3. Compound comminuted injuries of the patella were particularly likely 
to be followed by infection. 
4. In each of 15 cases complicated by infection of varying degrees of 
severity, unexcised, devitalized, traumatized intra-articular cartilage was 
present. 
Nineteen patients with wounds of the knee joint (all then available) 
were managed by an aggressive regimen of surgery, blood transfusions, and 
penicillin at the 21st, 23d, and 45th General Hospitals in the medical center 
at Naples and at the 17th General Hospital several miles away, as follows: 
1. Blood transfusions were given in amounts sufficient to maintain the 
hematocrit level at 40 or over. 
2. Penicillin was given intramuscularly in doses of 25,000 to 50,000 units 
every 3 hours. Systemic administration was supplemented by local instilla- 
tions into the knee joint in amounts of 5,000 units per cubic centimeter of 
physiologic salt solution. Systemic administration was always continued until 
all danger of continuing infection was past and, as a rule, until the wounds 
were healed. 
3. Surgically, these 19 cases were managed as follows: 
In eight cases, in which there was roentgenologic evidence of intra-articular 
trauma, the knee joint was explored. There was no definite evidence of infec- 
tion in any of these cases, but exposure at initial wound surgery had not been 
complete and exploration was undertaken to be certain that debridement had 
been adequate. In four cases, it had been. In the other four cases, potential 
foci of infection, in the form of devitalized areas of articular cartilage, were 
excised (fig. 71). The joint cavity was then thoroughly irrigated, the joint 
was closed, and penicillin was instilled into the cavity. Suppurative arthritis 
did not ensue in any of these eight cases, and in each case joint function was 
no more greatly affected than it had already been by the trauma of the 
original wound. 
In six wounds, in which definite, established suppurative arthritis was 
present but in which joint destruction had not yet occurred, the knee joint 
was widely exposed. The joint was cleansed ol all devitalized tissue, debris, 
and foreign material, after which blood clot and purulent exudate were removed 
by thorough irrigation. The synovial membrane w*as sutured, and, finally, 
penicillin was instilled into the joint cavity. For the next week, at intervals 
of 24 to 48 hours, aspiration, irrigation, and reinstillation of penicillin were 
carried out. Attempts at aspiration were usually fruitless because remarkably 
little fluid accumulated between treatments. Infection was controlled in all 
six cases, and, again, the ultimate function of the joint was limited only by 
the damage caused by the missile at the time of wounding (figs, 72, 73, and 74). 220 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 71. {See opposite page for legends.) 
AFIP C-44-265, CA-44-322 WOUNDS OF JOINTS 
In two cases, in which subacute infectious processes had been present for 
several weeks, the knee joint was reopened. A comminuted fracture of the 
patella was present in one of these cases. In the other, purulent exudate was 
dripping into the joint cavity from an infected fracture of the lower third of the 
femur. In both cases, necrosis of the articular cartilage had been caused by 
the infection and was not the direct consequence of wounding. All necrotic 
areas were curetted, and the edges of the cartilage left in situ were trimmed 
free of loose tags. The menisci, which were devitalized and friable, were also 
removed. The patella was resected in the first of the cases. After the cavity 
had been thoroughly irrigated, the synovial membrane was closed, and the 
aspiration-instillation regimen just described was instituted, beginning with the 
instillation of penicillin solution on the operating table. Results in both 
these cases were good. Infection was promptly controlled, and satisfactory 
healing followed delayed wound closure. The desirable program of post- 
operative mobilization was hampered in both cases by the complicating femoral 
fractures, but each of these patients had 10° to 20° of motion when he was 
transferred to the Zone of Interior, as well as at a later examination. 
In the three remaining cases, infection which endangered the limb was 
eradicated by resection of the knee joint (figs. 75, 76, and 77). In one of these 
cases, which was associated with a contralateral amputation in the upper third 
of the thigh, sepsis was severe enough to endanger the patient’s life. It had 
resulted from infection of a compound fracture of the medial tibial condyle, 
in which the line of fracture extended into the joint. The injury had looked 
relatively innocent but was poorty debrided. All three cases were treated by 
excision of the infected, necrotic bone and cartilage; resection of the joint; 
and staged procedures directed at wound healing. The infection was con- 
trolled, the wounds healed satisfactorily, and bony fusion was progressing when 
the patients were evacuated from the theater. 
4. The joint was immobilized after operation by a single plaster spica 
or a Tobruk splint. Movement was permitted when healing was progressing 
satisfactorily and it was thought that all danger of a flareup of infection was past. 
Figure 71.—Staged management of penetrating wound of right knee joint associated with 
comminuted fracture of lower third of femur. A. Wounds of knee and lower third of 
thigh observed in operating room just before reparative surgery. The small size of the 
wound of the knee joint makes it clear that intra-articular surgery has not been adequate. 
B. Extensively damaged medial condyle of femur seen on adequate exposure of joint. 
All devitalized articular cartilage was removed through this wide arthrotomy incision. 
The incision was extended proximally, and the comminuted fracture of the femur was 
fixed with multiple screws. C. Steps of reparative surgery. The aggressive surgical 
attack on this injury, which had been inadequately treated at initial wound surgery, 
undoubtedly forestalled suppurative arthritis and was followed by prompt wound 
healing. The femur united firmly and in perfect condition. 
396961°—57 16 222 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-292 
Figure 72.—Management of early established suppurative arthritis superimposed on 
multiple penetrating wounds of left knee. For reasons which are not clear, possibly 
because of the multiplicity of the penetrating wounds, this knee joint was not explored 
and debrided at initial surgery. A. Anteroposterior and lateral roentgenograms made 
in fixed hospital 10 days after wounding. B. Appearance of knee on same date. Note 
the bulging of the knee and the multiple wounds, from all of which pus oozed. C. 
Medial arthrotomy incision through which several areas of damaged articular cartilage 
were excised, together with several metallic foreign bodies embedded in the condyles 
of the femur and the partially devitalized medial meniscus. Areas of devitalized artic- 
ular cartilage and the friable lateral meniscus were removed through a lateral arthrot- 
omy incision. After thorough irrigation of pus and exudate, the synovial membrane 
was sutured in each incision, and the joint was filled with penicillin. A hip spica was 
applied for immobilization. The synovial fluid was aspirated, and the joint was irri- 
gated and filled with penicillin daily during the next 5 days, through a window in the 
cast. Systemic and local signs of infection rapidly subsided. Skin closure of each 
wound was carried out 12 days after the arthrotomy incisions were made. All signs 
of infection disappeared, and the wounds healed promptly. When the patient was 
evacuated to the Zone of Interior 5}4 weeks after wounding, the range of motion was 
30° from full extension. He was furnished with a removable splint for use at night, to 
maintain full extension of the leg at the knee as a precaution against flexion contracture. WOUNDS OF JOINTS 
223 
Standard Plans of Management (After May 1944) 
In the first months of the Mediterranean theater, as already noted, there 
was no theaterwide policy for wounds of the knee joint; each surgeon managed 
them in the light of his individual experience and training. As might have been 
expected, however, the differences between methods were more in details than 
in the basic pattern, which was generally as has just been described. The 
results accomplished during this early period seemed susceptible of improvement, 
particularly in the cases in which infection was present. That results could 
be improved was evident in the 19 injuries of the knee joint in which penicillin 
was tested in the Mediterranean theater and which were observed at about the 
time the reparative-surgery program for wounds of the soft tissues was becom- 
ing theaterwide. It was natural that this plan should be extended to wounds 
of the knee joint and that it should eventually become the standard plan of 
management for all wounds in this area, whether penetrating or perforating and 
whether or not they were complicated by infection. At the end of World War 
II, the surgical management of wounds of the knee joint had for all practical 
purposes come back to the concept enunciated by Pool in World War I;10 
that is, thorough debridement and immediate closure of the joint wound. The 
contribution of World War II was the extension of this program to the infected 
knee joint. 
Initial wound surgery.—Wounds of the knee joint, which were priority-two 
injuries, were treated at initial wound surgery by the same regimen as all other 
wounds, with such modifications as the location and character of the injury 
required. It was essential, for instance, to perform the operation on an operating 
table which could be broken at the knee; satisfactory exposure was otherwise 
difficult. Circumferential draping was used. A tourniquet was often applied 
to secure a dry surgical field. 
The incision and its extent were determined by the necessities of the special 
case. A separate arthrotomy incision was frequently better than approach 
through the battle wound. It was essential that the excisional procedure should 
include the removal of all foreign bodies, including loose bone chips; damaged 
menisci, and loose, fragmented and devitalized cartilage. Defects in the con- 
dyles were trimmed evenly. It was usually the wisest plan to excise a com- 
minuted patella. 
After thorough irrigation of the joint cavity, the synovial membrane, with 
the capsule, if possible, was sutured, and penicillin solution was instilled into 
the cavity. When loss of soft tissue precluded suture of the membrane or 
capsule, flaps of fascia or skin were rotated to secure the desired coverage. 
The joint was left open only when the extent of the damage made return of any 
joint function obviously impossible. In cases of this kind, it was always best 
to excise the remaining cartilage, which, since it was poorly nourished, avascular, 
10 See footnote 2, p. 211. 224 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 73.—Management of early established suppurative arthritis following wound of knee 
joint and comminuted fracture of patella. Ten hours after injury, wound wras opened and a 
foreign body removed; joint was irrigated, capsule closed, penicillin instilled into joint and 
given systemically; immobilization by long leg cast. Initial debridement had been incom- 
plete. Signs and symptoms of suppuration developed and persisted after patient was 
admitted to fixed hospital a wfeek later, in spite of continuation of penicillin. A. Swollen 
joint, granulating wound, and draining pus, 15 days after wounding. B. Medial arthrotomy 
incision, with inflamed synovial membrane and partially necrotic cartilage of comminuted 
patella visualized. Bit of cloth showm on gauze sponge wras removed from joint, together 
wdth coagulated fibrinous exudate in quadriceps pouch. Severely comminuted fragments 
AFIP Fd-448 
(Continued on opposite page.) WOUNDS OF JOINTS 
225 
AFIP Fd-448 
of patella were excised. C. Fragments of patella, some fibrinous exudate, and bit of cloth 
removed from joint. D. Instillation of penicillin into joint, through arthrotomy incision, 
after closure of synovial membrane and capsule. Old wound, which had broken open as 
result of infection, was excised; capsule closed. E. Wounds, after suture, through 
window in cast, 6 days later. F. Degree of active extension and flexion of leg at knee 3 
weeks later. Quadriceps power is sufficient to extend knee. Hand supports foot for 
photograph. Wounds healed promptly. 226 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C A-44-523, C-44-454, 92494, 92493 
Figure 74.-—Management of suppurative arthritis superimposed on moderately severe 
high-explosive shell fragment wound of left knee. At initial surgery 7 hours later, the 
knee joint was opened, and a foreign body embedded in the articular surface of the 
medial femoral condyle was removed. The joint capsule was sutured after irrigation 
of the cavity, and penicillin was instilled. In the fixed hospital 5 days later, local and 
systemic signs of suppurative arthritis were observed. The joint was aspirated and 
irrigated on two occasions, and penicillin solution was instilled into it. Four days 
later the temperature was 101° F.; the knee was swollen, boggy, and tender, and a 
seropurulent discharge exuded; maggots were crawling in the wound. A. Expo- 
sure of joint through proximal extension of old wound. Note intense hyperemia of 
synovial membrane and edge of damaged articular cartilage. Maggots were present in 
the joint cavity, which was thoroughly cleansed by irrigation. A piece of woolen 
cloth was removed, together with the devitalized area of articular cartilage, about an 
inch in diameter, which lay beneath it and which had been depressed into the condylar 
defect. The defect was trimmed evenly. The medial meniscus, although dull in 
(Continued on opposite page.) WOUNDS OF JOINTS 
227 
and traumatized, was a potential focus of infection. The remaining joint 
injury was then really only a compound fracture. 
The same principles of exposure and debridement were employed in indirect 
injuries of the joint produced by fractures extending into the joint, to insure 
that no debris, loose fragments of bone, or blood clots were left in the cavity. 
Immobilization was accomplished by a single hip spica or a Tobruk splint, 
with the knee in 10° to 15° flexion. Systemic penicillin therapy and the aspira- 
tion-instillation regimen of joint management were instituted and were con- 
tinued as long as indications existed. Postoperative instillation was carried 
out with a large needle, through a window in the cast. 
Reparative wound surgery.—Reparative surgery was undertaken at the 
general hospital 4 to 6 days after wounding. At this time, the cavity was 
again aspirated and irrigated, and penicillin was reinstilled, but the joint was not 
reopened unless there was reasonable doubt concerning the adequacy of initial 
wound surgery. If there was doubt, exploration was undertaken, as a precaution 
against the development of suppurative arthritis, and such additional excisional 
surgery as proved necessary was performed (fig. 71). The joint was well irri- 
gated before it was closed, and skin closure was effected by the usual technique. 
If for any reason reparative surgery could not be performed promptly 
after the patient’s arrival at the general hospital, the aspiration-instillation 
routine was carried out until operation could be performed. 
Immobilization was continued for 10 to 14 days after delayed primary 
suture. Then active mobilization of the joint was instituted, usually with the 
patient in balanced suspension in an Army half-ring leg splint, with Pierson 
attachment. Motion was progressivly increased from the position of full 
extension, to avoid flexion contracture. 
appearance, was not friable and was left in situ. The synovial membrane and capsule 
were closed, and the joint was filled with penicillin. Immobilization was accomplished 
by a Tobruk splint. B. Appearance of region of joint 3 weeks later. The operative 
wound is healed, but there is an unhealed area of partial loss of skin over the patella. This 
loss occurred at wounding. For 2 days after operation, synovial fluid had been aspi- 
rated through a window in the cast, the joint cavity irrigated, and penicillin instilled. 
Wound closure was possible 5 days after operation, by which time all signs of infection 
had subsided. It was necessary, however, to leave a small gap in the center unclosed, 
to avoid excessive tension on the skin margins of the lateral surgical incision. Immo- 
bilization was discontinued 2 weeks later; meantime, quadriceps exercises had been in- 
stituted. Six weeks after the operation for suppurative arthritis, the patient was 
evacuated to the Zone of Interior W'ith removable splinting for use at night as a pre- 
caution against flexion contracture. At this time the range of active motion was only 
10° to 15°. C. Anteroposterior roentgenogram made a year after wounding, showing 
extent of damage to medial condyle of femur. D. Range of active motion in knee a 
year later. Complete extension is possible but is not shown in this photograph. 
Figure 74. (Legend continued from opposite page.) 228 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-298 
Figure 75. (See opposite page for legends.) WOUNDS OF JOINTS 
229 
Figure 75.-—Management of suppurative arthritis of right knee joint, superimposed on 
damage resulting from severe perforating wounds. Injury included compound comminuted 
supracondylar and condylar fractures of femur and patella, with laceration of patellar tendon. 
Resection of joint. At initial surgery, it was recognized that the joint had been partially 
destroyed, and the comminuted patella was excised. In an endeavor to stabilize the con- 
dylar fragments as much as possible, a Steinmann pin was passed through them and brought 
out through the medial and lateral wounds, though the use of skeletal fixation in forward 
areas was not a recommended policy. When the patient was received at the general hos- 
pital on the 11th day after wounding, the joint and fracture site were bathed in purulent 
exudate. Efforts to control the suppurative process were not successful. A. Anteroposterior 
and lateral roentgenograms made just before reparative surgery. B. Appearance of knee 
just before reparative surgery, 3 weeks after wounding. C. Exposure of joint. The 
degree of destruction is such that restoration of function is obviously impossible. The 
Steinmann pin was removed, and the fracture site in the lower end of the femur was reduced 
and fixed by 2 screws. The almost totally destroyed condyles of the femur and the proximal 
end of the tibia were then excised. An external skeletal-fixation apparatus was applied to 
the extremity to maintain apposition of the femur and tibia. The operative wound was 
partly closed, so as to cover all exposed bone, and rubber-tissue drains to the dead space 
were inserted. A single hip spica was applied, incorporating the external skeletal-fixation 
apparatus. D. Articular surfaces of resected femur and tibia. Note destruction of artic- 
ular cartilage. E. Anteroposterior and oblique roentgenograms of resected knee joint in 
plaster cast. Note wire suture used to help maintain apposition of fragments. Nine days 
after resection, the wounds were clean, but the edges were not suitable for suture. The 
wound margins were trimmed back to healthy tissue, and old granulation tissue was excised. 
Five days later, at a third operative procedure, a small protruding portion of the external 
condyle was chiseled away, and the wounds were closed. Wound healing was obtained 
except for a persistent small sinus to the region of the internally fixed fracture. This man 
was evacuated to the Zone of Interior 6 weeks after operative resection of the infected knee 
joint. When he was observed several months later by the consultant in orthopedic surgery 
for the Mediterranean theater, the fracture had united, and the knee joint was fused. The 
wounds were well healed except for the small sinus just mentioned. When the fixation screws 
and sequestrum to which the sinus led were removed, prompt healing occurred. In this 
case, a knee joint hopelessly destroyed by the initial injury and superimposed suppurative 
arthritis was managed by early resection, and the optimal result which could be expected 
for such an injury was achieved within a minimum period of time. Internal fixation of the 
fracture of the distal end of the femur was an essential part of the surgery; for technical 
reasons, stabilization of the fracture was necessary before resection could be performed. 
External skeletal fixation, while useful in maintaining stability during the staged surgical 
procedure, was insufficient in itself for adequate immobilization, so after each operation the 
apparatus was incorporated in a single hip spica. 230 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
IT. S. Army photos 
Figure 76.—Management of severe suppurative arthritis superimposed on moderately severe 
damage to articular cartilage of left knee joint. Compound comminuted fracture of 
middle third of right femur. Resection of left knee joint. At initial surgery, high-ex- 
plosive shell fragments were removed from the joint, which was irrigated and closed. 
Penicillin solution was instilled, and penicillin was given systemically. A hip spica was 
used for immobilization. At the fixed hospital, the right femur wras placed in skeletal 
traction after the compounding wounds were closed. Aspirations, irrigations, and re- 
instillations of penicillin, the correct routine for the management of such wounds in a 
fixed hospital, were not instituted, and an infectious process developed and continued 
until the patient was extremely ill and the knee joint was grossly infected. A. Antero- 
posterior and lateral roentgenograms before initial surgery. Size and location of foreign 
bodies indicate considerable trauma to the articular cartilage. B. Anteroposterior and 
lateral roentgenograms 2 months after wounding, showing ravages of infectious process 
in joint. After proper preoperative preparation, the knee joint was resected. The 
resected surfaces were stabilized in reduction by the use of external skeletal-fixation 
apparatus, over which a single hip spica was applied. All wounds were left open for 
drainage but were closed 2 weeks later. C. Anteroposterior and lateral roentgenograms 
of resected knee joint, showing incomplete bony fusion about 2 months later. The bone 
destruction by the infectious process in this instance amounted to 3 inches and can be 
attributed not only to incomplete initial surgery but to failure to institute the proper 
regimen promptly in the fixed hospital when infection became evident. Re-arthrotomy 
should have been done at once. D. Healed wound several months later in the Zone of 
Interior. WOUNDS OF JOINTS 
231 
Management of infected knee joints.—The signs and symptoms of im- 
pending or established infection within the joint were chiefly pain, swelling, 
fever, and malaise. In the occasional case, if the manifestations were slight 
and if it appeared that initial wound surgery had been adequate, the aspiration- 
instillation routine with penicillin solution was carried out for a day or two, 
in the hope of aborting the infection. If the attempt was unsuccessful, no 
further time was lost. The joint was opened widely, was thoroughly cleansed 
of dead tissue and blood clot, was completely closed, and was filled with 
penicillin before it was immobilized (figs. 72, 73, and 74). Only when hope 
of a functioning joint had been entirely abandoned was the arthrotomy wound 
left open for drainage. The edges of the skin wound were freshened at this 
time, but closure was delayed until 5 or 6 days later. The usual postoperative 
regimen, including instillations of penicillin solution, was instituted. 
Resection of the knee joint.—Resection (figs. 75, 76, and 77) was limited 
to joints hopelessly destroyed either by the initial trauma or by infection. 
If it was performed on the indication of joint destruction, it was preferably 
carried out at the evacuation hospital, with the objective of preventing chronic 
infection and promoting wound healing. Resection for infection was oc- 
casionally necessary in a forward hospital, but the necessity for it on this 
indication more often became evident in fixed hospitals. The amount of bone 
excised at operation and the resultant shortening of the limb were predeter- 
mined by the extent of bone loss and the degree of destruction inherent in 
the trauma or the infectious process. Because of the shortening which resulted 
from the operation, the resected surfaces were designed to conform in extension 
rather than in slight flexion. 
Results of the Reparative-Surgery Program 
The reparative-surgery program for wounds of the knee joint had its 
first theaterwide application in May 1944, with the beginning of the Cassino- 
Rome campaign. Its results were immediately apparent. The incidence of 
wound infection in wounds of the knee joint dropped sharply. If infection 
was already present when patients were received in general hospitals, ap- 
propriate surgery and intensive postoperative care almost always controlled 
the process. A functioning joint, limited only by the damage done at wound- 
ing, was the usual result. Chronic infection seldom occurred except in joints 
hopelessly destroyed by trauma. For all practical purposes, the chief problem 
of wounds of the knee joint had been solved. The surveys described below 
furnished data to substantiate these conclusions. 
Disposition-board proceedings.—An examination of disposition-board 
proceedings for 1944, on file in the Office of the Surgeon, Mediterranean 
Theater of Operations, showed that in none of the 1,073 amputations performed 
for all causes had the operation been required for infection or sepsis following 
a properly managed wound of the knee joint (fig. 71). 232 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP C-44-236 
Figure 77.—Management of long-standing suppurative arthritis of right knee joint super- 
imposed on penetrating wound which damaged proximal end of tibia. Radical resection 
of joint. The left lower extremity had been amputated traumatically in the middle 
third of the thigh by the same shell explosion that caused the injury to the right knee. 
Forty hours after injury, the traumatic amputation was completed by the open circular 
method and other wounds were debrided, but little was done to the penetrating wound 
compounding the injury of the knee joint. After the patient was admitted to the fixed 
hospital 14 days later, signs and symptoms of sepsis were constant, there being no 
response to bilateral parapatellar incisions, penicillin therapy, blood transfusions, and 
immobilization. Pus extended up the fascial planes of the thigh, and incision and 
drainage were necessary. A. Anteroposterior and lateral roentgenograms 10 weeks 
after injury, showing complete destruction of right knee joint. At this time, the patient 
was quite toxic, temperature elevations to 102° and 103° F. occurred daily, and amputa- 
tion was seriously considered as a lifesaving measure. B. Interior of knee joint after 
exposure at operation 76 days after wounding through longitudinal incision extended 
proximally to drain another abscess in the thigh. The patella, which has been excised, is 
held beside the destroyed femoral condyle for demonstration purposes. All articular 
surfaces in the joint were found totally destroyed by the septic process. The healthy 
ends of the femur and tibia left after excision wrere held in approximation by a suture of 
stainless-steel wire placed anteriorly. Old wound edges were excised, but closure was 
not done. A hip spica provided postoperative immobilization. C. Resected joint. 
Shortening was of no consequence in this case because the opposite leg was already 
amputated. D. Dead, infected bone and cartilage excised from joint. WOUNDS OF JOINTS 
233 
AFIP C-44-236 
Figure 77. (See opposite page for legends.) 234 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 77—Continued. E. Partial closure of medial wound, with drainage, 6 days after first 
operation, after evident control of septic process. F. Closure of lateral wound at same 
operation. Drainage of abscess of calf. The depths of each wound were thoroughly 
irrigated before suture. G and H. Healed medial and lateral wounds 6 weeks later. Healing 
was entirely satisfactory, except for occasional small granulating areas. There were no 
sinus tracks. Local and systemic sepsis had been eliminated, and the patient was 
rapidly gaining weight and strength. A new hip spica was applied for transfer of the 
patient to the Zone of Interior. 
AFIP C-44-259. C-44-329 WOUNDS OF JOINTS 
235 
In 271 wounds of the knee joint studied from the same disposition-board 
proceedings, the cases were divided into those treated before the final drive 
for Cassino and Rome, which began 11 May 1944, and those treated after 
that date. 
In the 73 cases which made up the earlier group and which were treated 
by the original techniques, the incidence of infection in general hospitals was 
27.4 percent. In the 198 cases treated after the reparative program had 
become effective, the incidence of infection was 5.4 percent. 
In the earlier group, the infectious process continued in 8.2 percent of 
the cases until the joint had been completely destroyed, while in another 
8.2 percent of the infected cases the end result was not known. There were 
only 4 instances (2 percent) of complete joint destruction in the later series, 
and in 3 of these the recommended regimen for the management of early 
infection had not been instituted. In the remaining case, damage at wounding 
had been so severe that resection of the knee joint was necessary. 
General hospitals.—Reports from individual hospitals showed that when 
initial wound surgery had been adequate, results in wounds of the knee joint 
were greatly improved. 
At the 17th General Hospital, 194 wounds of the knee joint were analyzed, 
in 128 of which initial surgery had been adequate and in 6G of which it had 
not been. 
In 119 of the 128 cases in which initial surgery had been adequate, there 
was no evidence of infection when the patients were received in the fixed 
hospital, and closure of the wounds of the soft parts could be proceeded with 
at once. 
In 4 of the other 9 cases, in all of which infection was present, the process 
was controlled without surgery by the aspiration-instillation routine with 
penicillin solution. In two cases, secondary arthrotomy was performed, with 
excision of intra-articular devitalized tissue, and in another case incision and 
drainage controlled the infection. In these seven cases, a functioning knee 
joint was obtained. In the two remaining cases, bone damage had been 
extreme. Resection of the knee joint was necessary in one case and amputa- 
tion of the limb in the other, primarily because of trauma. 
In the 66 cases at the 17th General Hospital in which initial wound sur- 
gery had apparently not been complete, 16 joints were found to be infected 
when the wounds were exposed. In eight cases, infection was controlled 
satisfactorily by arthrotomy and secondary debridement. In another case, in 
which bone damage was severe, prolonged drainage was instituted through the 
open wound, without expectation that satisfactory function would ultimately 
be obtained. In the other seven cases, in all of which bone damage was 
extreme, resection of the joint was necessary in five cases and amputation in 
the other two. The results in the five resections were as satisfactory as this 
procedure permits. 236 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The 70th General Hospital received 45 patients with wounds of the knee 
joint after the Po Valley campaign, at the end of the fighting in Italy. Repar- 
ative surgery was rendered on an average of 7.7 days after wounding. In 
eight of these cases, arthrotomy was performed for exploratory purposes and 
to complete intra-articular debridement, on the indication of impending infec- 
tion. Recovery was uneventful in all. In the only two cases in the whole 
group in which infection became established, the process spread from infected 
fractures adjacent to the joint, a supracondylar fracture of the femur in one 
instance and a fracture of the upper tibia in the other. 
Resection of the knee joint.—It is known that 31 resections of the knee 
joint (figs. 75, 76, and 77) were performed in the Mediterranean Theater of 
Operations by United States Army surgeons; 24 of the operations were on 
United States Army personnel. 
Two of these operations were performed at initial wound surgery on the 
indication of extensive trauma. 
In six operations, all on French colonial soldiers and all at the 9th Evac- 
uation Hospital, which was then serving as a fixed hospital, initial wound 
surgery had not been adequate, and severe suppurative arthritis had followed 
relatively minor injuries caused by penetrating wounds. In each of these 
cases, it was thought that the infection present seriously endangered the 
vitality of the limb. 
In 3 other resections, the indication was also severe suppurative arthritis, 
superimposed in 1 case on minimal intra-articu)ar damage and in 2 cases on 
moderate damage. 
In the remaining 20 cases, the indication for resection was traumatic 
destruction of the joint, with impending or early established infection. 
The results in these 31 cases were satisfactory within the limitations of 
resection of the knee joint. There were no deaths. Rapid improvement 
invariably followed the operation. Most of the patients were evacuated to 
the United States with well-healed wounds, and nine are known to have had 
clinically stable limbs before they left the theater. In every case, it had been 
possible, without special difficulty, to achieve apposition of the bony struc- 
tures in the position of function. The shortening of the limb, which varied 
from 1 to 3 inches and which averaged 1 % inches, was dictated by the bone 
loss from trauma or infection. 
In a followup survey of various procedures conducted in the Zone of 
Interior early in 1945, it was possible either to examine or to secure accurate 
information about eight patients who had been subjected to resection of the 
knee joint overseas. In seven cases, the indication for the resection was 
traumatic destruction of the joint, followed by infection. In the eighth case, 
the original damage was moderate, but the joint had been destroyed by 
infection. 
In this case, as well as in six others, the wounds were healed. In the 
remaining case, there was a sinus to a condylar fracture just above the joint. WOUNDS OF JOINTS 
237 
Fusion was satisfactory in six cases, including the case in which the joint 
had been destroyed by infection; one of these patients was at a convalescent 
hospital and ready for a Certificate of Disability discharge. In another case, 
fusion seemed to be occurring, but only 3 months had elapsed since operation. 
In the remaining case, in which there was no evidence of fusion, it was thought 
that bone grafting would be required. 
The results in this small group of cases further confirmed the impression 
that resection of the knee joint has a definite, but fortunately limited, applica- 
tion in the management of severely traumatized and infected wounds of the 
knee joint encountered in military surgery. 
WOUNDS OF THE TU P JOINT 
Wounds of the hip joint (figs. 78, 79, and 80) presented even more diffi- 
cult problems in military surgery than wounds of the knee joint. Because 
they affected one of the two major weight-bearing joints of the body, they 
were always serious, even when the injury was not extensive. The immedi- 
ate case fatality rate was high, probably not because of the injury to the hip 
joint but because of associated injuries to overlying and adjacent major blood 
vessels. Later deaths were the result of associated intra-abdominal wounds, 
particularly wounds of the rectum or the urinary bladder. Such combinations 
of injuries were frequent, and their management taxed the ingenuity of for- 
ward- and rear-area surgeons alike. 
The management of wounds of the hip joint produced the least satisfac- 
tory results obtained in skeletal injuries in World War II. For this, there 
were a number of reasons: (1) The damage at wounding was often sufficient to 
destroy the joint and in itself was often enough to cause ankylosis. (2) In- 
fection was frequent. If the articulating surfaces of the femur and acetabulum 
had been damaged, as they had been in many cases, drainage was likely to be 
prolonged, and there was often evidence of systemic absorption and toxemia. 
(3) The high incidence of suppurative arthritis observed in general hospitals 
in cases in which trauma had been slight or moderate suggested that initial 
wound surgery had frequently not been adequate. In some of these cases, 
the joint was completely destroyed by the infectious process. (4) The prin- 
ciples of excisional surgery were the same for the hip joint as for all other joints, 
and their application to wounds in this area was equally necessary. 
On the other hand, the hip joint is not readily accessible, and adequate 
debridement required wide exposure and precise anatomic orientation. In- 
itial wound surgery, in short, was a procedure of magnitude, with which the 
average forward surgeon had usually had a limited experience if he had had 
any at all. The availability of a consultant in orthopedic surgery to the 
army surgeon (p. 5) might have contributed to the improvement of initial 
wound surgery in compound fractures of the hip joint and to a consequent 
improvement in the end results of these complicated injuries. 
396961°—57 17 238 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
U. S. Army photos 
Figure 78.—Management of suppurative arthritis superimposed on high-explosive shell 
fragment injury of hip joint. Initial surgery in this patient was inadequate; the hip 
joint was not opened, and the foreign body was not removed. Suppurative arthritis 
ensued, not controlled by removal of the foreign body 10 days later, without thorough 
intra-articular debridement. A. Anteroposterior roentgenogram of pelvis and hip 
joint in evacuation hospital showing high-explosive shell fragment lying in articular 
cartilage of head of femur. B. Anteroposterior roentgenogram of pelvis and hip joint 
4 weeks later, showing hip joint totally destroyed from infection. 
Survey of Cases, January 1945 
The results achieved in the treatment of wounds of the hip joint in the 
Mediterranean theater were recognized as so unsatisfactory that, in January 
1945, a survey was undertaken, on orders of the theater surgeon and at the 
request of the consultant in orthopedic surgery, to collect precise data concern- 
ing them. At this time, 15 casualties with injuries of the hip joint were hos- 
pitalized in the general hospitals of the Naples base area, the ratio being 1 to 
250 patients then hospitalized for all battle-incurred injuries. In addition, a 
search revealed 24 previous admissions for this cause in which the hospital 
records contained data sufficiently detailed for analysis. The material for the 
survey thus consisted of 39 cases. 
No case was accepted for this analysis unless there was roentgenologic 
evidence of trauma to bone or cartilage, on the reasonable assumption that a 
missile which penetrated the hip joint would inevitably produce some skeletal 
damage. A joint was classified as infected (1) if there was roentgenologic evi- WOUNDS OF JOINTS 
239 
Figure 79.—Management of suppurative arthritis superimposed on high-explosive pene- 
trating wound of left buttock, hip joint, and neck of femur. Life-endangering thoracic 
injury permitted only minimal debridement of wound of buttock in initial surgery. Ar- 
throtomy of hip joint was omitted. Suppurative arthritis could not be controlled, even 
after removal of intra-articular foreign body a week after wounding. No effort was made 
at this time to cleanse joint of debris or to insure good posterior drainage. A. Anteropos- 
terior roentgenogram showing foreign body overlying neck of femur. A lateral view demon- 
strated that missile had perforated femoral neck and come to rest anteriorly. B. Antero- 
posterior view of left hip joint, showing total destruction by infection 6 weeks after wounding. 
Patient was transported to ZI in hip spica before infection was controlled. 
AFIP C-44-358 240 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP FB-447, Fd-45-19 
Figure 80.—Management of suppurative arthritis of right hip joint, following damage to 
neck and head of femur by high-velocity missile. A. Anteroposterior roentgenogram 
of pelvis and hips made in evacuation hospital, showing fracture of neck of femur and 
retained foreign body. At initial wound surgery, the wound of entry was debrided, 
after which the joint was explored and the bullet and some loose bone fragments were 
removed. A hip spica was applied as transportation splinting. In the fixed hospital, 
the extremity was placed in balanced-suspension skeletal traction. Infection was 
persistent, and wound healing was not obtained. B. Anteroposterior roentgenogram 
made in fixed hospital 5 weeks after wounding, showing dead femoral head and de- 
struction of hip joint by infectious process. Soon after this film was made, the joint 
was opened through a posterior approach, and all dead bone was removed. The joint 
cavity was thoroughly irrigated, and the operative wound was sutured. A drain was 
inserted down to the old hip-joint cavity. Immobilization was obtained by a hip spica 
which extended to the knee on the opposite side. C. Dead head of the femur, which 
was removed along with other fragments of bone and cartilage. D. Healed wound, 
3 weeks after surgery on infected hip joint. The drain was removed 5 days after this 
operation, and healing occurred promptly. All signs of systemic toxemia also dis- 
appeared promptly. WOUNDS OF JOINTS 
241 
dence of progressive destruction, (2) if the patient presented the manifestations 
of toxemia, or (3) if there had been prolonged drainage from the joint. An 
unhealed compounding wound was not regarded, in itself, as evidence of joint 
infection. 
It is unfortunate that little precise information could be secured concerning 
the initial wound surgery performed in these 39 cases. In 13 cases, in which no 
infection had occurred, it could be ascertained that foreign bodies had been 
removed in several instances and that the joint capsule had been closed in two 
instances. In most of the 39 cases, however, including 26 cases of undoubted 
infection by the criteria just stated, the location and extent of the wounds sug- 
gested that exposure sufficient to permit adequate excision of devitalized tissue 
had seldom been accomplished. 
Certain observations made in this survey seemed highly significant. They 
are as follows: 
1. All six patients with concurrent intra-abdominal injuries also had infec- 
tions of the hip joint. The origin of the infection seemed obvious; it was 
assumed to have resulted from cross-infection from the associated injuries, in 
most of which the intestines were involved. 
2. Eighteen of the 19 patients with damage to the articular cartilage, 17 
of the 21 with involvement of multiple components of the hip joint, and 15 of 
the 19 with severe comminution had infections of the hip joint. These data, 
especially in the light of the similar data available for wounds of the knee joint 
(p. 219), clearly pointed to traumatized, devitalized, poorly nourished, unexcised 
articular cartilage as the focus of infection. 
3. The timelag from wounding to initial wound surgery, while prolonged, 
was substantially the same, on the average, in both the infected and the unin- 
fected group of cases (16 versus 17 hours). The timelag from wounding to 
reparative surgery was, however, considerably longer in the infected group, 12 
days compared with 7 days in the uninfected group. 
4. It was known that penicillin had been given in 22 of the 26 infected 
cases and in 12 of the 13 uninfected cases. 
5. In the 13 cases in which no infection was present, surgery in general 
hospitals had consisted only of wound closure. 
6. In 10 of the 26 infected cases, no additional surgery was performed in 
the general hospitals. The procedures performed in the other cases, after 
infection was evident and in an attempt to accomplish wound healing, included 
additional debridement (3 cases); additional drainage (3 cases); sequestrectomy 
(4 cases); excision of the head of the femur (2 cases); removal of foreign bodies 
and drainage, exploration of a sinus, and skin grafting (1 case each); and 
closure of the wound (1 case). In spite of these additional operations, wound 
healing was accomplished in only 2 of the 26 infected cases. 242 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Early Plans of Management 
Before the development of the program of reparative surgery, in the spring 
of 1944, patients with wounds of the hip joint, after initial wound surgery in a 
forward hospital, were transported to general hospitals in double hip spicas, 
extending only to the knee on the intact side. Transportation was usually 
possible within 5 to 6 days unless concurrent wounds required that the holding 
period be extended to 10 or 15 days, or even longer. Since established infection 
of the hip joint may become evident within 5 to 6 days, some wounds were 
infected before the patients ever left forward hospitals. 
After the patients reached the general hospital, the transportation spica 
was removed, the wound was dressed, and another spica was applied to hold the 
joint in a few degrees of abduction and external rotation and in about 30° 
flexion. Should ankylosis occur, this was the most desirable position. In occa- 
sional cases, skin traction or skeletal traction was used for a few weeks before 
the spica was reapplied. If suppurative arthritis developed, it was usually 
managed by open drainage, after which the patient was put up in plaster 
immobilization or in skeletal traction. 
Later Plans of Management 
The results of the survey undertaken in January 1945 confirmed the 
impression that the unsatisfactory results secured in wounds of the hip joint 
in the Mediterranean theater were chiefly caused by an inadequate approach 
to the problem. Confirmatory evidence was secured later in the year, when the 
theater consultant in orthopedic surgery was able to question the 
chiefs of various orthopedic sections in the hospitals in the Zone of Interior 
visited for another purpose (p. 189). Formal data were not compiled, but the 
unanimous opinion was expressed that, in the great majority of cases, infection 
of the hip joint was the result of retention of dead tissue and that it could not be 
controlled until this tissue had been removed by direct surgical attack. 
Early in 1945, an ideal regimen was worked out for wounds of the hip 
joint, based on aggressive surgery, adjunct chemotherapy, and liberal blood 
replacement. It was to include the following: 
1. Adequate exposure of the articulation, which, as already mentioned, 
was frequently a difficult technical procedure. 
2. As complete debridement as possible, followed by immobilization of 
the extremity. 
3. Transportation to a general hospital as rapidly as possible. 
4. Reparative operation as soon as preoperative preparation could be 
completed. If there were no evidences of infection, the operation was to be 
limited to closure of the wound. 
5. If signs of infection became evident in the forward hospital, radical 
secondary surgery was to be performed, as in wounds of the knee joint (p. 231). WOUNDS OF JOINTS 
243 
Wide exposure and thorough redebridement were recommended, with, if neces- 
sary, dislocation of the hip to secure adequate exposure. Since the operation 
was not an emergency, the services of an orthopedic surgeon qualified to under- 
take such extensive surgery were to be obtained. They were practically 
always available in the same or at some nearby hospital. 
6. If infection became evident after the patient reached the general 
hospital, the same sort of aggressive surgery was recommended. Here, 
qualified orthopedic surgeons were always available. Removal of devitalized 
bone and cartilage and of foreign material was to be carried out, as at initial 
wound surgery. Sometimes the removal of the dead and fractured femoral 
head would constitute, in effect, a resection of the joint. Elective resection 
for suppurative arthritis, as practiced by continental surgeons, is not known to 
have been performed by United States medical officers. 
It was realized that the proposed regimen represented a radical solution 
of the problem of wounds of the hip joint. It was also realized that the ex- 
cision of devitalized bone and cartilage, with dislocation of the hip, if necessary, 
to secure adequate exposure, might be followed by partial or complete restric- 
tion of joint function. On the other hand, it was felt that the hazard of sec- 
ondary surgery, under the protection of penicillin and blood replacement, could 
not possibly exceed the risk of severe infection of the joint, which might destroy 
life as well as limb. 
In the isolated cases in which this plan was followed, the results were as 
good as could have been expected under the circumstances, which were frankly 
disadvantageous. The program had, however, no theaterwide application. 
Almost as soon as it had been set up, the German armies in Italy capitulated, 
and fighting ended. In the light of the knowledge available at the end of the 
war, this program was felt to be the best plan possible for the management of 
wounds of the hip joints in future conflicts. 
WOUNDS OF THE SMALLER JOINTS 
In the great majority of wounds of the shoulder, elbow, wrist, and ankle 
joints, the policy of closing the synovial membrane or capsule, which eventually 
became theater policy, could not be practiced at initial wound surgery because 
of the extensive loss of soft parts and the bony destruction which had occurred 
at the time of wounding. Whenever it was possible, closure was effected after 
thorough excisional surgery had been carried out and the joint cavity had been 
irrigated. Transportation splinting was in accordance with the practices 
outlined for wounds in the special areas affected. 
Primary resection of the smaller joints was seldom if ever performed as a 
deliberate procedure at initial wound surgery. In many instances, however, 
what was in effect a traumatic resection had already occurred when the articulat- 
ing components were blown away at wounding. This frequently happened 
at the elbow joint and happened less often at the shoulder and wrist joints. 244 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
As the importance of complete excisional surgery became more and more 
clearly understood, debridement of the badly damaged joint, in the occasional 
case, at least, amounted to resection. 
The management of wounds of the smaller joints in general hospitals was 
essentially the same as the management of compound fractures in the special 
region affected. Early in the war, the plaster was removed; the wound was 
dressed and left open; and immobilization was again instituted, usually by 
plaster of paris. Later, when the principles of reparative surgery had become 
established, it became the practice, as in all other soft-tissue wounds, to suture 
the wound of the soft tissue over the joint if possible, preferably between the 
5th and 10th days after wounding. The closure was more often closure over 
a compound fracture extending into and involving a joint than closure over 
a joint injury. 
The old Willems method of early active motion was almost never employed 
in wounds of the shoulder, wrist, elbow, and ankle joints, though immobiliza- 
tion was discontinued just as soon as it was considered surgically sound from 
the standpoints of wound healing and fracture healing. This was usually 
between the second and third weeks after wounding, unless a fracture made 
further immobilization necessary. 
Suppurative arthritis was seldom a complication of penetrating wounds 
of the smaller joints of the upper extremity unless intra-articular damage had 
been considerable. In the ankle, suppurative arthritis was frequently super- 
imposed on the original wound if destruction of the articulating portions of 
the joint had been extensive. The infection was usually treated by open 
drainage and immobilization by piaster in the position of election. The best 
that could be hoped for in most cases was spontaneous or surgical fusion of 
the joint. 
Secondary resection was seldom done as an elective procedure for suppu- 
rative arthritis of the shoulder, wrist, and ankle joints. In most of the cases 
in which it was performed, it was, in effect, little more than delayed excisional 
surgery. At the 21st General Hospital, in which it was employed in a number 
of cases on the indication of severe infection, it was thought that the operation 
probably had a limited field of usefulness in suppurative arthritis of the elbow 
joint superimposed on severe trauma. CHAPTER IX 
Amputations 1 
Throughout the 2% years of land warfare in the Mediterranean Theater 
of Operations, the attitude toward amputation was one of extreme conservatism 
on the part of all medical officers—in mobile medical units as well as fixed 
hospitals in rear areas. Because of the tremendous possibilities of modern 
reconstructive surgery, the operation was almost never performed unless the 
extremity was damaged beyond salvage or unless, after salvage had been 
attempted, conditions developed which endangered life or made further efforts 
to save the limb futile. Severe compound fractures of the heel bone and of 
the bones of the leg or thigh associated with extensive loss of bone were clearly 
extremely serious injuries, but they were not, in the absence of other indications, 
considered indications for amputation. United States practices of conserva- 
tism in such severely wounded lower extremities were in some contradistinction 
to the surgical policies practiced by medical officers of some of the other war- 
ring nations. 
The theater policy for amputations was set forth explicitly in Circular 
Letter No. 46,2 29 August 1944, Office of the Surgeon, North African Theater 
of Operations. This letter was merely the official statement of a policy which 
had been in effect for more than a year and the general principles of which had 
been established earlier in 1943. Details of technique were described in this 
circular letter, and it was emphasized that casualties who required amputation 
should be told before operation, whenever their condition permitted, why this 
procedure was necessary. It was also suggested that, as soon as the patient 
was surgically comfortable and mentally receptive, an interview with a psy- 
chiatrist or chaplain might be useful. These instructions were based on the 
fact that about 1 in every 5 patients could be expected to exhibit psychic 
reactions, often depressive in type, a few days after operation. 
Particular attention was to be paid in this and other interviews to what 
the soldier might reasonably expect in the way of aid. He was to be told 
of the amputation centers which had been established in the Zone of Interior, 
the prosthetic appliances which were available, and the economic and other 
aid which he could be assured of receiving. Fortification of this kind before 
the patient became the target of sympathetic family and friends, the circular 
letter pointed out, might tip the scales in favor of rehabilitation, while its 
omission might result in lifelong disability and resentment. 
1 The data in this chapter on amputations in United States Army casualties were collected by Maj. Benjamin W. 
Rawles, MC, 45th General Hospital. The data on amputations in German prisoners of war were collected by Maj. 
George S. Hopkins, MC, and Capt. C. R. Brott, MC, 2d Auxiliary Surgical Team. 
2 See appendix, pp. 326-331. 
245 246 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP CA-44-158 
Figure 81.—Destructive injury of entire left leg from land- 
mine explosion. Note how the foot has been driven 
halfway up the leg. An injury of this sort is a true trau- 
matic amputation. 
INDICATIONS 
Amputations were performed either primarily or secondarily. The 
great majority (p. 269) were performed primarily, at initial wound surgery, 
and chiefly in forward hospitals. 
Indications, which did not differ from the usual indications for amputa- 
tion except from the standpoint of the degree of trauma, were as follows: 
1. Trauma at wounding (figs. 81, 82, and 83), in which the extremities 
were blasted off, blown off, torn off, or shot away. In such cases, the sur- 
geon’s function was merely revision of an amputation that had already oc- 
curred. Damage to the extremity of such a degree that future function was 
obviously hopeless also warranted amputation. In many cases of this kind, 
major blood vessels w-ere interrupted, but vascular insufficiency per se was not 
considered the indication for amputation; the damage to the extremity, aside 
from vascular damage, was regarded as sufficient indication for the operation. 
2, Vascular insufficiency per se. In this type of case, the reason for 
amputation was the interruption of a major blood vessel, with resulting im- 
pending or actual gangrene. Amputation on this indication was usually 
performed in fixed hospitals, though in some cases it was a secondary operation 
in an evacuation hospital. AMPUTATIONS 
247 
Figure 82.—Bilateral traumatic amputations of legs re- 
sulting from land-mine explosion. Appearance of the 
injuries before initial wound surgery, which obviously 
can consist only of completion of the traumatic ampu- 
tations. 
U. S. Army photo 
3. Infection. In this group of cases, amputation was necessary to control 
infectious processes, usually clostridial myositis, or was indicated because 
excision of tissue which had become necrotic had been so extensive that the 
extremity which was left was damaged beyond hope of function. Amputation 
on this indication was often undertaken to prevent loss of fife. 
4. Disease, including malignant tumors, trenchfoot, thrombosis, tuber- 
culosis, and other conditions. Amputation for these causes was uncommon 
in an overseas theater. 
TECHNICAL CONSIDERATIONS 
It was the official surgical policy in World War II that the open circular 
(so-called guillotine) amputation he employed routinely.3 This policy was 
set forth explicitly in Circular Letter No. 46, Office of the Surgeon, North 
African Theater of Operations, as already noted. 
The technical details of the operation were fully described in this circular 
letter, the basic direction being that open circular amputation be used routinely 
and that it be performed at the lowest possible level of viable tissue. The 
only exceptions to the latter requirement were that proximal amputation 
3 Circular Letter No. 91, Office o?1 he Surgeon General, U. S. Army, 26 Apr. 1943, subject: Amputations. 248 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP CA-44-634 
Figure 83.—Bilateral injuries of lower extremities resulting from land-mine explosion. 
On the left side, there has been a traumatic amputation through the thigh. On the 
right side, damage to the thigh and leg is so extensive that only primary amputation 
is possible. A. Appearance of injuries before initial wound surgery. B. Appearance 
of injuries after initial wound surgery. The right lower extremity has been amputated 
through the middle third of the thigh by the open circular technique. The stump 
of the left thigh has been shaped so as to present a similar circular stump. AMPUTATIONS 
249 
might be performed in preference to disarticulation and that such modifica- 
tions as good judgment dictated were permitted in amputations of the upper 
extremity. 
In practice, amputation at the lowest level of viable tissue not infrequently 
came into technical conflict with amputation by the open circular technique 
(fig. 84). These recommendations, in practice, could be applied concurrently 
only in cases in which the saw line was determined by the level of viability of 
soft tissue. This was generally true in amputations performed on the indica- 
tion of vascular insufficiency, as well as in some amputations for clostridial 
myositis. When trauma was the indication, as it was in the great majority of 
amputations, especially those performed in forward areas, the extensive com- 
pound fractures present almost invariably determined the level of the saw 
line. Only in the very occasional case was it found expedient to amputate 
through a long bone which was the site of a proximal fracture. Some viable 
muscle and skin were, as a rule, present below the level of the fracture or frac- 
tures that determined the saw line, and the use of the circular technique neces- 
sarily meant their sacrifice. In such cases, therefore, amputations were not 
performed at the lowest level of viable tissue. 
It was not easy, in some instances, to ascertain the true lowest level of 
viable tissue. This was well expressed in the report of an orthopedic team 
attached to the 2d Auxiliary Surgical Group, which pointed out that “where 
to amputate” sounded simple when it was followed by the statement “at the 
lowest possible level.” In extremities that had been blasted off or undergone 
extremely severe trauma, the report continued, muscle tissue might be found 
damaged for a distance of several inches above the site of the wound, and 
selection of the amputation site might be a matter of considerable difficulty. 
Often the muscle varied in color from deep red to purple and was congested, 
swollen, and noncontractile while its blood supply was apparently adequate. 
In most such cases, it was the policy not to select the higher level of undamaged 
and clean tissue for the amputation site but to choose, instead, the lower level, 
where there was no doubt that the muscle, while damaged, was still viable. 
The risk involved in this policy was overcome by watching the patient very 
carefully for signs of further necrosis or of the development of clostridial 
myositis. 
That these and other problems were usually solved with discretion and 
judgment is shown by the infrequency of reamputations in the Mediterranean 
theater (fig. 85), The conservative attitude expressed in the report just cited 
was theaterwide, and it is doubtful that any appreciable number of amputa- 
tions were done at an unnecessarily high level. 250 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 84.—Traumatic amputation of right leg, multiple penetrating wounds of left leg, 
caused by high-explosive shell fragments. A. Appearance of wounds in evacuation 
hospital after removal of emergency splinting and dressings. B. Appearance of 
wounds after preparation for initial surgery. Note large posterior flap of apparently 
viable skin on right leg. The tibia is completely fractured in the mid third. C. Ap- 
pearance of stump of right leg after amputation by prescribed open circular technique, 
with sacrifice of flap of skin seen in view B. The level of amputation approaches the 
critical level at the junction of the upper and middle thirds of the leg. The salvage 
of the presumably viable flap of skin might have permitted delayed wound closure and 
avoided a later undesirable reamputation at a higher level in a Zone of Interior hospital. 
AFIP CA-I4-600 AMPUTATIONS 
251 
AFIP CA-44-403 
Figure 85.—Amputation stump of left forearm, at junction of upper 
and middle thirds. The severe compound fracture of the lower end 
of the humerus, associated with the loss of soft tissue, was considered 
an indication for reamputation just below the middle of the upper arm. 
The required technique of circular amputation was as follows: 
* * * A circular incision is made through the skin at the lowest level compatible with viable 
tissue and the skin is allowed to retract; the fascia is then incised at the level to which the 
skin has retracted. The superficial layer of muscle is then cut at the end of the fascia and 
permitted to retract. At its point of retraction, the deep layers of muscle are cut through 
to the bone. After the deep muscles have retracted the periosteum of the bone is cleanly 
incised and the bone sawed through flush with the muscles. No cuff of periosteum is re- 
moved as in a closed amputation. Bone denuded of periosteum will sequestrate if infection 
is present and a ring sequestrum often results when the periosteum has been removed. It is 
important also that no periosteum be elevated or torn from the bone in the stump by rough 
handling. 
The standard technique for the open circular type of amputation was 
followed in the theater (fig. 86). Early in the war, some surgeons were in- 
clined to use the so-called meat-cleaver method, but this error was corrected 
by educational endeavors to demonstrate the proper inverted-cone stump. 
As experience increased, this error disappeared. 
Circular Letter No. 46 directed that the end of the stump be dressed with 
fine-mesh gauze, so applied that the gauze did not overlap the skin edges. 
Skin traction was then applied immediately (fig. 87) either by a stockinet 
cuff attached with ace adherent or by adhesive tape. Traction was best 
obtained by a light plaster cast with a wire ladder banjo (fig. 88). The cast 252 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP Fd^4-2 
Figure 86.—Technique of open circular amputation. A. Severe injury in region of right 
ankle, with established infection, for which secondary amputation was performed in a 
fixed hospital. Note destruction of heel. B. Lateral view of circular incision through 
skin, which has retracted. C. Medial view of incision of fascia and muscles at level 
to which skin has retracted in view B. D. Incision of periosteum, sawing of tibia, at 
level to which muscles have retracted in view C. E. Lateral view of section of fibula 
with Gigli saw at level slightly proximal to stump of tibia. In the open circular tech- 
nique, no particular effort is made to section the fibula % to 1 inch above the end of the 
tibia, as is done at definitive reamputation or revision of the stump. F. Open concave 
circular stump at completion of amputation. G. Stockinet applied in fixed hospital 
after dressing of open circular stump. H. Skin traction provided by means of weight 
attached to rope which passes over pulley and extends from stockinet attached to 
skin; lower extremity rests on half-ring leg splint. This is the most effective means of 
traction on the skin following open circular amputation. AMPUTATIONS 
253 
Figure 87.—Steps in application of skin traction after amputation of leg. 
always incorporated the joint above the amputation; a spica, for instance, 
would be used after a thigh amputation. Alternatively, if an Army half-ring 
splint was used in amputations of the lower leg, a posterior plaster-of-paris 
splint was provided from the mid thigh to beyond the stump, to prevent 
flexion contracture of the knee. The plasma tubing formerly employed was 
generally replaced by the elastic cord provided for this purpose in 1944 (fig. 
89). 
Reparative surgery.—Circular Letter No. 46 directed that all amputations 
in the thigh and all in the leg at or near the site of election should be treated 
by continuous skin traction after the patient reached a general hospital. 
Secondary suture or skin grafting of the terminal defect, with or without 
revision, was forbidden. It was recommended that the cast or splint be 
removed in the fixed hospital and that 6 to 10 pounds of traction be maintained 
over a pulley at the foot of the bed. Traction was to be continued for at 
least 6 weeks, until all layers of soft tissue had been firmly fixed by scar 
formation. 
Traction during evacuation to the Zone of Interior, for which amputees 
were given priority by air as soon as they became transportable, was provided 
by stockinet and a banjo plaster. 
Closure of wounds in the lower third of the leg, which was well below the 
site of election, and in the upper extremity was permitted by secondary suture 
in general hospitals provided that the wound was clean and the operation was 
done under penicillin protection. If closure was not feasible, skin traction 
was maintained. 
When the reparative-surgery program proved successful in the Mediter- 
ranean theater, it was natural that enthusiasm for it should lead to an extension 
of its principles to the amputation stump. The application of these principles 
in the management of compound fractures had amply demonstrated that 
closure of muscles and other soft parts over exposed bones prevented the access 
of organisms to the deeper tissues and fracture site, reduced scar formation, and 
simplified as well as shortened the period of healing (figs. 90, 91, 92, 93, 94, 95, 
and 96). In deference to the recommendations of The Surgeon General and 
the judgment of surgeons at the amputation centers in the Zone of Interior, an 
extensive clinical trial of reparative surgery as applied to circular flaps was 
396961°—57 18 254 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP CA-44-633, CA-44-199, Fd-44-2S 
Figure 88.—Use of plaster cast incorporating banjo made of wire ladder splint or steel rod, 
to which elastic traction is provided from stockinet fixed to skin. A and B. Upper 
extremity. C and D. Lower extremity. 
not undertaken. Delayed closure was strictly forbidden in Circular Letter 
No. 46 in amputations of the thigh and of the leg unless it could be carried out 
well below the site of election. In amputations of the lower third of the leg 
and of the upper extremity, closure by suture was permitted whenever it was 
surgically feasible. As a matter of fact, as already mentioned, modifications of 
technique were permitted in all amputations of the upper extremity in order 
to secure early closure. 
The number of cases in which the reparative-surgery program was applied 
in amputations was far too small to permit any conclusions concerning results. 
The data from three general hospitals, however, are recorded, for this small 
group of cases, all handled in 1944, might serve as a reference point should the 
problem arise in another war. 
At the first hospital, 77 of 338 casualties with major amputations (22.7 
percent) were submitted to suture of the stump before evacuation to the Zone AMPUTATIONS 
255 
Figure 89.—Traumatic amputation of right leg, compound fracture of both bones of left 
leg, caused by land-mine explosion. A. Appearance of wounds in evacuation hospital. 
B. Anteroposterior roentgenograms of both legs before initial surgery. C. Transporta- 
tion splinting after initial surgery, which included completion of the traumatic amputation 
of the right lower extremity by the open circular technique. After the ace adherent 
used to fix the stockinet to the skin has dried, elastic traction to the wire ladder splint 
will be provided. 
AFIP CA-45-736, CA-15-738 
of Interior. Twenty-one of the stumps were covered by skin grafts after 
fixation of the tissues had been obtained and skin traction was no longer 
effective. Healing was regarded as satisfactory in all of these cases. 
At the second hospital, 39 of 251 amputation stumps (15.5 percent) were 
sutured, 18 before the 12th day after wounding and 21 after that time. Wound 
healing was regarded as satisfactory in all of these cases. 
At the third hospital, delayed primary suture or skin grafting was carried 
out in 63 of 129 major amputations (49 percent). The results are unknown in 
28 of the 63 cases. In 29 of the other 35 cases, healing was known to be com- 
plete; 27 of the 35 were managed by delayed primary suture. It should be 
understood that failure of healing in the remaining six cases did not imply infec- 
tion but merely that granulating areas, most of which were inconsequential, 
were present. The hospital records were incomplete in the 28 cases in which 256 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 90.—Open circular amputation 
through middle third of forearm. A. 
Appearance of stump 7 days later. Note 
that sufficient skin is available to justify 
closure by suture. B. Appearance of 
stump after easy closure of skin over 
stump by interrupted vertical mattress 
sutures. Note absence of tension on 
suture line. C. Provision of elastic skin 
traction, as additional safeguard against 
tension after suture closure of stump. 
AFIP CA-44-540 
the results are listed as unknown, but such data as could be secured suggested 
that healing was also likely to be satisfactory in most of this group. 
Whenever the stump was closed, skin traction was maintained for 7 to 10 
days after amputation, in order to reduce tension on the suture line. 
An important point about the cases just discussed and about the other cases 
in the theater in which delayed primary suture was employed is that there was 
no known fatality in any of the series. No instance of clostridial myositis or 
other serious infection was reported, and there was no reported reamputation. 
Even though the end results are unknown in so many of the cases in which 
reparative surgery was employed, the facts which have just been stated are AMPUTATIONS 
257 
Figure 91.—Healed stumps 3}i weeks after amputation by 
open circular technique. Both patients had sufficient skin 
available for closure of the wound at reparative surgery 6 
days later. 
AFIP CA^4-543 
significant. The good results and, more important, the absence of fatalities 
and of invasive infections, were accomplished under a definite handicap, that 
the stump after a circular amputation is not plastically adapted to early 
closure of the skin and soft tissues by suture. For a fair test of the program, it 
would have been necessary to preserve normal skin, in the form of short flaps, 
when the initial operation was performed. This was not permitted. More- 
over, as already mentioned, the specified technique of amputation not infre- 
quently required the deliberate sacrifice of normal skin extending below the 
level of the saw line which had been determined by trauma to the bone. 
For these reasons, many surgeons in the Mediterranean theatre were of the 
opinion that the directive for routine amputation by the open circular technique 
might well have been somewhat modified. There was no desire to shorten the 
bone in order to permit the fashioning of flaps. It was merely desired to pre- 
serve as flaps all viable skin and soft parts, to facilitate early staged repair 
without tension. 
Traction during evacuation,—Early in the war, the skin traction secured 
with adhesive tape and the Army half-ring or full-ring hinged splint proved 
unsatisfactory for transportation. Universal adoption of the banjo traction 
cast, with stockinet and skin adherent (p. 25), greatly improved the situation. 
Traction was examined just before the casualty was evacuated and was re- 
applied if necessary. The apparatus also had to be checked at regular intervals 
during the course of transportation and readjusted if it became displaced. 
Priority air evacuation to the Zone of Interior was provided for amputees as 
soon as they became transportable. 258 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 92.—Closure of amputation stumps. The 2 soldiers whose 4 amputated lower extremi- 
ties are shown in these illustrations sustained their injuries at the same time, from the 
same shell, while they were in the same foxhole. A. Appearance of granulating stump 
of upper third of left leg 5 weeks after amputation. Skin traction had been maintained 
since operation. B. Healed stump of mid third of right leg in same patient shown 5 weeks 
after amputation and about 2 weeks after suture. C. Healed stump of upper third of 
left leg in second patient 1 month after suture. D. Healed stump of right thigh in same 
patient 1 month after suture. E. Stumps of same patient after revision and conditioning 
for prostheses in amputation center in Zone of Interior. F. Rehabilitated patient shown 
in views C, D, and E after fitting of prostheses. 
AFIP CA-44-539, CA-44-538; U. S. Army photos AMPUTATIONS 
259 
AFIP CA-44-500, C A -44-542 
Figure 93.—Closure of amputation stump. A. Closed stump 
of thigh 6 days after amputation by open circular technique 
and application of skin traction. B. Completely healed 
stump 26 days after closure. 
Revision of the stump.—It is known that revision of the amputation stump 
was necessary in the Zone of Interior in 95 percent or more of all amputations. 
Whether a wider use of closure of the stump by reparative surgery would have 
reduced this proportion substantially is a matter of speculation. A reduction 
of any consequence might not have been achieved. Revision of the stump 
before the fitting of the prosthesis might still have been desirable. The objec- 
tive of overseas surgery, to accomplish a healed wound before evacuation of the 
patient to the Zone of Interior, would, however, have been achieved to a greater 
degree than was accomplished under the directives in effect. 260 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
AFIP CA-44-360, CA-44-428 
Figure 94.—Closure of amputation stump. A. Appearance of stump of right leg after ampu- 
tation just below the middle. The stump had been in traction for 4 weeks. B. Appear- 
ance of stump 16 days after closure by suture. Note that healing was complete except 
for two small granulating areas. There was no sinus formation. 
It seemed likely that there would be relative technical advantages at the 
revision operation if the defects had been completely healed for several weeks; 
if scar formation was negligible; if infection was absent; and if skin was ample, 
in comparison with revision when the scar was firm and when granulation areas 
were present. The crucial test would have been in revision of amputations at 
critical levels in the lower femur and upper tibia, when further sacrifice of bone 
length was undesirable but would have been unavoidable if the end of the stump 
was covered with scar tissue and if normal skin was not available. 
ANALYSIS OF CASES 
The data discussed in the next several pages are derived from the following 
sources; 
1. Two hundred and eighty-three major amputations performed on 271 
United States Army casualties in 1943, and 1,096 major amputations performed 
on 1,000 United States Army casualties in 1944-45, a total of 1,379 amputa- 
tions performed upon 1,271 casualties. 
These cases were secured, without selection, from the proceedings of 
hospital disposition boards for the years in question. Since disposition boards 
are created only in fixed hospitals, it is obvious that the cases concern only 
those amputees who had survived the shock of wounding and who had recovered 
sufficiently to become transportable to the rear. There were no fatalities in AMPUTATIONS 
261 
Figure 95.—Amputation by open-flap technique, with closure of 
flaps without tension 6 days later, at reparative surgery. Appear- 
ance of stump showing complete healing 23 days after wounding. 
U. S. Army photo 
either the 1943 or the 1944-45 series. Deaths of amputees in fixed hospitals 
were infrequent, and fatal cases did not reach disposition boards. 
2. After captured German military hospitals came under control of the 
Surgeon, Fifth U.S. Army, at the end of hostilities in the Mediterranean theater 
in 1945, 1,389 major amputations were performed on 1,332 German prisoners. 
As soon thereafter as practical, all prisoners of war who required medical care 
were collected in a large hospital center previously established by German 
forces in Merano, Italy. The maximum enemy patient census during the 
period of United States Army responsibility for medical care was in the neigh- 
borhood of 20,000. 
The statistics analyzed do not include amputations of the hand distal to 
the wrist joint or amputations of the foot distal to the junction of the middle 
and distal thirds of the metatarsal bones. Disarticulations at the ankle, knee, 
wrist, and elbow were tabulated as proximal amputations, while disarticulations 
at the shoulder were tabulated as amputations of the upper arm. As in all 
collected scries, many items are lacking in many cases, particularly in the 
prisoner-of-war series and, to a lesser extent, in the series from 1943 disposition- 
board proceedings. 
Site of amputation.—The site of amputation in both United States and 
German casualties was usually the lower extremity (tables 28 and 29). The 
large number of amputations of the lower extremity among United States 
troops in 1944-45 is to be explained by the increasing use of land mines by 
the enemy as they retreated up the Italian peninsula in the last year of the 
war. In the 1943 series (table 30), land mines accounted for about 15 percent 
of all amputations, while in 1944-45 they accounted for almost 36 percent. 262 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Figure 96.—Amputation through leg near site of election, 
with preservation of long posterior viable flap of skin. 
Seven days after amputation, the flap was sutured to 
the anterior skin margin. Healed stump 24 days after 
wounding. 
AFIP Fd-45-17 
This same explanation may hold for the slightly higher proportion of lower- 
extremity amputations in United States as compared with German troops. 
The land mines which the Germans used so extensively as defensive weapons 
often played havoc with United States troops, but some Germans were also 
injured in their own minefields (table 31). 
The 1,096 amputations performed on 1,000 United States soldiers in 
1944-45 represented 927 amputations of single limbs, 84.6 percent of the total 
number. There were 73 double amputations (146 limbs) and 23 second-level 
amputations (reamputations). In the German series of 1,389 amputations, 
there were only 57 double amputations (114 limbs), representing 4.1 percent 
of the total number. In addition, one German soldier suffered the loss of 
three limbs; both forearms had to be amputated, and one leg was amputated 
at the thigh. There was no similar instance in the United States Army series, 
and there were no quadruple amputations in either series. 
Numerous other serious injuries complicated the wounds for which 
amputation was required in the 1944-45 United States Army series (table 32). 
The majority of injuries, fortunately, were limited to the skeletal system and 
could be treated by ordinary methods of fracture management. In 12 in- 
stances, the additional fracture was in the same extremity as that in which 
amputation was necessary. Comparable data were not available for the 1943 
United States Army series or for the prisoner-of-war scries. 
Causative agents.—There were only 5 amputations for disease in the 
combined United States Army series (table 30), 2 of them in the same patient, 
for trenchfoot. This is about what would be expected, since soldiers with AMPUTATIONS 
263 
Table 28.—Sites of amputation in 1,379 separate operations on United States Army troops 
Site of amputation 
1943 
1944-45 
Amputations 
Percent 
Amputations 
Percent 
Arm: 
Upper third _ _ 
14 
13 
5 
43. 8 
40. 6 
15. 6 
1 47 
24 
2 29 
47. 0 
24. 0 
29. 0 
Middle third 
Lower third _ 
Total _ _ 
32 
100. 0 
100 
100. 0 
Forearm: 
Upper third _ 
(3) 
(3) 
(3) 
16 
17 
4 32 
24. 6 
26. 2 
49. 2 
Middle third 
Lower third __ _ __ __ 
Total 
48 
65 
100. 0 
Thigh; 
Upper third . 
9 
28 
52 
10. 1 
31. 5 
58. 4 
34 
61 
5 162 
13. 2 
23. 7 
63. 1 
Middle third _ _ _ 
Lower third _ 
Total _ 
89 
100. 0 
257 
100. 0 
Leg: 
Upper third __ _ _ _ 
53 
(3) 
61 
46. 5 
118 
157 
6 363 
18. 5 
24. 6 
56. 9 
Middle third 
Lower third _ _ 
53. 5 
Total __ _ _ 
114 
100. 0 
638 
100. 0 
Foot: 
Upper third _ _____ __ 
(3) 
(3) 
19 
17 
52. 7 
47. 3 
Middle third __ _ _ 
Total 
36 
100. 0 
Total, upper extremity. 
80 
203 
28. 3 
71. 7 
165 
931 
15. 1 
84. 9 
Total, lower extremity __ 
Total, both extremities 
283 
100. 0 
1, 096 
100. 0 
1 Including 9 amputations at the shoulder joint. 
2 Including 4 amputations at the elbow joint. 
3 No cases in the special category or no data on breakdown of the site available. 
4 Including 9 amputations at the wrist joint. 
5 Including 18 amputations at the knee joint. 
6 Including 8 amputations at the ankle joint. 264 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Table 29.—Sites of amputation in 1,389 separate operations on German prisoners of war 
Site of amputation 
Amputations 
Percent 
Arm 
1 190 
13. 7 
Forearm2 _ _ _____ 
3 125 
9. 0 
T otal 
315 
22. 7 
Thigh: 
Upper third _ _ 
4 114 
8. 2 
Middle third _ _ _ 
193 
13. 9 
Lower third 
5 200 
14. 4 
Total _____ 
507 
36. 5 
Leg: 
Upper third ______ 
128 
9. 2 
Middle third . _ 
175 
12. 6 
Lower third _____ 
142 
10. 2 
Total _ ____ 
445 
32. 0 
Foot2 
122 
8. 8 
Total, upper extremity _ ___ 
315 
22. 7 
Total, lower extremity _ _ _ . 
1, 074 
77. 3 
Total, both extremities _ 
1, 389 
100. 0 
1 Including 11 disarticulations at the shoulder joint and 4 at the elbow. 
2 No data on breakdown of site. 
3 Including 41 disarticulations at the wrist. 
< Including 24 disarticulations at the hip joint. 
5 Including 79 disarticulations at the knee joint. 
recognized diseases are not sent into a combat zone. There were 29 amputa- 
tions for disease in the German prisoner-of-war series (table 31). No details 
concerning these operations were available. 
In both the United States Army and the German series, the great majority 
of amputations were performed for trauma, and most of the trauma was 
battle incurred (tables 30, 31, and 33). Although the number of United States 
Army troops in the theater was smaller in 1943 than in 1944-45, the proportion 
of accidental injuries was larger (table 30), a fact which can be explained in 
two ways: In North Africa, where most of the early fighting occurred, supply 
lines were long, and extensive travel by train and motor vehicle was necessary. 
This was also a period of extensive training for combat, and the number of 
soldiers injured by accidental explosions of live ammunition might be expected 
to be greater than in a period of more active combat. AMPUTATIONS 
265 
Table 30.—Agents of wounding and causes of amputation in 1,271 United States Army troops 1 
Agents and causes 
1943 
1944-45 
Total 
Cases 
Percent 
Cases 
Percent 
Cases 
Percent 
Wounded in action: 
Shell fragments, artillery, mortar, 
grenade 
132 
48. 8 
534 
53. 4 
666 
52. 3 
Mines 
41 
15. 1 
359 
35. 9 
400 
31. 5 
Small arms, machinegun, etc 
21 
7. 7 
36 
3. 6 
57 
4. 5 
Other. _ - . _ 
13 
4. 8 
8 
. 8 
21 
1. 7 
Total - 
207 
76. 4 
937 
93. 7 
1, 144 
90. 0 
Accidental injuries: 
Vehicles 
15 
5. 5 
15 
1. 5 
30 
2. 4 
Explosions, live ammunition 
19 
6. 9 
13 
1. 3 
32 
2. 5 
Bullets - _ 
8 
3. 0 
13 
1. 3 
21 
1. 7 
Train, trolley 
7 
2. 6 
8 
. 8 
15 
1. 2 
Mines 
4 
1. 5 
6 
. 6 
10 
. 8 
Machinery (crushing injuries) 
1 
. 4 
3 
. 3 
4 
. 2 
Thermal burns 
1 
. 1 
1 
1 
Other. 
9 
3. 3 
9 
Total 
63 
23. 2 
59 
5. 9 
122 
9. 6 
Disease: 
Trenchfoot 
2 
. 2 
2 
1 
Osteogenic sarcoma fibula 
1 
. 1 
1 
. 1 
Thrombosis 2 
1 
. 1 
1 
. 1 
Tuberculosis. 
1 
. 4 
1 
. 1 
Total _ _ . _ _ _ 
1 
. 4 
4 
. 4 
5 
. 4 
Grand total 
271 
100. 0 
1, 000 
100. 0 
1, 271 
100. 0 
i These 1,271 troops required a total of 1.379 amputations. 
2 Of popliteal artery, secondary to ligation of saphenous vein. 
The explanation of the slightly larger proportion of amputations caused by 
shell fragments and similar agents in the German prisoner-of-war series, than 
in the United States Army series, is probably heavier United States Army fire. 
The effect of land mines has already been mentioned. The larger proportion 
of injuries from small-arms fire in German prisoners of war is perhaps to be 
explained by the strafing from United States planes which the German troops 
suffered while they were retreating in the last months of the war. 
Except for the category of trauma, all these groups are small, and the 
statistical differences are not significant. On the other hand, personal observa- 266 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
tions indicate that most of the explanations which have just been advanced 
are valid. 
Indications.—When the indications for which individual amputations 
were performed are considered (tables 33, 34, and 35), certain differences 
between German and United States surgical practices suggest themselves. 
To consider only the operations for which indications are known in the United 
States Army series (table 33), 1,027 amputations—more than three-quarters 
of the total number—were performed for trauma, both combat connected and 
accidental. In the German prisoner-of-war series (table 35), the corresponding 
figure was 874 operations, not quite two-thirds of the total number. In the 
United States Army series, 195 operations (14.5 percent) were performed for 
Table 31.—Agents of wounding and causes of amputation in 1,332 German prisoners of war 1 
Agents and causes 
Cases 
Percent 
Wounded in action: 
Shell fragments, artillery, mortar, grenade, bomb 
804 
60. 4 
Mines _ . _ _ _ _ 
242 
18. 1 
Small arms, machinegun, etc _ _ _ _ 
182 
13. 7 
Total 
1, 228 
48 
92. 2 
Accidental injuries 
3. 6 
Disease. _ _ 
29 
2. 2 
Unknown causes ___ ____ 
27 
2. 0 
Grand total _ _ _ _ _ . 
1, 332 
100. 0 
1 These troops required a total of 1,389 amputations. 
Table 32.—-Complicating injuries in 1,000 United States Army amputees, Id^-J+B 
Site of amputation 
Complicating injury 
Leg 
Thigh 
Foot 
Forearm 
Arm 
Leg and 
thigh 
Both 
legs 
Thigh 
and fore- 
arm 
Fracture opposite extremity 
Additional fracture same ex- 
tremity _ 
77 
22 
3 
2 
6 
6 
1 
2 
1 
1 
i 1 
Fracture upper extremity _ 
16 
10 
1 
1 
2 
Fracture lower extremity. _ _ _ 
1 
3 
Spine, abdomen, chest, or com- 
bined 
12 
3 
2 
6 
Total 
111 
36 
6 
6 
15 
1 
3 
1 
1 Fracture of humerus in same extremity as injury requiring amputation. AMPUTATIONS 
267 
Table 33.—Indications for amputation in 1,344 of the 1,379 operations following wounds or 
injuries in United States Army troops 1 
Indication 
Combat-connected 
Accidental 
Total 
1943 
1944^5 
1943 
1944-45 
Ampu- 
tations 
Per- 
cent 
Ampu- 
tations 
Per 
cent 
Ampu- 
tations 
Per- 
cent 
Ampu- 
tations 
Per- 
cent 
Ampu- 
tations 
Per- 
cent 
Trauma. _ _ 
121 
43 
24 
2(21) 
(3) 
64. 3 
22. 9 
12. 8 
803 
131 
93 
(61) 
(32) 
78. 2 
12. 8 
9. 0 
53 
11 
2 
(2) 
80. 3 
16. 7 
3. 0 
50 
10 
3 
(2) 
(1) 
79. 4 
15. 9 
4. 7 
1, 027 
195 
122 
(86) 
(36) 
76. 4 
14. 5 
9. 1 
Vascular insufficiency 
Infection 
Clostridial myositis 
Other 
Total _ _ 
188 
100. 0 
1, 027 
100. 0 
66 
100. 0 
63 
100. 0 
1, 344 
100. 0 
1 Data were not available for the other 35 operations. 
2 Figures in parentheses are subtotals. 
Table 34.—Indications for 843 'primary and 243 secondary amputations in United States 
Army troops, 1944~4& 1 
Indication 
Primary 
Secondary 
Total 
Amputations 
Percent 
Amputations 
Percent 
Amputations 
Percent 
Trauma _ _ . 
Vascular insufficiency _____ 
Infection 
Clostridial myositis __ _ _ 
Other 
2 805 
35 
3 
3 (1) 
(2) 
74. 1 
3. 2 
. 3 
44 
106 
93 
(62) 
(31) 
4. 0 
9. 8 
8. 6 
849 
141 
96 
(63) 
(33) 
78. 1 
13. 0 
8. 9 
Total. 
843 
77. 6 
243 
22. 4 
1, 086 
100. 0 
1 Exclusive of 4 amputations performed for disease and 6 operations in which the indications are unknown. 
2 Including 1 amputation for thermal burn. 
3 Figures in parentheses are subtotals. 
vascular insufficiency. In the German series, the number of operations per- 
formed for this reason was 82, not quite 6 percent. The differences in the 
proportions of cases performed on the indication of infection is striking. In 
the United States Army series, 122 operations, about 9 percent, were performed 
on this indication; in 86 instances the infection was clostridial myositis. In 
the German prisoner-of-war series, 403 operations, almost 30 percent of the 
total number, were performed for infection. All 86 primary operations per- 
formed on the indication of infection were for clostridial myositis. 268 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Table 35.—Indications for 962 primary and secondary amputations in German prisoners 
of war 
Indication 
Primary 
Secondary 
Total 
Amputations 
Percent 
Amputations 
Percent 
Amputations 
Percent 
Trautna _ _ _ 
874 
2 
1 86 
63. 0 
. 1 
6. 2 
874 
82 
403 
30 
63. 0 
5. 9 
28. 9 
2. 2 
Vascular insufficiency 
Infection 
Disease _ 
80 
2 317 
30 
5. 8 
22. 7 
2. 2 
Total 
962 
69. 3 
427 
30. 7 
1, 389 
100. 0 
! Clostridial myositis. 
2 Variety of infection unknown. 
It should be pointed out again that vascular insufficiency was considered 
to be the indication for amputation in primary operations when the records 
indicated that the limb woidd have survived if the blood supply had not been 
interrupted. This group of operations, therefore, includes all instances of 
gangrene, including wet gangrene with superimposed infection, and all instances 
of infection in which the infection followed the interruption of a major artery. 
In the United States Army series, the proportions of amputations done 
on various indications changed in the following manner as the war progressed: 
In 1943, trauma of all kinds was responsible for 174 amputations, slightly 
under two-thirds of the total number of operations (283) (tables 28 and 33). 
In 1944-45 the proportion had risen to more than three-quarters (853 of 1,096 
operations) (tables 28 and 33). 
In 1943, injury to a major artery was responsible for just over 19 percent 
of all amputations (54 of 283) (tables 28 and 33). In 1944-45, the proportion 
was 12.9 percent (141 of 1,096 operations) (tables 28 and 33.) 
Infection was responsible for about the same proportion of amputations in 
both series, 9.2 percent (26 of 283 operations) (tables 28 and 33) in 1943, and 
8.8 percent (96 of 1,096 operations) in 1944-45 (tables 28 and 33). 
The increasing proportion of amputations in which trauma was the indi- 
cation and the decreasing proportion in which vascular insufficiency was the 
indication may fairly be assumed to reflect the better judgment and increased 
skill of United States Army surgeons as their experience increased. With 
increased experience in the management of vascular injuries, the limb was 
undoubtedly saved in some of the later cases in which, if they had been observed 
earlier, amputation would have been performed. The decrease in this category 
of indications may also be attributed to better control of infectious processes 
after initial surgery became more competent, penicillin had become available, 
and the practice of liberal blood replacement had become general. AMPUTATIONS 
269 
One not too speculative explanation for the disproportionately large 
number of amputations for infection in the German prisoner-of-war series is 
that the quality of United States Army medical care was better. An extremely 
important part of the explanation is that all of these German wounded were 
managed under the adverse conditions of wholesale retreat and surrender, 
when medical care can never be on a high professional level. 
Timing.—More than three-quarters of the United States Army casualties 
who required amputations were operated on primarily, with trauma as the 
chief indication (table 34). Trauma was also the principal reason for about 
20 percent of the secondary operations (44). In almost two-thirds of the 
secondary amputations for infection, the indication was clostridial myositis. 
In the German series (table 35) the proportion of casualties operated on 
primarily was somewhat less than in the United States Army series (table 34), 
and the proportion of cases in which infection was the indication for immediate 
amputation was considerably larger. In the cases in which secondary ampu- 
tation was performed, infection was responsible for a considerably larger pro- 
portion of cases than vascular insufficiency, which is the reverse of the situa- 
tion in the United States Army series. 
Multiple amputations.—In the 85 multiple amputations in the combined 
United States Army series (table 36), there are 8 separate combinations of 
operation. In 74 cases, however, the amputations were both on the lower 
limbs, and in all but 2 of the remaining cases one of the amputations was 
also on a lower limb. 
Table 36.—Combinations of levels in 85 multiple amputations in United States Army casualties 
Levels 
1943 
1944-45 
Total 
Both legs 
7 
30 
37 
Leg and thigh _ _ _ — _ _ _ 
3 
18 
21 
Both thighs__ _ 
1 
12 
13 
Leg and foot 
3 
3 
Thigh and forearm 
4 
4 
Leg and forearm 
3 
3 
Arm and forearm 
2 
2 
Thigh and arm_ 
1 
1 
2 
Total 
12 
73 
85 
Primary amputations were performed on the indication of trauma in 147 
of the 170 limbs, and 6 limbs were removed secondarily for the same reason. 
One amputation was done primarily for clostridial myositis, and seven of the 
secondary operations were done for this cause. All of the remaining opera- 
tions were performed secondarily, 3 for other varieties of infection, 4 for gan- 
grene following trenchfoot, and the other 2 for vascular insufficiency. 
396961°—37 19 270 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
In the German prisoner-of-war series, the indications for the 114 multiple 
amputations were trauma in 68 limbs, infection in 28, and vascular insufficiency 
in 7. The causes in the remaining 11 operations are unknown. 
Seventy-six of the eighty-five double amputations in the United States 
Army series (90 percent) were required by combat-incurred trauma, shell 
fragments and land mines being responsible in all but one case. The com- 
parable figures for the German series of multiple amputations are 54 cases 
(94.7 percent) with shell fragments (30) and land mines (22) responsible for 
all but 2 of the cases. 
Reamputation.—Reamputation was necessary at a higher level in only 23 
of the 1,096 amputations performed in United States Army hospitals in 1944-45. 
All but two were on the lower extremity. The majority of the secondary 
operations were for infection (16), chiefly clostridial myositis (13), which was 
usually superimposed upon the trauma for which the first amputation had 
been done. The original trauma had been caused by mines in 15 cases and 
by shell fragments in 7. In the remaining case the trauma was accidental. 
Details on reamputations are not available in the 1943 United States 
series nor in the prisoner-of-war series. CHAPTER X 
Noncombat Orthopedic Lesions 
In addition to wounds involving the bones and joints, patients in the 
hospitals of the Mediterranean Theater of Operations presented, almost from 
the day it came into existence as the North African Theater of Operations, two 
other groups of orthopedic lesions.2 
The first of these lesions was the simple type of fracture which resulted 
from the many kinds of trauma to which a soldier in an overseas theater was 
subjected behind the fighting lines. These injuries were sustained, for the 
most part, in the performance of such tasks as are commonly a part of noncom- 
bat activities. A considerable number were sustained during athletic contests 
and other recreational activities. 
This type of fracture needs no extended discussion. Most of them were 
treated by simple manipulation and plaster immobilization, supplemented, 
occasionally, by simple forms of traction. Open reduction and internal fixation 
were performed on the same indications as in civilian practice. The attitude 
was conservative, and these special techniques were not resorted to unless 
adequate reduction had not been accomplished by simpler measures. 
The second group of non-combat-incurred lesions comprised the orthopedic 
disabilities ordinarily seen in civilian practice, including painful feet, painful 
backs, painful and unstable knees, recurrent dislocations of the shoulder, and 
old fractures of the carpal scaphoid bone. Some of these conditions were 
known to exist before the soldiers were inducted. They sometimes caused only 
minimal disability during the training period in the Zone of Interior but pro- 
duced sucli disability under conditions of combat that the soldiers frequently 
reported on sick call and had to be hospitalized for investigation, evaluation, 
and treatment. In some cases, the disability was of such long standing and so 
evident that one wondered how the patients had ever been classified for over- 
seas duty. These lesions were of military importance because of the disability 
which they caused, their chronic and recurrent character, and the two serious 
consequences to which they gave rise in an active theater of combat; namely, 
loss of manpower and utilization of hospital-bed space and of other medical 
facilities. 
Early in the North African experience, it was not at all unusual for soldiers 
hospitalized with these complaints to state that they had suffered considerable 
1 The material in this chapter is largely based on a survey made by Maj. Newton C. Mead, MC, 12th General Hos- 
pital, after V-E Day. 
2 The injuries described in this chapter were sometimes produced during combat, as the result of falls and other acci- 
dents, but they were not produced by missiles, and for convenience of reference they are therefore described as noncombat 
lesions. 
271 272 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
difficulty from them during training but that appropriate therapy had permitted 
them to continue on duty. Sometimes a soldier would state that he had duly 
reported his trouble when he was given his final physical examination before 
embarking for overseas, and that the existence of the condition had been ver- 
ified, but that the examining officer had said that he would be reclassified over- 
seas for limited duty. Many of these men were never of combat usefulness. 
Some of them were of limited usefulness even on limited duty. A few were 
promptly returned to the United States, as being completely unfit for any sort 
of duty in an overseas theater. There are no supporting statistical data for 
any of these statements, but they are substantiated by the observations of 
many of the orthopedic surgeons who served in the theater. 
The early confusion in respect to these noncombat orthopedic conditions 
was probably unavoidable. As the war progressed, the situation was gradually 
rectified and in the last year only a small percentage of the soldiers who reached 
the Mediterranean theater had conditions of sufficient seriousness to warrant 
classification to limited duty. If a policy of similar strictness had been in effect 
throughout the war and if these disabilities had been diagnosed and properly 
evaluated in the Zone of Interior, time, effort, and expense would have been 
saved, and badly needed hospital-bed space would have been conserved 
overseas. 
GENERAL PRINCIPLES OF MANAGEMENT 
Soldiers with the noncombat type of orthopedic lesions were more closely 
studied in fixed hospitals. When the difficulties became apparent in forward 
areas, every effort was made to screen out those whose complaints were trivial 
and functional and to return them promptly to duty. Under the stress of a 
heavy combat load, however, this was not always possible, for these complaints 
frequently required a great deal of time for investigation and evaluation. As a 
result, the majority of the patients had to be transferred back to fixed hospitals. 
This was unfortunate. Experience in all fields throughout the war clearly 
indicated that the farther to the rear soldiers were evacuated, the more difficult 
it was to return them to combat duty. 
As this statement suggests, the psychogenic factor played an important 
part in these complaints and greatly increased the problems of management 
and disposition. This group of patients did not consist of malingerers in the 
ordinary sense of the term. These men honestly regarded their disabilities 
as sufficiently serious to prohibit their participation in heavy duty and in 
combat. Liaison between orthopedic and neuropsychiatric medical officers 
was obviously called for and proved very profitable, though it was not until 
the winter of 1945 that concrete steps were taken to stop the practice of send- 
ing numbers of these soldiers from forward areas to fixed hospitals. At this 
time, as part of the neuropsychiatric program in the theater, a reinforced 
field hospital platoon was designated and set up under the supervision of 
Maj. (later Lt. Col.) Calvin S. Drayer, MC, consultant in neuropsychiatry, NONCOMBAT ORTHOPEDIC LESIONS 
273 
Office of the Surgeon, Fifth U.S. Army, close to the division area, to receive 
patients with chronic or vague complaints directly from clearing stations. 
The professional staff of this field hospital platoon consisted of various spe- 
cialists, among them an orthopedic surgeon. All were men of judgment and 
experience. When soldiers complaining of orthopedic conditions were ad- 
mitted to this platoon, they were quickly but thoroughly studied and screened. 
When observation seemed to establish or made it seem likely that there was 
ground for the soldier’s complaints, he was evacuated to a fixed hospital in 
the rear for further investigation and possibly for treatment. Otherwise, 
he was promptly sent back to the line. This plan of management made it 
possible to return a large number of soldiers to combat status without their 
ever leaving the forward area. 
At the fixed hospital, the emphasis was always upon rapid evaluation 
of the complaints of these patients, with an equally prompt decision as to 
their disposition. In civilian practice, the emphasis in such conditions is 
upon precise diagnosis and the institution of therapy. Only later is any prog- 
nosis made as to the duration of temporary disability or the extent of perma- 
nent disability. In overseas hospitals, the first consideration was whether 
the complaints had a physical basis and, if so, whether it was of sufficient 
seriousness to prevent the soldier’s immediate return to a duty status. If the 
answer was “No,” the surgeon’s first duty was to discuss his condition with 
the patient and to make it clear to him that his disability was not sufficient 
to prevent him from performing his military duties. The question at issue 
was whether he could perform them adequately. If it was thought that he 
could, he was promptly returned to combat duty. 
If a clear-cut decision could not be arrived at promptly, a detailed routine 
of investigation was begun, including roentgenologic examination and labora- 
tory studies. While it was in progress, physical therapy was often instituted, 
in an effort to relieve symptoms and shorten the period of hospitalization. 
When the diagnostic routine was completed, the patient was again evaluated, 
and disposition was accomplished, the preference being given to duty status 
whenever it was felt that he could assume the necessary duties and could 
continue to perform them. Patients who could not be returned to duty at 
once were kept in the hospital and were treated as intensively as possible. 
Reevaluation was carried out after the lapse of 10 days to 2 weeks, and final 
disposition was then accomplished. A soldier who could not be rehabilitated 
within this period was unlikely to be ol further combat usefulness. 
The essential factor in this routine of evaluation, treatment, and dis- 
position was the promptness with which it was carried out. The whole military 
experience showed that, in such conditions as these, prolonged hospitalization 
and treatment were seldom more effective in salvaging a soldier for duty than 
were shorter periods. The more prolonged the hospitalization, in fact, the 
more difficult it was to return soldiers to duty status, whether the condition 
was acute, chronic, or recurrent. 274 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The soldier who really needed treatment was given the benefit of all the 
standard treatment appropriate to his condition, but he was disposed of just 
as promptly as good orthopedic practices permitted. The first and paramount 
mission of the Medical Corps is to maintain the fighting strength of the Army. 
This objective required the salvage of all possible manpower, together with 
the most efficient possible use of all hospital and other medical facilities, in- 
cluding the time of medical officers. Undoubtedly, in an occasional instance, 
some injustice was done, and soldiers were returned to active duty too soon. 
This worked no individual hardship, however, for those who had real com- 
plaints promptly reported to sick call again. The general policy was con- 
sidered highly effective. It provided full medical care for those who really 
needed it, while at the same time it reduced the days lost from duty for soldiers 
who had mild forms of orthopedic lesions and who really needed no hospital- 
ization and no treatment beyond explanation and reassurance. 
THE MANAGEMENT OF PAINFUL BACKS AND FEET 
Lesions of the back and the feet were the two non-combat-connected 
orthopedic complaints most commonly encountered in overseas theaters. 
They accounted for a considerable loss of manpower but need no extended 
discussion because, in spite of their importance, no new techniques were de- 
veloped for their management and no special studies were made from which 
conclusions concerning them could be drawn. 
Painful Backs 
When a soldier complaining of back pain was admitted to a general or 
station hospital, the routine was (1) to take a careful history, with particular 
reference to the time and circumstances of the first appearance of the disability; 
(2) to make a physical examination; and (3) to obtain anteroposterior, lateral, 
and oblique roentgenograms of the lumbar and sacral spine. In many cases 
in which there was organic reason for the complaint, the chief diagnostic 
evidence was roentgenologic. Mild arthritic changes were not considered 
disabling in themselves. Moderate or extensive changes were considered con- 
firmatory of the clinical complaints, and treatment was promptly instituted. 
If the symptoms were not promptly relieved, possible transfer to limited-duty 
status was considered. Congenital anomalies, other than spondylolisthesis or 
evidence of extensive structural weakness, were not considered disabling in 
themselves. Bone tumors and destructive lesions were practically always 
regarded as justification for evacuation to the Zone of Interior for continued 
hospitalization and definitive treatment. A clinical syndrome suggesting 
rupture of the intervertebral disk was a special problem, which is discussed in 
the neurosurgical volume of this series. 
Treatment for painful backs was usually limited to bed rest on a hard 
bed, with movement minimized by the use of a board between the mattress and NONCOMBAT ORTHOPEDIC LESIONS 
275 
the springs, and physical therapy consisting of infrared heat and massage. 
Simple braces and supporting canvas belts were sometimes made in the hospital 
braceshops. They were useful for soldiers who had been on limited duty or 
who were being assigned to it, but these devices were never effective in returning 
a soldier with a painful back to combat duty. 
In the majority of chronic complaints referable to the back, maximum 
symptomatic improvement was usually obtained in about 2 weeks, and with 
few exceptions it was possible to determine by this time whether disposition 
should be to combat duty or to a limited-duty status. In acute back strains, 
a longer period of treatment was often justified, but maximum symptomatic 
improvement was usually obtained by the end of the third or fourth week, and 
disposition could be made with assurance by that time. 
Painful Feet 
Painful feet were more of a problem than painful backs. Soldiers with 
symptomatic flat feet who were admitted to clinics or hospitals raised questions 
of disposition rather than treatment. Such measures as rest and physical 
therapy were of no value. Arch supports did not reach the Mediterranean 
theater until early in 1944. They provided some relief for soldiers on duty in 
rear areas but appeared to be of little value in returning to combat duty 
soldiers who complained of their feet. There were numerous complaints about 
these supports, the most frequent being that they were too high in the longi- 
tudinal arch and often caused pain from excessive pressure. It was frequently 
possible to remedy these defects in the braceshops of general hospitals, but the 
general impression was that the use of arch supports was of limited value in the 
management of painful feet in a theater of operations. 
Surgical intervention for hallux valgus was seldom undertaken overseas. 
The operation only occasionally made possible the return of a patient to 
combat duty, and after the first months of the war it became the rule to assign 
patients with this condition to limited duty if they proved unfit for combat 
and to make the disposition without surgery. 
Operation on a single hammertoe on an otherwise normal or almost normal 
foot was frequently carried out by standard techniques. In most such cases, 
the soldier could be returned to full duty. Operation was seldom undertaken 
for hammertoes associated with a flat metatarsal arch and with dorsiflexion of 
all the toes. Experience promptly showed that surgery seldom permitted 
full-duty disposition and that the wisest plan was to assign the soldier to limited 
duty without surgery. 
March fractures accounted for a certain proportion of painful feet observed 
overseas, though most such fractures occurred during training in the Zone of 
Interior. This subject is discussed in detail elsewhere in this series. It might 
be said here that while weight bearing was not permitted if it was painful, 
there was an increasing tendency overseas to omit prolonged immobilization 
from the routine of treatment. In some instances, a plaster boot was worn 
for a few weeks, but many times only a metatarsal pad was applied. 276 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
SURVEYS OF MANAGEMENT OF NONCOMBAT 
ORTHOPEDIC LESIONS 
Surveys were carried out in the Mediterranean theater for three special 
types of injuries; namely, recurrent disabilities of the knee, including injuries 
of the semilunar cartilage and loose bodies in the joint (osteochondritis dis- 
secans) ; recurrent dislocations of the shoulder; and simple fractures of the carpal 
scaphoid bone. The purpose of each of these investigations was the same—to 
determine what success had been achieved in restoring to a useful duty status 
the patients who had been subjected to surgery. The cost of treatment to the 
Army, in terms of utilization of hospital days, was investigated in each survey. 
An attempt was made to follow up patients who had received surgical 
treatment for meniscus injuries, in order to determine, at least by inference, 
how they had stood up under the duties to which they were assigned. Results 
in other lesions were evaluated simply on the basis of hospital disposition. The 
classification and disposition of patients employed in the Mediterranean theater 
in 1944 and 1945 were as follows: 
Category A covered soldiers whose physical condition was considered as 
qualifying them to perform full military duty, without any restrictions. Those 
who required a preliminary period of conditioning, up to 6 weeks, before being 
returned to full-duty assignments, were temporarily classified as A2. 
Category B covered soldiers who were capable of limited service, according 
to the degree and manner specified by the hospital disposition board. This 
classification was frequently invalidated by failure of the units to which they 
were assigned to observe the specifications. The subcategory B temporary 
covered soldiers who were expected to prove eligible, after a certain period of 
conditioning, for reclassification to Category A. Only disposition boards in 
general hospitals were authorized to place officers in class B. 
Category C covered soldiers who could not be restored to any duty status 
within the holding period permitted in the theater. These patients were evacu- 
ated to the Zone of Interior. Disposition to category C was authorized only in 
general hospitals or in station hospit als acting in the capacity of general hospitals. 
Soldiers who were classified to full duty in the Army had to be able to 
perform full duty. In the very nature of ground combat, there could be no 
relief from certain strenuous duties and no halfway performance of them. In 
the Army Air Forces, the situation, for obvious reasons, was rather different, 
and disposition in hospitals devoted exclusively or almost exclusively to Army 
Air Forces personnel could be carried out by somewhat different criteria. For 
one thing, patients returned to duty with the Air Forces were quartered in 
relatively comfortable barracks, easily accessible to the hospital, in sharp 
contrast to the foxholes and pup tents which were usually the lot of infantry- 
men. The situation was roughly similar to that of a civilian industrial com- 
munity. Hospitals supporting the Army Air Forces were not usually in the 
direct chain of evacuation from the front lines and were therefore not con- 
stantly crowded with battle casualties, as were the other hospitals included in NONCOMBAT ORTHOPEDIC LESIONS 
277 
these surveys. Their work, for this reason, could be conducted somewhat 
along the lines of a civilian hospital. 
There were also other differences. The Army Air Forces had its own 
flight surgeons, whose responsibilities were entirely toward its own personnel. 
These surgeons had opportunities to become acquainted with the men, they 
were familiar with their duties, and they could control and supervise their 
activities during periods of rehabilitation. Because they were in a position to 
judge what duty a patient just released from the hospital was capable of 
assuming, disposition of Army Air Forces personnel was often made to class A 
duty, with the tacit understanding that there would be a period of conditioning 
and rehabilitation under the flight surgeon’s supervision before full duty was 
actually attempted. This arrangement eliminated the period of reconditioning 
at a replacement center which ground troops often had to undergo and which 
was always unpopular. Furthermore, there was never any necessity in the 
Army Air Forces for heavy marching or for ground operations over unfavorable 
terrain. Finally, although precise evaluation is impossible, the morale factor 
undoubtedly played an important part in the generally better results secured 
in elective surgery in the Army Air Forces. 
In 1944, the Army Air Forces discontinued class B duty and placed per- 
sonnel returning to duty in either class A or class C. This was a feasible plan 
in that branch, whose duties, while exacting and hazardous, were very different 
from the duties of ground troops. Many patients who were placed in class A 
in the Army Air Forces would have been placed by practical necessity in 
class B had they belonged to other branches of the service. 
IN FERNAL DERANGEMENTS OF THE KNEE 
1943 Survey 
Early in the North African campaign, the management of internal de- 
rangements of the knee joint in a theater of operations was recognized by 
certain orthopedic surgeons as a problem which needed investigation. An 
investigation of a series of operations performed before 15 July 1943 was 
therefore undertaken (by Maj. Oscar P. Hampton, Jr., MC) in 2 general and 
6 station hospitals in the Mediterranean Base section. Special attention was 
paid to the followup, which was concluded as of 1 November 1943. Whenever 
possible, the patients were traced to their current assignment. 
This investigation covered 150 arthrotomies of the knee joint, 140 under- 
taken for lesions of the semilunar cartilages and 10 on the indication of osteo- 
chondritis dissecans. The medial cartilage was removed in 120 cases, the 
lateral cartilage in 12, and both cartilages in 4. In four cases, although the 
joint was opened, neither cartilage was removed. These 150 patients spent 
an average of 72 days in the hospital. At the time the survey was concluded, 
five were still hospitalized, the average period of hospitalization to that date 
being 95 days. 278 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The results of the remaining 145 arthrotomies were as follows: 
Returned to full duty after spending an average of 53 days in the hospital, 
67 patients (46 percent). 
Returned to limited duty after spending an average of 89 days in the 
hospital, 56 patients (39 percent). 
Evacuated to the Zone of Interior after spending an average of 83 days 
in the hospital, 22 patients (15 percent). 
Of the 84 combat troops included in the 150 cases, 28 were returned to 
full duty and 42 to limited duty, 12 were evacuated to the Zone of Interior, 
and 2 were still hospitalized at the conclusion of the survey. 
These figures require further analysis. They show, first of all, that, after 
the expenditure of an average of 72 days of hospitalization per patient, there 
was less than an even chance of restoring the soldier to combat duty or, if he 
had been on limited duty, of making him fit for combat duty. They show, 
next, that 2 of every 3 patients who had been combat troops could not be 
returned to their former status. 
Finally, the hospital-stay days require analysis. The average period of 
hospitalization for the whole series, 72 days, is low because it includes a num- 
ber of extremely early dispositions. One combat soldier, for instance, was 
returned to his infantry division on the eighth postoperative day, and 10 
others were returned in less than 30 days. Obviously, these dispositions 
cannot be accepted at their face value; any duty disposition made within less 
than 6 or 8 weeks after arthrotomy must have necessitated some restriction 
of duty. In a number of the hospitals surveyed, other patients were observed 
whose disposition had been effected within unusually short periods and who 
had had to be hospitalized for reclassification. 
In the light of these facts, it was concluded that arthrotomy for a torn 
semilunar cartilage in an overseas theater of operations was often of very 
doubtful value. If a soldier had a disability of such seriousness that he could 
not perform combat duties, it was probably more sensible to downgrade him 
to limited duty, without operation, than to spend the time and effort and utilize 
the hospital-bed space required to restore him to full duty, since the chances 
of success were no more than 50 percent and since the chances of his being 
able to perform full duty further reduced the percentage. 
Establishment of Theater Policy 
Circular Letter No. 48, Office of the Surgeon, North African Theater of 
Operations, published 18 November 1943,3 took full cognizance of these facts. 
Its substance was as follows: 
1. Operations for repair or reconstruction of the collateral or cruciate 
ligaments of the knee or for recurrent dislocation of the patella were forbidden. 
3 See appendix, pp. 312-316. NONCOMBAT ORTHOPEDIC LESIONS 
279 
2. Excision of a semilunar cartilage or of joint mice was permitted, but 
only in selected cases, in which there had been careful evaluation of the 
patient’s age; the findings on roentgenologic examination; the relative stability 
of the joint; and, most important of all, the soldier’s mental outlook. 
3. Operation was not to be performed for primary injuries of the semilunar 
cartilage unless the knee was locked and could not be unlocked either by gentle 
manipulation or by skin traction for 5 or 6 days. In all other cases, treatment 
was to be limited to pressure support, rest, graduated to protected weight 
bearing and then full weight bearing, and carefully supervised quadriceps 
exercises for 2 to 10 weeks. These soldiers were to be returned to duty as soon 
as symptomatic relief was obtained. 
4. Arthrotomy was to be performed only for (1) persistently locked knees 
and (2) unlocked knees if the disability made it impossible for the soldiers to 
perform noncombat duty. The latter indication was to be employed only in 
exceptional cases. 
5. Soldiers with recurrent disability in which the knee was not locked 
or in which it could be unlocked by conservative management were to he re- 
turned to duty. If, however, the total disability in any calendar year exceeded 
90 days, they were to be returned to the Zone of Interior. 
6. Operations for the removal of a cartilage from each knee or for the 
removal of both cartilages from one knee were to be performed only on the 
written recommendation of a disposition board in a general hospital. 
7. Elective arthrotomy was to be performed only on the orthopedic services 
of general hospitals. The patient was to be held, for a minimum of 6 weeks in 
the hospital in which the operation was performed, to permit the operating 
surgeon to supervise the regimen of postoperative exercises and graded motion 
which were essential to good results. If prevailing evacuation policies did not 
permit holding for this length of time, the operation had to be performed in 
a hospital farther to the rear. After 6 weeks in a general hospital, the patient 
was to be transferred to a convalescent hospital for further supervision. Full 
instructions for the continuation of corrective exercises were to be sent with 
him. 
The implications of these policies were perfectly clear. If a soldier with 
an injured meniscus or other knee disability could perform any type of duty 
in his present condition, he was to be placed in the appropriate classification 
and returned to duty. If he could not perform even limited duty satisfactorily 
because of frequency of recurrence of the difficulty or persistent locking of the 
knee, he was to be considered a possible candidate for surgery unless there 
were contraindications to operation. If these existed, he was to be returned 
to the Zone of Interior. Among these contraindications were arthritic changes 
of any considerable degree, definite cruciate relaxation, and age (usually over 
30 years). Operation was not to be undertaken if the soldier showed any signs 
of hypochondriac tendencies or emotional instability. In short, all cases for 
surgery were to be selected on an individual basis, and no elective surgery on 
the knee was to be done routinely. 280 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
1944 Survey 
In order to secure additional statistical data concerning the management 
of knee disabilities, the Surgeon, Mediterranean Theater of Operations, directed 
all general and station hospitals in the theater to submit specified information 
for 1944 for inclusion in Essential Technical Medical Data for March 1945.4 
Similar requests were made of the 6 general and 8 station hospitals which were 
formerly in the Mediterranean theater but which had been sent to the European 
theater after the invasion of southern France. Hospitals which did not submit 
the data as directed were visited by Maj. Newton C. Mead, MC, on the order 
of the Surgeon, Mediterranean Theater of Operations, in the summer of 1945, 
after the fighting had ended, in order to secure the required statistics. 
A direct followup of these patients would not have been practical, but 
an indirect followup was possible. The Central Postal Directory Service sup- 
plied their current Army or civilian addresses, with the dates of transfer, and 
also supplied information concerning the dates of transfer to other theaters 
or of evacuation to the Zone of Interior. If the soldier had been sent to the 
Zone of Interior, it was frequently possible to determine whether he had been 
evacuated from a hospital, sent home on furlough, or assigned to new duty. 
These data permitted reasonable assumptions as to the type of duty performed 
since operation and, in many cases, based on the length of time spent on each 
assignment, permitted assumptions as to the efficiency of his performance. 
The reports of the Adjutant General’s Office on theater strength and on 
the number of weekly admissions for injuries provided background material 
against which the importance of injuries of the meniscus could be assessed. 
Material from the 26th General Hospital (129 cases) was analyzed sep- 
arately. This hospital supported the Army Air Forces, and such hospitals, as 
already pointed out, occupied a somewhat special position. 
Essential data.—In the 14 general and 22 station hospitals of the Medi- 
terranean theater which were surveyed by the plan just described, there were 
1,527 admissions for injuries of the meniscus during 1944. Elimination of 
duplicate admissions, of cases in which the records were too fragmentary for 
use, and of the 129 Army Air Forces cases reduced the number to 960 cases. 
Six hundred and eighty-four of these nine hundred and sixty patients were 
treated conservatively in the theater or returned to the Zone of Interior for 
surgery, and 276 wore submitted to arthrotomy in the theater. 
The 684 patients treated conservatively spent 18,588 days in the hospital, 
an average of 27.2 days per soldier. Their disposition was as follows: 
Discharged to category A (full military duty), after spending a total of 
5,961 days, and an average of 22 days, in the hospital, 271 patients (40 percent). 
Discharged to category B (limited duty), after spending a total of 9,922 
days, and an average of 30.72 days, in the hospital, 323 patients (47 percent). 
4 The data could not be secured early enough for publication in the March report and were analyzed personally later, 
after all the material became available. NONCOMBAT ORTHOPEDIC LESIONS 
281 
Classified to category C (evacuation to the Zone of Interior), after spending 
a total of 2,705 days, and an average of 30 days, in the hospital, 90 patients (13 
percent). 
The 276 patients treated by arthrotomy were classified as follows on their 
discharge: 
To category A, after spending an average of 57.2 hospital days, and an 
average of 46.15 postoperative days, in the hospital, 132 patients (48 percent). 
To category B, after spending an average of 74.61 hospital days, and an 
average of 60.15 postoperative days, in the hospital, 120 patients (43 percent). 
To category C and returned to the Zone of Interior, after spending an aver- 
age of 86.71 hospital days, and an average of 69.79 postoperative days, in the 
hospital, 24 patients (9 percent). 
The proportion of patients returned to category A duty after arthrotomy 
was substantially the same in both 1943 (46 percent) and 1944 (48 percent). 
The difference in those returned to category B duty in the 2 years was also not 
great (39 percent in 1943 and 43 percent in 1944). What is more significant 
is that these percentages do not differ very greatly from the percentages of 
patients returned to category A duty (40 percent) and category B duty (47 
percent) in 1944 without operation. To express it differently, even the very 
careful selection of cases practiced in 1944 did not materially improve the 
chances of returning a soldier to useful duty in the theater after arthrotomy, 
while it took at least twice as long to accomplish by surgical measures sub- 
stantially the same results as could be achieved without surgery. 
The reduction in hospital-stay days, including postoperative-stay days, 
in 1944 as compared with 1943, undoubtedly reflected a better selection of cases 
for surgery. The averages were often considerably increased by unsuccessful 
attempts at conservative therapy, which in some instances lasted as long as 90 
days. It is not entirely accurate to charge this time against surgical cases, 
but the error, such as it is, cannot be avoided. A more or less prolonged trial of 
conservative therapy will usually be necessary in the management of a condi- 
tion so difficult to evaluate as the recurring meniscus syndrome. The decrease 
in hospital-stay days in 1944 was largely due to the elimination from the surgical 
series of patients with atrophic quadriceps muscles, relaxed collateral ligaments, 
and a tendency to psychoneurosis and emotional instability. These are the 
patients who always remain in the hospital for long periods of time after opera- 
tion. 
It is unfortunate that the basis of comparison and the estimation of results 
in these two series must be classes of disposition, but in the 1943 series no figures 
on actual duty performance could be secured for comparison. Furthermore, 
the classification to duty at the time of discharge from the hospital did not 
necessarily indicate the type of duty to which the soldier would be assigned when 
he left the replacement depot or conditioning camp. 
When the 1944 survey was undertaken, there was a general feeling in the 
theater that the performance of the patients returned to duty—and particularly 
to full duty—was probably less good than the discharge classifications would 282 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
seem to imply. The attempt at followup studies in the 1944 survey was in- 
tended to settle this question by the indirect evidence of the length of time the 
soldier remained in the particular duty to which he had been assigned. 
This information was available in 269 of the 276 cases in which arthrotomy 
was performed. The length of the followup ranged from less than 3 months 
to 9 months. Duty of less than 3 months was not regarded as evidence of 
satisfactory performance. On these criteria, when the investigation was con- 
cluded, 109 of the 132 troops assigned to full duty (82.6 percent) were still 
performing their duties satisfactorily, as were 105 of the 120 assigned to limited 
duty (87.5 percent). If these figures can be accepted at their face value, the 
results of arthrotomy in selected cases in 1944 were reasonably satisfactory. 
Results of arthrotomy in the 26th General Hospital.—The 26th General 
Hospital, as already noted, was surveyed separately because of its predomi- 
nantly air personnel. The orthopedic section of this hospital made the diag- 
nosis of injury of the semilunar cartilage 224 times in 1944. One hundred 
and nineteen patients were hospitalized, of whom 65 were treated conserva- 
tively and 54 by surgery. Fifty-two of the surgical histories were sufficiently 
detailed for analysis. 
The 65 patients treated conservatively spent an average of 15.74 days in 
the hospital, as compared with an average of 27.2 days for the 684 patients 
treated conservatively in other branches of the service. A total of 95 percent 
were discharged to full or limited duty (chiefly full duty) as compared with a 
total of 87 percent (chiefly limited duty) in ground troops. 
The 52 arthrotomized patients spent an average of 42 days in the hospital 
and an average of 29 postoperative days, against 64 days and 52 days, respec- 
tively, for ground troops. Ninety-eight percent were discharged to full or 
limited duty (chiefly full duty) against 91 percent for ground troops. At the 
end of the survey, 76 percent of those discharged to duty were known to be 
performing their duties, against 71 percent for ground troops. The probable 
reasons for better results in elective surgery in Army Air Forces patients have 
already been discussed (p. 277). 
Previously arthrotomized soldiers.—Seventy patients who had previously 
been subjected to arthrotomy were admitted to hospitals in the Mediterranean 
theater during 1944. It had been expected that a great deal of useful infor- 
mation coidd be obtained from this group, but the expectation was not realized. 
The surgery had been performed in overseas hospitals in only 16 cases, and 
only in these cases was it possible to learn the details of the previous operations. 
If, however, this small group is representative, it suggests that arthrotomy in 
an overseas theater is an operation of doubtful value, for only 5 of the 16 could 
be returned to duty after their period of hospitalization. The other 11 were 
sent back to the Zone of Interior, in 8 instances specifically because of unstable 
joints or severe synovitis. 
In 19 other cases, the soldiers had demonstrated their ability to perform 
useful duty after surgery, at least for a certain period of time. Most of them 
had done full duty, for an average of 15 months. The results of surgery, NONCOMBAT ORTHOPEDIC LESIONS 
however, were not permanent. When they were discharged from the hospital 
on their second admissions in 1944, only 4 of the 19 could be reassigned to 
full duty, and 7 had to be returned to the Zone of Interior. Moreover, of the 
12 assigned to some duty in the theater, only 9 were still assigned to it at the 
time of the followup investigation in 1945. 
Comment.—Although the statistical data in this survey were disappoint- 
ing, they were sufficient to indicate trends and to substantiate, in large part, 
clinical impressions. The important considerations of the study were as follows: 
1. The frequency of these knee injuries was greater than had been realized. 
Statistics furnished by the Adjutant General’s Office, Mediterranean Theater 
of Operations, indicated that on any given day in the theater 4,811 patients 
were hospitalized as the result of nonbattle injuries and that injuries of the 
meniscus were responsible for approximately 2.81 percent of these admissions. 
These figures took no account of the large number of patients with this type 
of injury who were under treatment while on a duty status in the orthopedic 
clinics throughout the theater. The inclusion of these figures would have 
increased the proportion of meniscus injuries, though by how much is not known. 
2. Many of the difficulties were the result of old athletic injuries. A sur- 
prising number were blamed on obstacle courses in basic training. A good 
many of the more recent injuries were caused by falling or by twisting the knee 
on night problems or on patrols on rough or mountainous terrain. Some 
injuries were traced back to precipitate motions while under fire and in this 
sense were combat incurred. Drunkenness was an influential factor in a few 
cases. 
3. Accurate diagnosis was often difficult because the history, sometimes 
deliberately and sometimes unconsciously, was colored by the soldier’s desire 
to use the knee injury as a means of avoiding combat dangers. The symptoms 
of a trick knee were sufficiently well known to occasional soldiers for them to 
be able to recite histories which, although false, were extremely convincing. 
The surgeon had to keep an open mind, so that his experiences with actual 
malingerers and with patients who exaggerated their complaints would not 
lead him, unconsciously, into considering all soldiers in this unfavorable light. 
4. The diagnostic problems raised by the unreliability of many histories 
were increased by the meager objective evidence which these patients so often 
presented. One of the most useful objective signs was atrophy of the quad- 
riceps; this process tends to occur rapidly after any knee injury, and its absence 
always led to suspicion of the seriousness of the soldier’s complaints. 
5. Although roentgenograms were made routinely, they were usually 
negative. They were chiefly useful in ruling out chip fractures and osteo- 
chondritis dissecans. 
6. Generally speaking, a patient who presented himself with a locked knee 
which could not be unlocked by a few days of traction became an automatic 
candidate for surgery. He was totally disabled, and he could become of mili- 
tary usefulness only when the acute condition was relieved. Manipulative 
reduction under anesthesia was substituted for arthrotomy if there was any 284 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
contraindication to the joint operation. If the roentgenograms revealed osteo- 
arthritis, manipulative reduction was usually used. 
The patients whose knees were either unlocked on admission or could be 
readily unlocked with traction sometimes told a story of recurrent locking. 
The problem in these cases was not one of diagnosis but one of expediency. 
The decision to perform operation or withhold it had to be based on the possi- 
bility of the individual soldier’s future usefulness in the theater and the length 
of time it would take in the hospital and in rehabilitation for him to achieve a 
duty status. Statistics for the theater indicated that even in carefully selected 
cases, return to full military duty could be accomplished in less than half of all 
arthrotomized patients. Of the surgical cases surveyed in 1945, 82.6 percent 
of the 132 troops assigned to full duty were successfully performing their duties 
from 3 to 9 months after operation. Only 16 of the 109, however, 14.7 percent, 
were serving with infantry units, in which the need was greatest and combat 
was most arduous and most dangerous. 
Routine classification for temporary limited duty for all arthrotomy cases, 
with special care in assignment to duty, might have been a better solution than 
the attempt, so soon after surgery, to distinguish between soldiers fit for full 
duty and those fit only for limited service. This plan would have been effec- 
tive, however, only if each case could have been carefully reviewed within a 
minimum of 90 days by a board of medical officers well versed in knee-joint 
surgery. Such a policy would have resulted in shortened hospitalization and 
more satisfactory final disposition of these patients. Without a specially 
qualified disposition board, it would not have been effective, and the system 
employed probably gave about as good results as could have been expected. 
7. The prognosis for arthrotomy for knee injuries was much less favorable 
in overseas hospitals than civilian experience might suggest. One reason was 
that the patients could not receive the close personal attention from the surgeon 
which is so desirable in such operations. A postoperative routine of quadriceps 
exercises, for instance, often had to depend for its success on such attention as 
overworked ward personnel could give to it; when battle casualties were numer- 
ous, attention to such refinements was necessarily scant. The chief difference 
between military and civilian practice was that some soldiers regarded the 
hospital as a haven from the dangers of battle, and their cooperation in reha- 
bilitation exercises was a good deal less than enthusiastic. 
The comparison between a football player with a knee injury and a soldier 
with the same type of injury, although often made, was never sound. Because 
athletes can return to violent activity on the football field within 6 to 8 weeks 
after menisectomy, it did not follow that soldiers could return to combat duty 
within a similar period of time. The circumstances are widely different. The 
injured athlete, outside of the game, is in the hands of a trainer and has access 
to heat lamps, massage, and other forms of therapy. When he goes on the field, 
his knee is well strapped. He remains in the game for only brief periods at 
first and may be removed on the first indication of trouble. Even at its NONCOMBAT ORTHOPEDIC LESIONS 
285 
roughest, a football game is divided into alternate periods of action and rest, 
and at the most only an hour is spent in actual play. 
The lot of an infantryman is very different. He must carry heavy packs 
and equipment many miles over rough ground or mountainous terrain, often 
in darkness, often in rain, snow, or mud. He cannot, like the football player, 
leave the game. He must continue until his mission is accomplished, even if 
his knee swells and is painful. When he has an opportunity to rest, it is likely 
to be in a wet foxhole, often in cold and freezing weather. The commanding 
officer of a combat unit cannot always, like a football coach, consider his men 
first and the outcome of combat next. He must utilize every man at his dis- 
posal. A man unable to keep up with his comrades is a liability. 
The chief fallacy of the comparison concerns morale. The football player, 
anxious to retain his place on the team, cooperates in every effort at rehabili- 
tation. The infantryman has only his sense of duty to urge him back to combat. 
Every instinct of self-preservation makes him call attention to any symptom 
from his knee. It requires a man of strong character to return to combat and 
to stay in it in spite of a knee which swells and becomes painful when it is 
overtaxed. This is why such stress was put upon a favorable mental attitude as 
an absolute prerequisite to surgery of the knee joint in any theater of operations. 
Technical considerations.—Techniques of menisectomy were practically 
the same in all hospitals in the Mediterranean. Tourniquets were used uni- 
versally. A straight, short incision medial or lateral to the patella was also used 
universally; sometimes it was curved into a J or a reverse J. Retractors were 
employed, of such shapes as to minimize intra-articular trauma. 
An attempt was always made to remove as much of the cartilage as pos- 
sible through the anterior incision. A separate posterior incision was some- 
times made to insure that it had been entirely removed. The trend to total 
removal of the cartilage through two incisions became somewhat more marked 
as the war progressed. When the cartilage was entirely in the intercondylar 
notch or when it could be placed in it after lateral dissection, total removal 
was effected, for all practical purposes, through an anterior incision only. If 
a half inch or so was left in situ, no difficulties need be expected. When, how- 
ever, the cartilage could not be displaced into the notch, it was best to make a 
separate incision posteriorly to remove the remaining inch or inch and a half. 
The majority of surgeons excised the fat pad only if it was swollen and appeared 
chronically inflamed. Routine removal was not practiced because postopera- 
tive effusions, which required aspiration, seemed somewhat more frequent when 
the pad was removed. 
One hospital which used sulfanilamide powder in the joint in about half 
of its cases discontinued the practice when postoperative synovial thickening 
was found to be more frequent than in the cases in which the sulfa drug was 
omitted. One or two hospitals used a posterior plaster slab for a week, but 
pressure dressings alone were most often employed. 
396961 57 20 286 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Preoperative and postoperative quadriceps exercises were always stressed. 
One or two hospitals permitted weight bearing on the second or third post- 
operative day and encouraged rapid return to complete ambulation. The ma- 
jority of surgeons preferred to delay weight bearing until 7 to 10 days after 
operation and to keep the patient on crutches for the next 2 or 3 weeks. What- 
ever the practice, care was always taken to see that the ability to extend the 
knee completely was not lost. 
JOINT MICE (OSTEOCHONDRITIS DISSECANS) 
Loose bodies in the joint and osteochondritis dissecans are conveniently 
discussed together. They are related clinically and the terms were often used 
interchangeably on the histories examined in Mediterranean-theater hospitals. 
It must not be inferred, of course, that all loose bodies observed were the result 
of osteochondritis dissecans. The term is technically reserved for those cases 
in which a definite defect of the articular surface is demonstrable by roent- 
genograms or at operation. The defect may contain an avascular osteocarti- 
laginous body, or the affected nodule may have been extruded into the joint 
cavity. 
Osteocartilaginous loose bodies were not seen frequently enough in Medi- 
terranean-theater hospitals to be regarded as a common cause of disability. 
They were, however, encountered often enough to warrant the adoption of a 
policy for their management. 
Data sufficient for evaluation of the usual methods of treatment in this 
condition were secured from the 12th, 33d, and 45th General Hospitals. A 
total of 29 arthrotomies was performed for joint mice in these 3 hospitals over 
the same period in which about 84,500 patients were admitted for all causes. 
Of the 29 operations, 22 were on the knee, 4 on the elbow, and 3 on the ankle 
joint. 
Avascular nodules were removed from craters in the femoral cond}de in 
4 of the 22 arthrotomies on the knee joint; the crater was then curetted, and 
overhanging articular cartilage was removed. Two patients were discharged 
to limited duty, and the other two were evacuated to the Zone of Interior. 
Ten of the remaining patients, who presented defects of the patella or who re- 
quired no treatment of the crater, were discharged to full duty, and five others 
with the same conditions were discharged to limited duty. The disposition of 
three other patients in this category is unknown. 
Three of the four patients operated on for loose bodies in the elbow joint 
were returned to full duty. The disposition of the fourth case is unknown. 
All three patients subjected to arthrotomy of the ankle joint were classified 
to limited duty. 
Statistical conclusions would not be warranted in so small a number of 
cases, but discussions with many orthopedic surgeons in the Mediterranean 
theater permit certain generalizations. Disposition to appropriate duty with- 
out arthrotomy was recommended when the loose body was not producing NONCOMBAT ORTHOPEDIC LESIONS 
287 
symptoms and did not change its position on repeated roentgenologic examina- 
tion. This policy avoided the loss of service time and conserved hospital space 
and medical effort. If the symptoms were troublesome, the policy depended 
upon the joint affected. In a non-weight-bearing joint such as the elbow, 
which was otherwise adequate, the results of surgery were likely to be good 
and return to duty reasonably prompt. If a weight-bearing articular surface 
was affected, especially if the defect was large, it was unlikely that the results 
would be good enough and return to duty prompt enough to justify operation 
in an overseas theater. In any event, surgery for joint mice and osteochon- 
dritis dissecans was permitted only by qualified orthopedic surgeons, only in 
general hospitals, and only after complete investigation of the patient as well 
as his orthopedic status. 
RECURRENT DISLOCATIONS OF THE SHOULDER 
The lack of uniformity in the management of recurrent dislocations of 
the shoulder in the hospitals of the North African theater early in the war was 
officially eliminated in November 1943 when Circular Letter No. 48 was issued 
from the Office of the Surgeon, North African Theater of Operations. A 
previous history of recurrent dislocation of the shoulder was not to be accepted 
per se if it rested on the soldier’s testimony. Instead, diagnosis was to be 
made only if a history of one or more episodes, preferably with supporting 
roentgenologic evidence, appeared on the Army medical record. Operation 
was to be undertaken only with the written approval of the disposition board of 
a general hospital following demonstration that the disability was such as to 
prevent noncombat duty and then only when the soldier’s age and mental 
attitude offered reasonable prospect of military rehabilitation. 
Guided by these general instructions, an experienced surgeon was permit- 
ted to formulate his own policies of management and select such surgical 
techniques as he preferred. 
Survey of cases.—In an effort to determine the effectiveness of this policy, 
a survey of the cases observed in the theater in 1944 was carried out in 1945, 
by the plan already described for derangements of the knee joint. The survey 
covered the experiences of 16 general and 25 station hospitals. Five other 
hospitals were not surveyed, for one reason or another, but it was not thought 
that the small number of patients missed would in any way alter the value of 
the investigation. Data were not available from all hospitals for all items 
desired. 
In all, there were 314 admissions for this cause during 1944, 71 of which 
were duplicate admissions, which reduced the number of cases to 243. Thirty- 
eight of the 243 patients were treated by surgery and 205 by conservative 
measures. Operation would have been justified in almost all of these patients 
in civilian life, and the fact that only 15 percent were submitted to surgery 
indicates an extremely conservative attitude toward surgery for recurrent 
dislocations of the shoulder in a theater of operations. 288 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
The 205 patients treated without operation on whom information as to 
disposition was available spent a total of 3,566 days in the hospital, which is 
an average of 17.4 days. Disposition was as follows: 
Discharged to full duty, after spending a total of 1,224 days, and an 
average of 13.02 days, in the hospital, 94 patients (46 percent). 
Discharged to limited duty, after spending a total of 1,736 days, and an 
average of 21.17 days, in the hospital, 82 patients (40 percent). 
Classified to category C, after spending a total of 606 days, and an average 
of 20.9 days, in the hospital, 29 patients (14 percent). 
The 30 (of 38) patients treated surgically on whom information as to 
disposition is available spent a total of 1,874 days in the hospital, which is an 
average of 62.47 days. Disposition was as follows: 
Discharged to full duty after spending a total of 515 days, and an average 
of 51.5 days, in the hospital, 10 patients. 
Discharged to limited duty after spending a total of 1,359 days, and an 
average of 67.95 days, in the hospital, 20 patients. 
There were no category C dispositions in this group. If the original 
category A and B dispositions could have been maintained, on which matter 
there is no information, these are reasonably satisfactory results. 
One hundred and twenty of the 205 patients not operated on were dis- 
charged from general hospitals and 85 from station hospitals. The propor- 
tionate distribution of the various types of disposition showed considerable 
differences in the two types of installation. In the 16 general hospitals included 
in the survey, 30 percent (36) of 120 patients were classified as category A, 
50 percent (60) as category B, and 20 percent (24) as category C. In the 25 
station hospitals, the respective proportions were 68 percent (58) category A, 
26 percent (22) category B, and 6 percent (5) category C. Both the total- 
and the average-stay days were also materially fewer in the station hospitals. 
At first glance, it is hard to see why the results in the station hospitals 
should be, apparently, so much more favorable than in the general hospitals. 
Superiority of treatment does not explain it, for the same conservative meas- 
ures, chiefly rest and physical therapy, were used in both. Analysis of the 
preliminary figures seems to furnish the explanation, which is that considerable 
number of the patients discharged from the general hospitals had been trans- 
ferred to them from station hospitals, chiefly, it would seem, because they 
presented problems of management and disposition. These patients required 
a longer time for investigation and in general represented a less favorable 
group of cases. They therefore, it. is reasonable to assume, not only increased 
the average period of hospitalization in general hospitals but also required a 
greater percentage of category B and C dispositions in those institutions. It 
also seems probable that the attitude toward disposition was more conserva- 
tive in general hospitals and the criteria for category A disposition somewhat 
stricter, than in station hospitals. Disposition in noncombat injuries of 
all sorts was always a matter of judgment, not of rules, and neither documentary 
nor statistical data are available to confirm or disprove this reasoning. NONCOMBAT ORTHOPEDIC LESIONS 
289 
It should be borne in mind, in interpreting these statistics, that most 
admissions to station hospitals were noncombat troops and that admissions 
to general hospitals were combat troops plus transfers from station hospitals. 
Station hospitals would therefore be expected to make more category A 
dispositions. 
Comment.—The relative frequency with which recurrent dislocation of the 
shoulder was encountered in the Mediterranean Theater of Operations was 
frankly surprising to some orthopedic surgeons, who regarded the number of 
cases as disproportionately great in comparison with civilian experience. As a 
matter of fact, the actual number of cases observed was considerably greater 
in 1944 than the 243 upon which this discussion is based. This number makes 
no allowance for the soldiers treated on a duty status in dispensaries and out- 
patient clinics. What proportion of the total cases is represented by the 243 
cases treated in hospitals it is not possible to say. It is clear, however, that 
these soldiers furnished a serious medicomilitary problem. Their disability 
made them an actual loss to their organizations and also required the utilization 
of medical personnel and hospital facilities, sometimes for long periods of time. 
Before the management of any case of recurrent dislocation of the shoulder 
was decided upon, it had to be evaluated individually, in the light of the follow- 
ing considerations: 
1. It had to be established that the lesion was a true dislocation. It was 
not uncommon to find that what a patient called a dislocation was simply a 
relaxation of the joint, associated with frequent subluxations and a general 
feeling of instability. An occasional soldier could produce, at will, luxation of 
sufficient extent to be demonstrated to the medical examiner. Some, who were 
malingerers at heart, could furnish a glib history of numerous previous recur- 
rences. A careful series of questions and a careful physical examination usually 
settled the matter, but many a medical examiner, in these circumstances, was 
glad to be able to fall back on the instructions in North African Theater of 
Operations Circular Letter No. 48, that there must be a definite Medical Depart- 
ment record of a previous dislocation or a supporting roentgenogram before the 
diagnosis was made or concurred in. 
2. The degree of disability caused by the lesion had to be determined. 
Intelligent management and disposition were impossible without such an evalu- 
ation. Dislocation of the shoulder was seldom completely disabling except 
for a brief period following the actual luxation. The type of dislocation followed 
by partial disability for a few days or even a few weeks was the variety most 
often seen in Army orthopedic clinics. It rendered the soldier unfit for combat 
infantry duty, as well as for certain other types of duty, but still permitted 
him to handle many useful assignments without danger of serious or permanent 
injury to himself. 
In some cases, the dislocation recurred frequently, sometimes every few 
weeks. There was no pain between the episodes, and no disabling muscle 
atrophy occurred. Fear of recurrence, however, materially reduced the 
soldier’s efficiency and in a sense made him chronically disabled; he tried not 290 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
to abduct his arm because he was afraid of producing a recurrence. This type 
of lesion was amenable to surgery; it was fear rather than the lesion per se 
which disabled the patient. On the other hand, surgery promised very little 
from the standpoint of returning him to useful duty if muscle atrophy or painful 
tendonitis was part of the clinical picture. In such cases, it was best to defer 
disposition as long as possible and permit the soldier to continue in his current 
assignment. A patient in this condition was practically never found in front- 
line service, and the outcome of operation sometimes resulted in his further 
downgrading. 
3. When a case suitable for surgery was encountered, two points had to 
be settled before operation was recommended. The first was whether the 
prognosis with surgery was good for some form of duty in the theater. If it 
was not, operation was not justified overseas, and the correct policy was either 
to continue the soldier in his current assignment, if he were capable of perform- 
ing his duties, or to return him to the Zone of Interior for surgery. The second 
point was related to the first. What was the man’s mental attitude? This 
consideration always had at least as much to do with the decision to undertake 
surgery as did the physical lesion, and in some instances it had more to do 
with it. 
4. The final consideration was the essentiality of the soldier. Key per- 
sonnel were sometimes operated on overseas, in disregard of ordinarily accepted 
criteria, because they were regarded as useful or essential. Nonessential men 
were left in their current status or, if surgery was clearly indicated, were 
returned to the Zone of Interior for treatment. 
FRACTURES OF THE CARPAL SCAPHOID BONE 
The results of the methods used in fractures of the carpal scaphoid bone 
during the North African campaign were not conclusive, and considerable doubt 
was felt as to the soundness of the techniques employed and the criteria of dis- 
position. Circular Letter No. 48, Office of the Surgeon, North African Theater 
of Operations, 1943, offered guidance in the management of this injury as 
follows: 
Greater care must be exercised in making a precise and prompt diagnosis 
of carpal fractures and dislocations, since early reduction is essential for a 
satisfactory result. Surgical treatment of an old, unrecognized fracture of the 
scaphoid will not rehabilitate a soldier. If his disability is complete, he should 
be transferred to the Zone of Interior. 
The exact method of treatment was left to the decision of the surgeon 
who encountered the case, and disposition was according to the judgment of 
the disposition board of each hospital. 
Survey of cases.—In an effort to determine the effectiveness of the meth- 
ods employed in the management of fractures of the carpal scaphoid bone, 
a survey of the cases observed in the theater in 1944 was carried out in 1945 
along the general line of the plan described for derangements of the knee joint. NOXCOMBAT ORTHOPEDIC LESIONS 
291 
Because of the nature of this injury, the circumstances of this survey 
and of the surveys already described were not entirely similar. As in the 
other investigations, no account was taken of patients not hospitalized for 
their injuries, which means that the number of carpal scaphoid fractures 
analyzed does not nearly indicate the total number of cases observed. This 
injury was often treated in outpatient clinics, without hospitalization. At 
the 182d General Hospital, for instance, there were no admissions for this 
cause during 1944, but 50 carpal scaphoid fractures were treated in the out- 
patient clinic. Unfortunately, the records for outpatient clinics were gen- 
erally so fragmentary as to make their use in this investigation worthless. 
Patients with fractures of the carpal scaphoid bone, particularly in station 
hospitals, were often discharged to duty or to quarters status after the frac- 
ture had been reduced and they had adjusted themselves to their casts, the 
remainder of their treatment being conducted in outpatient orthopedic clinics. 
As a result, the figures collected for hospital-stay days do not nearly reflect 
the length of time required for return to duty or other disposition. They 
merely show the length of time hospital facilities were utilized in the care 
of carpal scaphoid fractures and do not indicate the length of time the men 
affected were unable to perform useful duties for their organizations. 
The information analyzed includes data from the hospitals transferred to 
the European theater after the invasion of southern France. These hospitals, 
however, were not asked to supply the number of carpal scaphoid fractures 
in the hospital 1 March 1945, as, obviously, no such patients were from the 
Mediterranean theater. On this date, there were 58 patients with carpal 
scaphoid fractures in the general and station hospitals in the Mediterranean 
theater. Admissions for noncombat injuries during the week ending 1 March 
1945 had numbered 3,335. This means that fractures of the carpal scaphoid 
bone accounted for 1.73 percent of all such admissions. 
During 1944, 16 general and 23 station hospitals in the Mediterranean 
theater reported the admission of 291 soldiers with fractures of the carpal 
scaphoid bone. The number of cases available for analysis is reduced to 180 
by the elimination of 92 duplicate admissions and of 19 other cases in which 
the records were too incomplete to be used. Disposition of these patients 
was as follows: 
Returned to full duty, after average hospitalization periods of 44.89 days, 
128 patients (71 percent). 
Returned to limited duty, after average hospitalization periods of 79.21 
days, 27 patients (15 percent). 
Classified to category C, after average hospitalization periods of 49.28 
days, 25 patients (14 percent). 
Since the average time for the healing of carpal scaphoid fractures is 3 to 
4 months, no clinical significance can be read into the figures for hospitaliza- 
tion. Most of the category A and B dispositions must have been made with 
the hand and forearm still in plaster, the patients being assigned to light 
duties with their outfits. Whether the dispositions made when they were 292 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
discharged from the hospital prevailed when the casts were removed it is 
not possible to say. 
Methods of management.—Although no theaterwide policies of manage- 
ment were established, orthopedic surgeons all tended to use the same general 
principles in carpal scaphoid fractures. Both military and civilian experience 
indicated that one routine was required for recent or fresh fractures and 
another for old fractures. The prognosis of fresh fractures was good if early, 
efficient immobilization was instituted and was continued until union had 
occurred, assuming, of course, that the fragments were in good position. 
The prognosis was less good, and was often poor, if adequate treatment was 
not begun within the first few days after the injury or if immobilization was 
inadequate or was not continued until healing occurred. If the blood supply 
of the fragments, as demonstrated by roentgenograms, remained adequate, 
healing could be expected under proper management in 3 to 4 months. If 
one or more of the fragments was avascular, healing was likely to be delayed 
and was frequently unsatisfactory. 
The following principals, based on these concepts, were followed by many 
surgeons in the theater. If they had been universally adopted, most of the 
poor results observed in these injuries would have been avoided. 
All sprains of the wrist were examined roentgenologically, with the idea 
of demonstrating or eliminating possible fractures of the carpal scaphoid bone. 
This was an essential precaution. In the orthopedic clinic of the 182d General 
Hospital, all nine of the old carpal scaphoid fractures which had to be treated 
for nonunion had been regarded as sprains when they were sustained and bad 
not been correctly immobilized. The situation was entirely different in 41 
fresh injuries, which were recognized as soon as they occurred and were 
promptly and properly immobilized. Healing was complete in every instance 
within 12 weeks, and the fracture line had usually disappeared entirely by this 
time. A smaller series from the 46th General Hospital also pointed to the role 
of the missed fracture in poor results. In this hospital, disposition-board 
records showed that 6 or 7 nonunions of carpal scaphoid fractures occurred in 
cases in which early care had not been given, while the course of 12 promptly 
treated fractures was uncomplicated and satisfactory. 
If a fracture was not demonstrable in the roentgenograms but it still seemed 
likely that the bone had been broken, the wrist and thumb were put up in a 
plaster cast. The cast was removed cautiously at the end of 2 weeks, and addi- 
tional roentgenograms were made. A new cast was applied if a fracture was 
visualized on these films. 
If a fracture was visible in the first roentgenograms, a plaster cast was at 
once applied. It included the forearm and hand, with the thumb encased to 
the distal joint. The wrist was in dorsiflexion and radial deviation, and the 
thumb was abducted and in the position of semi apposition. The cast extended 
only to the distal palmar crease and allowed free finger motion, which made it 
practical for the patient to use his hand for light, simple work. He was told NONCOMBAT ORTHOPEDIC LESIONS 
293 
that correct immobilization would determine the end result and was instructed 
to report to the clinic as soon as the cast became loose or soft. 
The cast was removed between 6 and 8 weeks after it was applied, and addi- 
tional roentgenograms were made. At this time, it was possible to determine 
the vascularity or avascularity of the fragments and to arrive at some decision 
as to disposition. If calcification seemed to be proceeding and union to be 
occurring, the prognosis was considered good, and the patient was retained in 
the theater of operations for further treatment. If the relative density of one 
or more fragments indicated avascularity, the prognosis was not considered 
good. The healing process in such a case was likely to be prolonged, possibly 
requiring many months, and unless treatment could be continued in an out- 
patient dispensary disposition to the Zone of Interior was recommended. Con- 
tinued use of overseas hospital facilities was not regarded as justified under these 
circumstances. 
Complete, sound healing of a carpal scaphoid fracture could be assumed 
only when the fracture line had completely disappeared. Immobilization was 
necessary until there was roentgenologic proof that this had occurred. 
Old carpal scaphoid fractures, which had been unrecognized or had been 
treated improperly, were likely to show nonunion; avascular necrosis; and 
traumatic arthritis, with instability of varying degrees. Some soldiers with 
lesions of this kind could perform combat duty. Others suffered from so much 
pain and weakness that they were more or less disabled and were often unfit 
even for limited duties. 
The procedures employed to correct the consequences of neglected carpal 
scaphoid fractures included drilling, bone grafting, excision of the fragments, 
or prolonged immobilization. All gave uncertain results and treatment was 
likely to be time consuming. Such methods were therefore not indicated in a 
theater of operations unless the particular officer or enlisted man was performing 
essential duties and the prognosis in the case was particularly favorable. 
Careful evaluation and correct disposition of patients provided the answer 
to the problem of old carpal scaphoid fractures. A period of observation, during 
which rest and physical therapy were employed, might promise enough improve- 
ment to justify assignment to limited service or even to full duty. If treatment 
was likely to be prolonged, however, it was not logical to institute it overseas. 
If the soldier’s disability prevented his performing even limited service in the 
theater, the better plan was prompt evacuation to the Zone of Interior. 
Ninety-five records of old carpal scaphoid fractures wTere available for 
analysis in the 1944 survey. Less than half of the soldiers (40) could be 
returned to full duty, after spending an average of 23.23 days in the hospital 
and unknown periods of time in further treatment in outpatient clinics. The 
remaining patients were almost equally distributed between categories B and 
C. The hospital-stay days in the category C group averaged 31.54 days and 
in the B group 19.41 days. There was no economy of military manpower and 
medical facilities in these results. 294 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Principles of disposition.—In carpal scaphoid fractures, as in other non- 
combat injuries in which the symptoms were chiefly subjective, the mental 
attitude of the patient was of primary importance in determining his dis- 
position. Exaggeration of minor difficulties was often suspected but was 
extremely difficult to prove. The soldier who persisted in his complaints was 
usually, therefore, successful, at least eventually, in his attempts to avoid 
duty. Frequently he had to be given the benefit of the doubt. The disposition 
board had the major responsibility of conserving manpower for combat, but 
it had an equally important responsibility in limiting the duties of soldiers 
to work which they could reasonably be expected to perform successful!}7 and 
perform without injury to themselves. CHAPTER XI 
Disposition of Patients From Orthopedic Services 
of General Hospitals1 
GENERAL PRINCIPLES OF DISPOSITION 
An important phase of the management of wounded in any overseas 
hospital was to determine, as promptly as possible, the expected duration of 
hospitalization required for each patient before return to duty or some other 
disposition. Ideally, this determination was made immediately after the 
patient’s admission to the hospital, on two military principles, (1) that because 
manpower, resources, and other hospital facilities were limited, they must 
be conserved and utilized as efficiently as possible; and (2) that a soldier who 
could not be returned to duty with a reasonable degree of promptness should 
be evacuated farther to the rear or to the Zone of Interior, in order to leave 
empty beds and other hospital facilities for casualties arriving from areas 
farther forward. 
In forward hospitals in the Mediterranean theater, holding policies varied 
with the rate of casualty flow. When casualties were heavy, only those patients 
expected to return to duty within 48 hours were held. In very quiet periods, 
on the other hand, the holding time might be extended from 10 to 21 days. 
The great majority of duty dispositions from forward hospitals, in addition 
to those for medical conditions, were for minor sprains, bruises, and super- 
ficial wounds. Patients with bone and joint injuries obviously had to be sent 
to the rear, for care in fixed hospitals. 
The same plan of prompt estimation of hospitalization time was employed 
in fixed hospitals, so that soldiers whose military value to the theater was 
ended could be sent to the Zone of Interior as soon as was feasible. In the 
Mediterranean theater, soldiers whose return to duty could be expected within 
90 days or, at other times, within 120 days, were held for treatment in the 
theater. All others were evacuated to the Zone of Interior as soon as was 
compatible with good surgical practice. 
In practice, the determination of transportability was always on an 
individual basis. Not only the risk to life but the possible effect of evacuation 
on future function and anatomic restoration were considered in the timing. 
The general plan was to effect the transfer during some lag period of treat- 
ment, when no specific therapeutic procedure was required. It was also 
1 The extensive data on which the material in this chapter is based were collected and tabulated by Lt. Col. George 
A. Duncan, MC, 45th General Hospital. 
295 296 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
necessary to correlate individual transportability with the availability of 
transportation facilities. 
Civilian standards for discharge from the hospital or return to work were 
not applicable in military dispositions. A soldier returned to duty had to be 
ready to perform all his assigned tasks in his special branch of the service. 
For that reason, hospitalization was necessarily prolonged in comparison 
with the period which would be required for a comparable condition in civilian 
practice. 
Dispositions in the Mediterranean theater were as follows: 
Category A, to full duty. 
Category A2, to a replacement depot for 6 weeks. As a practical matter, 
most patients discharged from fixed hospitals were sent to these depots. Those 
who had been classified as category A were returned to duty at once. The 
others (category A2) underwent reconditioning for 6 weeks. At the end of this 
time, each soldier appeared before a medical board consisting of a surgeon, an 
orthopedic surgeon, and an internist, for determination of his final disposition. 
As a general rule, some 80 percent or more of men classified as category A2 
had their classifications raised to A at the end of the reconditioning period. 
Replacement centers, like the convalescent centers organized in fixed hospitals, 
were operated in the Mediterranean theater by the Combat Conditioning 
Command. 
Category B, to limited-duty assignment, usually noncombatant. 
Category C, to the Zone of Interior. 
In the early days of the Mediterranean theater, there was a decided 
tendency to hold some soldiers with bone and joint injuries in the theater, in 
the hope that they could be returned to duty. This tendency was strengthened 
by the pressure brought upon the Medical Corps bj' combat commanders to 
return as many men as possible to duty. Orthopedic surgeons fully appreciated 
the importance of the maintenance of manpower, but many of them felt— 
and events proved that they were correct—that the pressure exerted in favor 
of duty dispositions would result in the return to duty of many soldiers of 
questionable fitness, who would be unable to carry out the tasks expected of 
them and who would thus be a liability to their commands. 
As experience increased, the fallacy of the original policy as it applied to 
bone and joint injuries became apparent. The very nature of the injuries 
which required the admission of the patients to the orthopedic sections of 
fixed hospitals automatically established many of them as immediate candidates 
for evacuation to the Zone of Interior as soon as their condition permitted. 
The best that could be expected for others was disposition to limited assign- 
ments, usually noncombatant, within the theater. Only a limited number of 
casualties with simple fractures and a very much smaller number with major 
compound fractures or with joint injuries of any severity could be returned to 
duty within a 120-day holding period, much less a 90-day period. Even 
wounds of the hands and feet with only moderate bone and joint damage re- 
sulted in long periods of disability, and the majority of dispositions in these DISPOSITION OF PATIENTS 
297 
groups had to be to category B or C. The few patients with injuries of the long 
bones who could be returned to full or limited duty had usually sustained 
incomplete fractures. 
For a large part of the war, it was the practice in many forward hospitals 
to evacuate to the rear soldiers with chronic, noncombat conditions related 
to the bones and joints. This was a regrettable expenditure of medical effort 
and hospital-bed space. Some of these men, it is true, obviously required 
category C disposition, and their evacuation to the rear was justified. Many 
of them, in fact, should never have been sent to serve in forward combat units. 
The others, however, required no additional treatment, and their cases could 
have been disposed of immediately in forward hospitals by their prompt return 
to duty. The practice, described elsewhere (p. 272), of screening these men 
directly behind the battlefront, which was instituted in the late months of the 
war, was the solution of this particular problem. 
The return to duty of patients with injuries to bones and joints from 
general hospitals overseas was considerably less than might have been ex- 
pected, even in the light of the nature of most injuries of the bones and joints. 
A large part of the explanation in such cases was the mental attitude of the 
soldiers. It was difficult to maintain a proper attitude toward return to duty 
after long periods of hospitalization, and the experience of the Mediterranean 
theater paralleled the experience in other theaters, that the farther from the 
firing line a soldier was removed, the more difficult it was to get him back to 
full duty, even when his condition was such that return to full duty was en- 
tirely justified. 
A SAMPLE HOSPITAL EXPERIENCE 
An analysis of the disposition of 4,287 patients with bone and joint in- 
juries and diseases treated on the orthopedic section of the 45th General 
Hospital during 1944 bears out what has been said earlier in this chapter. 
This hospital had come into the North African theater early in 1943 and by 
the beginning of 1944 was thoroughly experienced in the problems of military 
orthopedic surgery, including the problem of disposition of patients. Its 
experience may be taken as typical of the experiences of many other general 
hospitals in the theater. 
The 4,287 patients in this series represented approximately 20 percent of 
the total (medical and surgical) hospital admissions for 1944. More than 60 
percent were battle casualties. The cases further represented 5,203 separate 
orthopedic diagnoses and 1,546 diagnoses of additional injuries not connected 
with the bones and joints. 
Of these 4,287 patients, 24 percent were returned to full duty, either 
directly from the 45th General Hospital or after the 6-week period of recondi- 
tioning just described. Nineteen percent were returned to limited duty in the 
theater. The remaining 57 percent were evacuated to the Zone of Interior. 
The predominance of Zone of Interior (category C) dispositions is the more 298 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
impressive when it is recollected that the total figure of 4,287 includes innumer- 
able sprains, many non-combat-connected simple fractures, and many chronic 
noncombat orthopedic conditions. The patients in these special groups ac- 
counted for a large number of the category A dispositions to full duty. 
Very few patients with compound fractures of the long bones of the 
extremity were returned to duty within the theater holding period of 90 or 
120 days. Of 374 patients with fractures of the femur of all types, for instance, 
only 19 were returned to full duty, and 334 were evacuated to the Zone of 
Interior. The same proportions held for most patients with fractures of the 
bones of the leg and of the arm and forearm. Even fractures of bones of the 
hand and foot disqualified a large number of patients for further overseas duty. 
In 179 compound fractures of the metacarpal bones, for instance, there were 
91 dispositions to category C and only 49, well under a third of the total number, 
to full duty. In 224 compound fractures of the metatarsal bones, there were 
150 dispositions to category C and only 43, less than 20 percent of the total 
number, to full duty. APPENDIX 
Pertinent Circular Letters 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 512 
15 May 1943 
CIRCULAR LETTER NO. 13 
MEMORANDA ON FORWARD SURGERY 
1. Surgical Echelons, 
a. The welfare of the patient and the tactical necessity for rapid evacua- 
tion demand a clear understanding of the function or mission of each unit of 
the Army Medical Corps. This is best arrived at by dividing the treatment 
of a casualty into two stages—primary and definitive. Separate groups of 
units provide each stage of treatment. In general, the equipment of each 
group is designed for that purpose only. 
h. Stations of the first and second echelons—Aid Stations, Collecting 
Stations and Clearing Stations are equipped and staffed for the primary phase 
of treatment. Arrest of hemorrhage, splinting of the injury, resuscitation 
measures needed to make the patient transportable and administration of 
sulfonamides are the urgent functions of these stations. In addition, the 
treatment of minor injuries that allow immediate return to duty is carried out 
without evacuation. A Clearing Station is not designed to provide definitive 
treatment of battle casualties. 
c. During combat, especially with long distances in evacuation to the 
rear, Surgical Teams are attached to certain Clearing Stations. It is their 
function to give emergency surgical treatment to selected cases requiring 
immediate operation. This treatment would not otherwise be available in 
this echelon. The lack of facilities for pre-operative X-ray examination and 
for post-operative care of adequate duration place a grave responsibility on the 
surgeon in the selection of cases for surgery. These same limitations exist during 
quiet times. The length of the evacuation line to the next echelon and changing 
tactical conditions require frequent redefinition of the surgery undertaken in 
the clearing station. 
299 300 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
d. It must be remembered that the lightly wounded soldier, or a casualty 
due to accident may regain full combat status within the Theater if proper 
surgical treatment is carried out, but the Theater may be deprived of his 
service by faulty surgical judgement. Because a surgical procedure appears 
simple is not sufficient reason for performing it in a Clearing Station unless the 
man can be returned to immediate duty without evacuation to the rear. 
e. Hospitals of the third echelon (Evacuation Hospitals) are designed 
to initiate definitive surgical treatment to battle casualties. The more delay 
there is before reaching this echelon and the more hands the patient passes 
through in reaching it, the poorer will be the final result. The evacuation line 
is not an assembly line in which each surgeon does his bit to the patient. It is a 
conveyance line along the course of which the progress of the patient may be 
halted to save life or limb or render him transportable. 
/. While Evacuation Hospitals are adequately equipped and staffed to 
perform rehabilitation operations, it is not the function for which they were 
designed. Even in quiet times these patients are evacuated to the fourth 
echelon for operation unless the Commanding Officer assumes full responsibility 
based on a knowledge of the existing tactical situation as well as the surgical 
aspects of the individual case. 
2. Surgical Procedures. 
a. Dressings: Ideally, the primary phase of treatment is completed in 
the first unit reached that is equipped to provide it. The dressing is then left 
undisturbed until the patient reaches an Evacuation Hospital for operation. 
There are certain safeguards and adjustments that must take place enroute, 
but these do not include inspection of the wound by removal of the dressing unless 
definite indications are present. A compound fracture is halted at the Clearing 
Station for more adequate immobilization or resuscitation, but this need not 
involve redressing the wound unless there is reason to arrest continuing hemor- 
rhage. A wound is not redressed solely for the purpose of reapplying local 
sulfonamide. Oral administration is sufficient safeguard. 
b. The same principles apply after operation has been completed and 
the patient is being evacuated to the rear. 
c. Uninformed hands do unnecessary dressings. The best safeguard for 
the patient is an adequate and legible record that accompanies him. A receiv- 
ing officer is then in a position to refer to the record instead of looking at the 
wound. Many wounds after debridement and arrival at the base can be 
closed by secondary suture. Infection arising from contamination at the 
time dressings are changed makes this impossible. 
d. Wound Management: Common mistakes in war surgery are: (1) 
Suture of wounds. (2) Tight Plugging by Packs. Hemorrhage is controlled 
by a stitch ligature if from a large vessel. Otherwise, by a temporary pack, 
elevation and firm pressure. If a pack is left in a wound make a note that it 
should be removed at the first opportunity. Vaseline gauze is laid loosely in a 
wound, not packed in. (3) Failure to Immobilize Site oj Injury. Large wounds APPENDIX 
301 
are immobilized even though fracture has not occurred. (4) Overexcision of 
skin. Circular defects are slow to heal. Very little skin need be excised, and 
in some instances none at all. (5) Failure to Open Deep Spaces during definitive 
treatment by freely incising fascial planes. 
p. Compound Fractures: It is essential to distinguish splinting applied 
for a limited time as a transportation splint from apparatus or splinting designed 
for reduction and prolonged or rigid immobilization. An adequate transporta- 
tion splint prevents additional soft part injury and further deformity. It 
cannot in itself cause nerve injury, pressure sores, or jeopardize the circulation 
of the extremity. It provides adequate fixation for ambulance transport over 
rough roads, but may not secure the fragments in rigid fixation or exert the 
traction necessary for further reduction. 
q. Plaster Casts: A more liberal use of plaster of paris casting is urged. 
Plaster casings or slabs applied as temporary transportation splints are padded 
and either bivalved or completely split. Encircling bandages and cotton 
rolling under the cast are also split as it soon becomes inflexible with dry blood 
or serum. Plaster casings applied directly to the skin are rarely found advisable 
in forward areas. If a skin plaster is applied for a definite indication, bony 
prominences are padded and the cast is immediately split in its full length. 
No encircling bandages or adhesive strips are placed under a plaster. 
(1) All plaster casts applied in forward areas should he split or bivalved 
as soon as sufficiently dry. 
r. Skeletal Traction: There is no indication for the use of skeletal traction 
or skeletal fixation in conjunction with transportation splinting in the forward 
area. 
s. Internal Fixation: The use of hone plates or screws is not recommended 
in stations forward of an Evacuation Hospital. 
t. Humerus: Skin traction, skeletal traction and high abduction spica 
plasters or splinting are not only uncomfortable hut dangerous transportation 
methods. A hanging plaster is unsuitable for transportation purposes. A 
simple U plaster slab running from the affected shoulder over the anterior 
aspect of the forearm and upward to the axilla is usually sufficient. The wrist 
is supported by a bandage sling. Following definitive surgery, the same type 
of splinting may be used for further transport, or a carefully applied spica with 
limited abduction (30°-35°) may be used. 
u. Femur: Traction applied by a clove hitch, ankle bracelet or through 
the boot is not advisable for longer than six hours. This type of traction should 
be changed to skin traction at the Clearing Station. 
v. Attention is drawn to the Tobruk transportation splint highly recom- 
mended by the R. A. M. C. reports from the Middle East. Medical Officers 
should be familiar with the design and methods of application of this splint 
and a more frequent use is suggested. 
396961°—57 21 302 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
w. If a plaster spica is used the extremity is fixed in slight abduction 
and care taken to see that the upper part of the cast does not impinge on the 
costal margin. If the other leg is not tied into the spica, and it rarely need be, 
the plaster casing is extended well above the costal margin with fenestration 
provided for the abdomen. 
x. Spica casting for either the upper or lower extremity must be well 
applied with adequate padding to avoid discomfort and pressure sores during 
transportation. These complications as well as easier application have led to 
the development of the Tobruk splint. 
y. Amputation: In military surgery an amputation is a two-stage opera- 
tion—the first stage performed in the overseas theater, the final stage, if 
necessary, in the Zone of the Interior. 
(1) The circular type Guillotine is the amputation of choice. The 
indications for primary amputation are control of hemorrhage, destruction of 
circulation, removal of irreparably destroyed extremity and as a step in the 
debridement of a traumatic amputation. The site of primary amputation is 
the lowest possible level of viable tissues regardless of the eventual utility of 
the stump so formed. 
(2) Delayed amputation is performed for circulatory insufficiency, 
infection, gas gangrene in which more conservative measures have been inade- 
quate or in the judgement of the surgeon will be inadequate, and uncontrollable 
secondary hemorrhage. The site of secondary amputation is determined by 
the judgement of the surgeon with respect to preservation of maximum bone 
length. 
(3) Sulfanilamide is dusted on the end of the stump and vaseline 
gauze dressing applied. Skin traction is applied on the operating table and 
continued until the stump is healed. All lower leg amputations are splinted with 
a posterior slab to prevent flexion deformity of the knee. The splint extends 
below the level of the stump. Transport in ring Thomas splint with support 
of the stump and continued skin traction. 
(4) Adhesive plaster traction is recommended in the forward areas 
where a bulky dressing may be desirable. Stockinette applied with skin glue 
may be substituted at the base. Adhesive plaster traction strips must extend 
to the edge of the incised skin and be anchored by two circular strips. They 
should not extend upward beyond the base of the limb. 
(5) Secondary closure of amputation stumps is not recommended. 
z. Peripheral Vascular Insufficiency: Following wounds that jeopardize 
the blood supply of an extremity transport beyond an Evacuation Hospital is 
delayed until the collateral circulation has been demonstrated adequate or 
until amputation has been performed. Immobilization for transport, or the 
additional trauma and shock incident to transport may be a determining factor 
in producing gangrene. APPENDIX 
303 
(1) Principles guiding treatment of a limb with defective circulation 
are as follows: (1) Immediate restoration of blood volume with plasma supple- 
mented by whole blood transfusion to establish normal oxygen carrying capacity 
of the blood. (2) Prevention of loss of body heat by dry woolen coverings for 
body and limbs. (3) Do not ligate a major artery in continuity. Divide the 
vessel between ligatures. (4) Ligate and divide the companion vein. (5) The 
extremity supplied by the divided vessel should not be elevated but slightly 
depressed. Wrap in wool or cotton. Do not directly heat. 
(2) To stimulate the development of collateral circulation the follow- 
ing measures are recommended: (1) Heat the body (not the limb) under a 
cradle. (2) Novocain block of sympathetic chain repeated daily if necessary. 
(3) Under special circumstances, sympathectomy, (4) Vasodilating drugs are of 
questionable efficacy. (5) Passive vascular exercises. (6) Incision of deep 
fascia planes if a tense hematoma is present. 
(3) Arterial spasm may be encountered when a missile passes close to 
an artery or there is an adjacent fracture. There is no external bleeding or 
hematoma. The limb is cold, numb and muscle action lost. Peripheral pulses 
are absent. There is no pain in contrast to occlusion of the artery by an 
embolus. 
(4) Peripheral pulses return in a few days as color and warmth re- 
appear in the limb. Treatment is directed toward warming the body, and the 
use of sympathetic novocain block. If the vessel is exposed during debride- 
ment direct application of procaine may be tried. 
(5) All casualties with defective circulation in an extremity, par- 
ticularly of the leg should be under close observation for the development of 
gas gangrene. 
(S) F. A. Blesse 
F. A. BLESSE, 
Brig. General, AUS, 
Surgeon. 
DISTRIBUTION: 
CG, Fifth Army 500 
CG, II Corps 450 
CG, NAAF 300 
CG, ABS 500 
CO, MBS 800 
CO, EBS 
CO, Hq. Comd., AF 50 
SURGEON, NATOUSA 100 304 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 534 
9 June 1943 
CIRCULAR LETTER NO. 16 
SUBJECT: MEMORANDA ON FORWARD SURGERY ESPECIALLY 
APPLICABLE TO AMPHIBIOUS OPERATIONS 
1. General Principles of Wound Management: 
a. Surgical operation performed under unfavorable conditions without 
facilities for proper after care is often more hazardous than prompt evacuation 
if the patient is transportable or can be made so. 
b. Wounded evacuated by water should, particularly during early phases 
of combat, be so bandaged and splinted that they can swim or at least remain 
afloat should emergency require it. 
c. Overdosage with morphia produces dangerous coma and respiratory 
depression that may delay the administration of an anaesthetic or render 
evacuation transport hazardous. 
d. All wounds are left open after debridement, frosted with sulfonamide 
and loosely filled with vaseline gauze. There are no exceptions. (See below for 
specialized regional situations). 
e. Only bruised and devitalized skin need be excised, and this with 
narrow margin. Avoid circumscision of wounds leaving circular defects by 
using linear extensions to gain exposure. 
f. During debridement open all deep pockets and transversely divide 
fascial planes. 
g. Do not pack wounds with gauze or sulfonamide. 
h. Immobilize site of extensive injury even if fracture is not present. 
i. Continue oral administration of sulfonamide. 
j. Make notations on casts and on Field tags and records, (casts are 
frequently changed) particularly of what was done at operation. These notes 
are not merely for statistical purposes although essential as such. They are 
required for the subsequent care oj the patient. 
2. Plaster Casts. 
a. Split or bivalve all casts as soon as dry. There are no exceptions. 
b. Pad all casts and split padding as well as cast. Non-padded plaster 
is not suitable for transportation splinting. 
c. Apply no circular adhesive or bandage under cast. APPENDIX 
305 
d. Maintain foot in neutral position with correction of tendency toward 
equinus, valgus or varus. 
3. Compound Fractures. 
a. Objects to be achieved in initial surgery are control of infection and 
safe, comfortable transportation. Reduction and rigid fixation of fracture 
can be accomplished at The Base. 
b. Careful debridement as priority case. No internal fixation forward 
of Field or Evacuation Hospitals. Do not pack wound—loosely fill with vase- 
line gauze. Splint for transportation. Skeletal fixation or traction not recom- 
mended for transportation splinting. 
c. Femur: Evacuate in Tobruk splint (See Appendix) as early as cir- 
cumstances permit to reach Base for correction of deformity. A fractured 
femur should reach a General Hospital in the rear within 10 days. Do not 
evacuate with clove hitch or boot traction—use skin adhesive. 
d. Knee-joint: In debridement minimize incisions that compound 
joint. Remove accessible foreign bodies. Irrigate joint with saline. Close 
synovial membrane. Loosely fill debrided wound with vaseline gauze. 
Evacuate early, immobilized in plaster or preferably Tobruk splint. 
e. Leg: Careful debridement all wounds in multiple injuries, as circu- 
lation frequently impaired and gas gangrene likely. Penetrating wounds of 
calf may require incision for hemostasis as deep hematoma impedes circulation. 
Bivalve rather than split casts so inspection dressings may be possible without 
losing position in compounded fractures. Hold patient if circulation is ques- 
tionable, otherwise evacuate as early priority. 
f. Humerus: Use modified Velpeau plaster bandage to hold arm to 
trunk, or “U” plaster. Skin traction, skeletal fixation, high abduction spica 
and hanging cast unsuitable for transportation splinting. 
10. Amputations: 
a. Circular type guillotine is amputation of choice. In forward surgery 
performed for control of hemorrhage, destruction of circulation, removal of 
an irreparably destroyed extremity, and as a step in the debridement of a 
traumatic amputation. The site is the lowest possible level of viable tissues 
regardless of the eventual utility of the stump. 
b. Gas gangrene infection occurs in certain cases with 24 hours delay 
in evacuation from the field. Amputate only if more conservative surgery 
and full dosage (80,000 to 100,000 units of polyvalent anti-toxin) are judged 
inadequate. 
c. Apply skin traction on the operating table and maintain during 
evacuation. 306 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
d. No sutures. There are no exceptions. 
(S) F. A. Blesse 
F. A. BLESSE, 
Brig. General, AUS, 
Surgeon. 
Incl: Appendix 
DISTRIBUTION: 
To all Medical Officers 
CG-Fifth Army 900 
CG-NAAF ' 450 
CG-ABS 500 
CG-MBS 800 
CG-EBS 700 
CO, PIq. Command AF 50 
Surgeon, NATOUSA 250 
APPENDIX 
Tobruk Transportation Plaster.—Recommended for fractures of the femur, 
wounds involving the knee joint and fractures of the leg near the knee. 
1. Dress wound and retain dressing with strips of adhesive plaster. No 
circular dressing or bandages should ever be put on under a plaster case. 
2. Support patient with a pelvic rest, or bowl under sacrum. One assist- 
ant holds the foot by the heel and toes and exerts traction. The foot is kept 
at right angles. A second assistant supports the fracture and keeps the knee 
bent at 10 degrees flexion with the palms of the hands not the fingers. 
3. Apply traction strapping as close up to the wound as possible. Fold 
distal ends of straps into cords. 
4. Pad the heel and malleoli with wool. Turn back the traction straps 
from the region of the malleoli while winding the wool round. Pad the knee 
prominences similarly. There have been some cases of foot drop from pressure 
on the external popliteal nerve. Pad the upper part of the thigh close to the 
ring of the splint with a layer of wool. Pad the entire extremity with sheet 
wadding or stockinette. 
5. Lay a strip of tin (obtainable from ration boxes etc.) wrapped in paper 
over the anterior surface of the length of the limb to beyond the toes. 
6. Prepare a plaster slab (6 thicknesses)—apply posteriorly as high as 
possible and distally over heel and sole of foot to project 3-4" above the toes. 
7. Complete plaster cast with circular bandages round the slab enclosing 
the whole of the leg and foot except the dorsum of the toes and mould. Do not 
cover over traction straps further than just above the malleoli. 
8. The traction straps are now emerging from the plaster just above the 
malleoli. Turn them back and cut the plaster away from where they emerge, APPENDIX 
307 
sufficiently to free the straps from the plaster. This allows the traction to be 
on the leg and not on the cast. Trim the plaster over the dorsum of the toes. 
See that the little toe is free. 
9. Apply Thomas Splint preferably half-ring and fit lower part of ring 
against Tuber Ischii and adductor muscles. Hold up ring so as to obtain cor- 
rect position and insert pads of wool anteriorly and laterally between the ring 
and the thigh to maintain the position. Tie traction straps to notch in splint 
and insert spreader and Spanish Windlass. 
10. Wind plaster bandages round the side bars of the splint, and round the 
limb to anchor the splint to the limb. 
11. Support distal end of splint with splint bracket. 
12. When plaster is moderately firm cut down on thin strip over whole 
length plaster and withdraw strip and split the plaster. Cut the underljdng 
padding with scissors or knife. It is not necessary to cut stockinette. 
13. With indelible pencil draw diagram of fracture and write simple details, 
date of wounding, treatment, date of application of plaster, unit, etc. 
NOTE. This splint is only intended as a transportation splint for the journey 
to the base. There is no need to aim at accurate apposition in the Forward 
Area. On arrival at the Base Hospital X-ray examination should be made, 
position corrected if necessary and routine treatment employed. 
This form of fixation will do quite well even for fractures of the upper third 
of the femur for transport. 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 534 
26 June 1943 
CIRCULAR LETTER NO. 19 
Operations on the Knee Joints IV 
IV—OPERATIONS ON THE KNEE JOINTS. 
1. Careful surgical judgement is to be exercised in the selection of cases for 
excision of semilunar cartilages. A history of locking is essential. Instability 
of the knee joint is a contraindication. Post operative care in the form of early 
weight bearing without crutches and exercise of the quadriceps muscle groups 
instituted early under supervision is essential to recovery. 308 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
2. Operations for major knee disabilities such as repair of collateral or 
cruciate ligaments, or removal of both cartilages are to be undertaken only on 
recommendation of a Disposition Board of a General Hospital. 
For the SURGEON: 
(S) E. Standlee 
E. STANDLEE, 
Colonel, M. C., 
Deputy Surgeon. 
DISTRIBUTION: 
CG, Fifth Army 600 
CO, ABS 500 
CG, MBS 600 
CO, MBS Center District 200 
CG, EBS 600 
CG, NAAF 450 
CG, Force 141 300 
CO, HQ Comds., AF 50 
Surgeon, NATOUSA 150 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 534 
22 June 1943 
CIRCULAR LETTER NO. 20 
SUBJECT: Tunisian Campaign..Comments by Hospitals of the Zone 
of Communications on the Treatment of Battle Casualties in 
Forward Areas. 
NOTE: At the end of the final phase of the Battle of Tunisia, several 
hospitals of the Zone of Communications were asked to submit comments on 
the surgical treatment of battle casualties received during the campaign. 
Although quotation marks have been eliminated, the following paragraphs are 
direct transcriptions of these comments and suggestions. Specific case his- 
tories have been assembled in the Appendix with designations as footnotes. 
Many of the principles emphasized in these comments have been incorporated 
in Circular Letters, and they should be carefully observed by all Surgeons in 
the Theater. 
Figures in parentheses refer to case histories in the Appendix. Comments 
in parentheses were not received from the hospitals. APPENDIX 
309 
1. General Considerations. 
a. In general, the great majority (90%) of patients received from the 
combat zone have been well and adequately treated, and good judgement has 
been exercised in selection of cases suitable for evacuation to this general 
hospital. 
b. In several instances the severity of the injury has not seemed to 
warrant evacuation to this point, where, with a large proportion of the cases 
prospectively to be evacuated to the Zone of the Interior, it is inevitable that 
the patients should acquire an exaggerated idea of the severity of their injury, 
and a reluctance toward return to duty. (1) 
c. There are rare instances of patients who were so critically ill on 
admission that their evacuation has appeared unwise and unduly hazardous. 
d. Many patients might have been returned to full or limited service if 
they had not been told that they were to be sent to the Zone of the Interior, 
or that they would not regain full function of an injured part. 
e. Almost all of our patients have spoken with appreciation of the skilled 
and kindly treatment they have received in the most forward areas—litter 
bearers, battalion surgeons, and on back. Most of the patients have had 
excellent treatment and in particular the work of the Surgical Teams has been 
outstanding. 
/. A number of our patients have received wounds due to shell fragments. 
The vast majority of these wounds have been satisfactorily treated by excision 
and left open. Most of them have healed kindly and have required only second- 
ary closure or skin grafting for complete healing. 
g. Judging from the comparatively small number of war casualties 
treated in this hospital it seems evident that delayed primary suture of wounds, 
particularly in patients who are to be evacuated is an ill-advised procedure. 
(This does not apply to secondary suture in a Base Hospital where the patient 
can be held until healing is complete.) The suture of wounds using a gauze 
pack as a drain should be avoided. The pack dries and acts as a plug rather 
than a drain. 
2. Initial Treatment of Wounds. 
a. Adequate debridement of wounds in combination with a filling of 
vaseline gauze and the use of sulfa drugs and plaster immobilization has pro- 
duced clean wounds in most instances. The patients have arrived in good 
condition, relatively comfortable, and have only rarely showrn even slight 
temperature elevation. 
b. The extent of some wounds suggests that skin removal has been too 
extensive in many cases. 
c. Large numbers of foreign bodies are still present in the wounds in 
many cases. The metallic foreign bodies only occasionally are responsible for 
persistent draining sinuses. In one case fragments of cloth were found just 
beneath the skin, where even casual debridement might have discovered them. 
d. Conservation of digits. Numerous fingers with compound injuries 
and lacerated tendons have been treated conservatively, often with tendon 310 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
suture and splinting. An over heroic attempt lias been made in the presence of 
sepsis to preserve digits devoid of function. The protracted splinting in these 
cases results in diffuse stiffness of the hand unrelieved by late amputation of 
the useless digits, and necessitating evacuation to the Zone of the Interior. 
From the standpoint of military usefulness the results of early amputation in 
badly damaged fingers have been more satisfactory. 
e. There have been several instances of attempted primary tendon repair 
in severe crushing or gunshot wounds of the hand. None of these has been 
successful. 
/. Packing. The commonest criticism of the packing of wounds is that 
excessive amounts of gauze have been used, frequently acting as a plug, and 
often introduced through a small wound of entrance. In several cases through 
and through gauze strips have been used to pack perforating wounds of the 
extremities. Coarse meshed dry gauze has been used for packing in many 
cases, the removal of which is difficult and unnecessarily traumatizing. When 
it is necessary to use dry gauze packs to control bleeding, early removal is 
urgent and a notation that such packing has been employed would ensure an 
early change of cast. 
g. On many occasions when the casts were removed and the wounds 
dressed, tight vaseline packs were found in place and when these were removed 
there was a gush of dammed back discharge. It seems desirable that the 
vaseline gauze strips be laid from the bottom of the debrided wound out over 
the skin in an axis at right angles to the wound. Having lain such strips all 
about the circumference of the wound the remaining central cavity can be 
filled with vaseline gauze folded back and forth. It is worth repeating that the 
debridement should be complete, the sulfanilamide sprinkled into all crevices 
of the wound and the vaseline packing inserted loosely. 
(It is recommended that the term “pack” be dropped from common usage 
and reserved specifically for a temporary procedure used to control hemorrhage.) 
h. Immobilization. Many casts are excessively thick and heavy. 
Insufficient padding, or padding carelessly applied, has resulted in pressure 
sores in several cases. The use of circular bandages inside casts, or of slings, 
may result in constriction or pressure sores. Simple linear incision of a circular 
cast is not sufficient safeguard against swelling and circulatory embarrassment. 
In one instance of simple uncomplicated fracture of both bones of the leg, 
amputation was barely averted because of circulatory damage which could 
have been avoided by proper padding or bivalving of the cast. 
i. We particularly condemn the use of the skin tight plaster on the acute 
injury, even those split up the front. We have had about 20 cases of fracture 
of the leg and a few of the arm come to us in plasters applied directly to the skin 
at the time of debridement in forward hospitals. With very few exceptions the 
skin has been blistered when these casts were removed. Sheet cotton, stock- 
inette, cloth of any kind or even newspaper should be used to protect the skin. 
j. Insufficient splinting and immobilization has been applied. (2) (3) 
Contractures have developed which have been very troublesome and in some APPENDIX 
311 
cases have necessitated evacuation to the Zone of the Interior for this reason 
alone. Cock-up splints for radial nerve injuries are generally too short. 
Patients with peroneal palsy are not protected against foot drop. 
k. Hip spicas in the majority of cases are carried unduly high and cause 
a considerable amount of unnecessary discomfort. In shoulder spicas a common 
error is to place the arm in too great abduction, and in or behind the frontal 
plane of the body rather than forward of it. Patients transported in “hanging 
casts” for fracture of the humerus do not travel well. (4) 
l. Of the 272 patients treated, 111 were compound fractures, all but four 
of whom entered this hospital by air ambulance in excellent condition. The 
great majority of these patients had been treated by early debridement, local 
application of a sulfonamide packing with vaseline gauze and application of a 
padded plaster cast. 
m. Fractures have been well immobilized and the plaster work has been 
excellent. In only a few instances has it been necessary to remove plaster 
because of constriction. 
n. In badly comminuted fractures where good position has been obtained 
at operation loss of position is to be feared with change of cast. These cases 
are problems. While we favor the 10th to 12th day change of plaster we have 
allowed them to go several weeks pending soft tissue fixation of the fragments. 
It would be helpful if plasters in such cases could be bivalved rather than split 
down the center, so the dressing might be done and a new cast applied over the 
remaining half. 
(Bivalving plasters prior to transportation means strengthening the halves 
by slabs and secure approximation before evacuation.) 
o. Penetrating or perforating injuries of the knee have frequently been 
opened surgically in forward hospitals, foreign bodies or bone and cartilage chips 
removed, the joint irrigated thoroughly, sulfanilamide inserted into the joint, 
the synovial membrane closed and the wound then packed open. All so treated 
have done well with a minimum of synovial reaction. After the operative pro- 
cedure all cases should be immobilized in a long leg plaster to the groin and the 
use of a cross stick at the ankle to prevent rotation. 
3. Amputations. 
a. The small number of amputations seen would have benefited had 
they been transported in Thomas splints with skin traction applied to the skin 
flaps. The open wounds were clean but the skin had retracted to the point 
that reamputation will probably be necessary to accomplish a serviceable stump. 
b. In two instances a final amputation was done at too high a level to 
permit use of an artificial limb. Several cases of amputation have arrived with 
severe flexion contracture of the knee for lack of a posterior splint. Several 
cases of severe hip flexion contracture have been received as a result of omitting 
posterior splints following thigh amputations. 
c. Out of twelve cases of anaerobic gas bacillus infection in one hospital, 
2 were in sutured amputation stumps. 312 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
d. In the following case, (5), a conservation type of amputation was 
performed through a level far below the site of vascular occlusion in an infected 
leg. I think the lesson here is that the line of demarcation in infected extremi- 
ties with vascular occlusion does not mark the level at which an amputation 
stump will be sustained. Circulation just enough to maintain viability of 
tissues will not withstand an amputation or cope with an infection. Amputa- 
tion in such cases must be high, if possible above the level of vascular 
occlusion. 
(S) F. A. Blesse 
F. A. BLESSE, 
Brig. General, AUS, 
Surgeon. 
Incl: Appendix 
DISTRIBUTION: 
CG, Fifth Army 600 
CO, ABS ' 500 
CG, MBS 600 
CO, MBS Center District 200 
CG, EBS 600 
CG, NAAF 450 
CG, Force 141 300 
CO, HQ. Comd., AF 50 
Surgeon, NATOUSA 150 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 534 
18 November 1943 
CIRCULAR LETTER NO. 48 
PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED... I 
PARAGRAPH III, CIRCULAR LETTER NO. 19 IS AMENDED.__ II 
USE OF EXTERNAL SKELETAL FIXATION APPARATUS 
(ROGER ANDERSON) IN TREATMENT OF FRACTURES 
OF THE EXTREMITIES III 
DELAYED OPEN REDUCTION AND INTERNAL FIXATION 
OF COMPOUND FRACTURES WITH OR WITHOUT SEC- 
ONDARY SUTURE OF WOUND IV 
FRACTURES OF CARPUS V 
HERNIATED NUCLEUS PULPOSUS VI 
“PARRY” OR MONTEGGIA FRACTURE VII APPENDIX 
313 
THE TOBRUK SPLINT AND HIP SPICAS VIII 
TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA IX 
I—PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED AS 
FOLLOWS: 
Operations of the Knee Joint 
Follow-up studies on over 200 operations performed in this theater for 
removal of dislocated or ruptured semilunar cartilages and other derangements 
of the knee joint have been compiled. Appraisal of these results lead to tlie 
following recommendations: 
1. Operations for the repair or reconstruction of the collateral or cruciate 
ligaments of the knee, or for recurrent dislocation of the patella, are not to be 
performed in this theater. 
2. Careful study and mature surgical judgement will be exercised in the 
selection of cases for excision of a semilunary cartilage or joint mouse. 
a. Elective arthrotomy of the knee will be performed only on the 
Orthopedic Service of a General Hospital. 
b. Initial injuries of the semilunar cartilage without locking and those 
that unlock by gentle manipulation, or after 5 to 6 days of skin traction, will 
not be subjected to operation. Pressure support, rest, graduated to protected, 
then full weight bearing and carefully supervised quadriceps exercise for 2 to 
10 weeks, are suggested as a method of management. Following symptomatic 
relief these soldiers may be returned to duty. 
c. Arthrotomy will be limited to: 
(1) The persistent locked knee. 
(2) The unlocked knee in a soldier who cannot perform non- 
combat duty because of his disability. This will be only the exceptional case. 
d. Contraindications to be considered are age, arthritic changes, in- 
stability of the joint and, in particular, any but the most favorable mental 
attitude of the soldier. 
e. Recurrent cases, not locked, and those recurrent cases that unlock 
with non-operative therapy, are to be returned to duty unless the total period 
of disability in any calendar year exceeds 90 days. Under such circumstances, 
they will be transferred to the Zone of the Interior. 
f. Operation for the removal of both cartilages from one knee or for 
one cartilage from each knee is to be performed only on written recommenda- 
tion of a Disposition Board of a General Hospital. 
3. A General Hospital in which arthrotomy of the knee is performed will 
be expected to hold the patient for a minimal period of six weeks, so that the 
operating surgeon may supervise the regimen of post-operative exercises and 
motion essential to a good result. Proper post-operative supervision is as 
essential to recovery as the operation. If prevailing evacuation policies in- 
dicate that the patient cannot be held for at least 6 weeks post-operatively, he 
should be transferred farther to the rear for operation. 314 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
4. After 6 weeks in a General Hospital, the patient may be transferred to 
a Convalescent Hospital for further care with full instructions relative to con- 
tinuation of corrective exercises. 
II—PARAGRAPH III, CIRCULAR LETTER NO. 19 IS AMENDED AS 
FOLLOWS: 
Operations for Recurrent Dislocation of the 
Shoulder Joint or Chronic Dislocation of the 
Acromio-clavicular Joint 
1. The history of a patient relative to previous dislocation of the shoulder 
is notoriously unreliable. Before making a diagnosis of recurrent dislocation, 
one or more episodes should be confirmed on Army Medical Records, preferably 
with supporting X-Ray evidence. 
2. Operations of this type will be performed only with written approval 
of the Disposition Board of a Geneual Hospital following demonstration that 
the disability is of a nature that the soldier cannot perform non-combat duty 
and when his age and mental attitude give a reasonable prospect of military 
rehabilitation. 
Ill—USE OF EXTERNAL SKELETAL FIXATION APPARATUS 
(ROGER ANDERSON) IN TREATMENT OF FRACTURES OF 
THE EXTREMITIES. 
1. This is a highly specialized method for the treatment of carefully 
selected cases, chosen on the basis of special indications. 
2. The use of external skeletal fixation is to be limited to surgeons with 
training and experience in the method. If a special indication for use of the 
method is found in a hospital without such a surgeon, the patient will be 
transferred to a hospital with this trained personnel. 
3. A patient with the apparatus in place is not to be transferred from one 
hospital to another within the theater except under emergency conditions. 
When a transfer is essential, he is to be routed to a hospital where there is a 
surgeon experienced in the method. Patients are not to be evacuated to the 
Zone of the Interior with the apparatus in place, but will be held for a sufficient 
time to permit the removal of pins and the substitution, if indicated, of con- 
ventional means of splinting. 
4. Clinical records of each patient, on whom the method is utilized, will 
be forwarded through channels to the Surgeon, NATOUSA, after the treat- 
ment is completed. This record will contain essential data for identification 
of the case, date of injury, fracture diagnosis, original treatment, character of 
the wound if compound, problem involved and indication for use of the method, 
length of time required to apply the apparatus and reduce the fracture, number 
of X-Ray films required, date and extent of any observed distraction, incidence 
of pin infection and other complications, date of removal of the apparatus and 
subsequent treatment, result and disposition. APPENDIX 
315 
IV— DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF 
COMPOUND FRACTURES WITH OR WITHOUT SECONDARY 
SUTURE OF WOUND. 
1. This procedure is still under trial with reference to indications, hazards, 
and incidence of serious complications. Its use is restricted to special groups 
authorized to assume the responsibility as a special study. 
V— FRACTURES OF CARPUS. 
1. Greater care is to be exerted in making a precise and early diagnosis of 
carpal fractures and dislocations. Early reduction is essential if a satisfactory 
result is to be obtained. 
2. Operative treatment for old unrecognized fractures of the scaphoid will 
fail to rehabilitate a soldier in this theater. If complete disability is present, 
he should be transferred to the Zone of the Interior. 
VI— HERNIATED NUCLEUS PULPOSUS. 
1. Recommendation Par. II, Circular Letter No. 19, 26 June 1943, is 
interpreted to apply to all patients, Army, Navy or Allied Force under treat- 
ment for this condition in U. S. hospitals. 
VII— “PARRY” OR MONTEGGIA FRACTURE. 
1. Attention is directed to fracture of the shaft of the ulna with dislocation 
of the head of the radius. Uncommon in civilian practice, this fracture due 
to direct violence to the forearm (blow with rifle butt or other blunt weapon), 
is not infrequent in military experience. It is essential that the dislocation of 
the radius be recognized and proper treatment instituted at the time of initial 
treatment. 
VIII— THE TOBRUK SPLINT AND HIP SPICAS. 
1. Experience has shown that the use of Tobruk splint is best limited to 
fractures of the lower one-third of the femur, supra-condylar fractures, and 
wounds damaging the knee joint. Even in these injuries it has no advantages 
over a well applied hip spica. 
2. The most comfortable and efficient hip spica for immobilization of a 
fracture of the femur for transportation, following initial surgical treatment, 
is a short waisted, double spica extending only to the knee on the well leg and 
maintaining 20 to 30 degrees of abduction with the knee slightly flexed. The 
plaster on the injured leg is carried beyond the toes by a plaster slab, leaving 
the toes fully exposed anteriorly. Care is taken to avoid equinus and to hold 
the foot in a neutral position between valgus and varus. 
3. High waisted plasters that extend to or above the costal margin cause 
discomfort. It is better to tie in the well leg and stop the plaster just above 
the iliac crest. 316 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
4. The chief responsibility of the surgeons of the forward area in the 
management of all compound fractures is the prevention of infection, rather 
than the anatomic correction of deformity. Early evacuation to the Base (a 
fractured femur should reach a General Hospital within 10 days) will allow 
for definitive reduction of the deformity. 
IX—TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA. 
1. Meticulous nursing care is essential for the prevention of bed sores. 
This care is interrupted by rapid evacuation through a chain of hospitals. 
While it is important to transfer these cases to the Base, when they are trans- 
portable, they should not be subjected to long ambulance lifts. On arrival at 
an intermediate station, careful nursing care should be provided immediately. 
If there are signs of pressure sores, the patient should be held for corrective 
measures before further transfer. These patients do not complain of pain 
and quite different criteria are required in an estimation of whether they are 
to be classified as “transportable” than are found applicable in the management 
of other casualties. 
For the SURGEON: 
(S) E. Standlee 
E. STANDLEE, 
Colonel, M. C. 
Deputy Surgeon. 
DISTRIBUTION: 
Surgeon, NAAF 400 
Surgeon, NAASC 300 
Surgeon, EBS 400 
Surgeon, MBS 300 
Surgeon, ABS 150 
Surgeon, IBS 100 
Surgeon, PBS 500 
Surgeon, AMGOT 25 
Surgeon, CD MBS 50 
Surgeon, Seventh Army 350 
Surgeon, Fifth Army 600 
Surgeon, Hq. Command, AF 50 
Surgeon, NATOUSA 200 APPENDIX 
317 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 534 
CIRCULAR LETTER NO. 26 
19 April 1944 
SUBJECT: Wound Management. 
1. The keystone of successful wound management is the initial surgical 
operation. When this is performed correctly the complications of infection are 
absent or minimal and secondary suture may be carried out promptly and suc- 
cessfully. To coordinate the initial surgery in the forward area with the defini- 
tive surgery at the base observance of the following principles is essential. 
2. Initial Wound Surgery. 
a. Adequate assistance and instruments, a good light and access to the 
wound that is unhampered by faulty position of the patient are basic require- 
ments. Ample preparation of a wide field by shaving the skin will allow for 
extension of the incision or counter incision. 
b. Bold incision is the first essential step in an operation on a wound. 
Adequate exposure is necessary to carry out excision of devitalized tissues. On 
the extremity the line of the incision is placed parallel with the long axis of the 
limb; elsewhere it follows the natural lines of skin structure. Only the de- 
vitalized skin of the margins of the wound is excised in a strip rarely wider than 
2 to 3 mm. Circular defects are to be avoided. 
c. Incision and excision of the fascial layers is carried out in the same 
manner to give free access to devitalized muscle. Unrestricted exposure of suc- 
cessive anatomic layers permits the complete excision of devitalized muscle and 
the removal of foreign bodies. The operation on a wound is an anatomic dis- 
section and should never be made to resemble a digital pelvic examination. 
d. The surgeon must be familiar with the blood supply of muscles, partic- 
ularly large groups like the gastrocnernius-soleus muscles of the calf and respect 
these vessels in his dissection. Deep recesses of the wound containing foreign 
bodies may be approached by counterincisions planned anatomically rather 
than by sacrificing normal muscle structures. 
e. Use fine hemostats. Use the finest ligatures compatible with the 
procedure. Include the smallest possible amount of tissue in ligating a bleeding 
point. Do not repeatedly bite the wound with tissue forceps. Sponge gently 
with pressure instead of wiping. Remaining devitalized tissue produced by the 
missile or by the surgeon must slough before the wound can be closed by secondary 
suture. 
f. Large wounds in regions of heavy muscles particularly when compli- 
cated by comminuted fracture require especial care. The depths of these 
306961 °—57 22 318 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
wounds must be opened by a long incision with counterincision if necessary to 
allow free drainage of blood and tissue that may not be identified as dead at the 
time of debridement. 
g. Only enough vaseline gauze is used to separate the surfaces of the 
wound. It should be smoothly laid in the wound—not “packed”. 
h. Local application of sulfanilamide is a minor adjunct to surgery and 
is used as a fine frosting of the surfaces. It is not to be “rubbed in”. 
i. Ether, white soap, and benzene have slight but definite necrotizing 
effects on living muscles. Green soap, hydrogen peroxide and various other 
substances used as detergents have greater necrotizing effects. Physiological 
saline solution, petrolatum and boric acid ointment are innocuous. If a deter- 
gent is needed, white soap is the least objectionable. 
j. Old wounds (48 hours or longer) are managed in accord with the same 
principles except that in selected cases of established pyogenic infection and 
anaerobic cellulitis with toxicity the general condition of the patient to withstand 
radical surgery may be improved by immobilization, penicillin and repeated blood 
transfusions until an optimum time is selected for intervention. In postpone- 
ment of surgery the advantage that accrues from the immediate drainage of 
septic hematomas, large masses of dead muscle and fascial plane abscesses is 
not to be forgotten. Postponement of surgery is not justified if clostridial 
myositis (gas gangrene) may be present, 
3. Secondary Wound Surgery. 
a. On arrival at a hospital where bed care can be assured for a period 
of 15 days the first dressing is removed in the operating room under aseptic 
precautions. X-ray films should be at hand. If the primary wound operation 
has been a complete one, all superficial wounds and many deep wounds may be 
closed by secondary suture at this time (4 to 10 days). Foreign bodies in soft 
parts adjacent to the wound are removed. Following suture, the part is im- 
mobilized preferably by a light plaster, or if this is impractical, by bed rest. 
b. The presence of residual dead tissue or established infection indicated 
by profuse discharge of pus, reddening and edema of the wound margins, per- 
sistent fever or toxicity are the common indications for delay in secondary 
suture. When these indications are present but minimal, the wound is allowed 
to “clean up”. Moist dressings, heat and azochloramine are generally con- 
sidered to hasten this process. Additional surgical excision of devitalized frag- 
ments may speed the process. Secondary suture can then be performed in a 
few days. If established infection is severe, or if the patient is toxic and anemic 
from deep seated sepsis, a course of penicillin therapy and blood transfusions 
is instituted and followed by radical wound revision. 
c. Closure of wounds that compound fractures or joints is only to be 
undertaken when the surgeon is completely familiar with the use of penicillin 
as an adjunct to surgical wound revision. Penicillin will not “sterilize” a 
wound that contains devitalized bone, fascia, tendons or foreign bodies. Im- 
mediate success may be obtained, but delayed abscess formation, joint infections APPENDIX 
319 
and osteoperiostitis are likely to appear as sequelae. The wound revision that 
is an essential part of “cleaning up” wounds that complicate fractures or joints 
for closure, either at the time or subsequently, is not to be taken lightly. 
Preparation of the patient by transfusions, diet and accessory surgical proce- 
dures is essential. 
d. Wounds that have been properly laid open at the initial operation 
tend to gape widely and give the impression of extensive skin loss. This appear- 
ance is actually due to loss of support of the deep fascia. Skin defects are more 
apparent than real in the majority of cases and closure of a defect is made 
from local tissue with suture in a straight line when possible. Undermining 
with advancement or rotation of flaps provides sufficient skin in nearly all 
instances and is preferable to grafting. 
e. Technical considerations that are important to the success of second- 
ary wound closure are: 
(1) Atraumatic handling of tissue (see par 2, e). 
(2) Avoidance of tension sutures. 
(3) Accurate approximation of skin margins. The epithelial bridge 
is the main support of the wound for a considerable period of time. 
(4) Obliteration of dead spaces by pressure dressings and immo- 
bilization. 
(5) Leaving sutures in place for 12 days if stitch infection does 
not develop. 
(6) Suture in straight lines rather than creation of sharp angles. 
(7) Closure by adhesive plaster strips is not as satisfactory as suture. 
f. The conditions that most often jeopardize results are: 
(1) Suture of wound that is discharging a large amount of pus. This 
usually means dead tissue in the depths. 
(2) Hemolytic streptococcus infection. 
(3) Diphtheria wound infection. 
(4) Too early motion. (Wounds breaking down for this reason should 
be immediately resutured.) 
(5) Unrecognized foreign bodies adjacent to the wound. 
g. Preliminary bacteriologic analysis of the flora of a wound does not 
provide information pertinent to making the decision to perform secondary 
suture or allow the prediction of the result. If the suture is not successful 
because of infection, appropriate studies and corrective therapy is instituted 
before resuture is attempted. Infection may be considered indicative of the 
susceptibility of the individual to the predominate wound organisms. 
4. Specialized Problems. 
c. Amputations. 
Secondary closure of a circular guillotine amputation stump is not com- 
monly indicated, as it is impossible to suture the inelastic fascia without waste- 
ful shortening of the bone. Bone length can be saved by continuing the skin 320 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
traction for an additional period of time—4 to 6 weeks. Closure of stumps by 
sliding flaps, plastic resection with sacrifice of bone length, or formal reamputa- 
tion are procedures to be carried out in the Zone of the Interior rather than in 
an Overseas Theater. Skin grafting of defects may be performed for temporary 
resurfacing of stumps that will later require plastic procedures or reamputation. 
It should not be employed when further use of skin traction will promote 
healing or covering of the bone end with normal skin. Vertical incisions in the 
stump made for infection or as part of the initial debridement should be closed 
by secondary suture while skin traction is being maintained to cover the 
defect at the end. 
e. Closed Plaster Treatment (Truetta). 
The regimen of closed plaster management of war wounds has not been 
judged applicable to the field conditions of this theater. It is advisable to 
remove the initial dressing for inspection of the wound in all cases at least by 
the 15th day. Incorporation of pins or other fixation devices in the initial 
plaster to maintain the reduction of fractures obtained at the initial operation 
has been found impractical as a means ol transportation splinting. 
While the necessity for the rapid turnover of large numbers of casualties 
might justify an adoption of the closed plaster method of management of 
compound fractures, a high penalty in the form of skeletal deformity would 
be the inevitable result. Results obtained by secondary suture do not justify 
the use of closed plaster for soft part wounds. 
Infrequent change of plaster as practiced in the theater has many advan- 
tages, particularly when it is desired to allow granulations to cover exposed 
bone in deep irregular wounds (Orr). It is also an accepted method of manage- 
ment for established infection of bone particularly when the wound has caused 
an extensive loss of overlying soft parts or there is a bone defect. Small surfaces 
of bare cortical bone may be removed surgically when this permits closure of 
the defect by suture. When resurfacing by skin graft is possible in a shallow 
wound the bare cortical bone may be left for spontaneous sequestration. 
f. Military Aspects. Secondary wound surgery in an Overseas Theater 
must be measured against the objectives that are sought. In general, these are: 
(1) To return a soldier to duty with a minimum number of days lost. 
(2) To return patients to the Zone of Interior at an earlier date and 
in better condition. 
(3) To reduce ultimate disability and deformity by preventing or 
cutting short a phase of late wound infection with fibrosis and other harmful 
sequelae. 
An aggressive attitude is desired in the case of any soldier who may be 
returned to duty in this theater. On the other hand, to suture a small clean 
wound that is compounding a fracture of the femur is merely a stunt, as the 
soft parts will be healed before the bone unites. APPENDIX 
321 
It is not desirable to embark on elaborate plastic procedures such as crossed 
extremity skin flap grafts or operations undertaken for cosmetic purposes. 
For the SURGEON: 
(S) E. Standlee 
E. STANDLEE 
Colonel, M. C., 
Executive Officer. 
DISTRIBUTION: 
All Medical Installations 
Surgeon, SOS NATOUSA 800 
Surgeon, Fifth Army 500 
Surgeon, Seventh Army 100 
Surgeon, AAFSC/MTO 800 
Surgeon, NATOUSA 200 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 534 
1 July 1944 
CIRCULAR LETTER NO. 36 
SUBJECT: Penicillin Therapy in Wound Management, Surgical Disease, 
Burns, and Anaerobic Infections 
1. General. 
a. In World War II, two quite different policies have governed the use 
of chemotherapeutic agents in the management of wounds. Chemotherapy 
has been recommended: (1) as a substitute for adequate wound surgery, seek- 
ing to delay and minimize operative procedures; (2) as an adjunct to established 
and progressive surgical measures designed to achieve better results with an 
increased margin of safety. The latter has been and will continue to be the 
policy governing the management of the wounded in this theater. 
b. The use of penicillin as an adjunct to surgery outlined in this circular 
is defined as therapy rather than prophylaxis. Routine immunization of troops 
with tetanus toxoid is a prophylactic measure. Administration of penicillin 
for contaminated wounds and established infection is a therapeutic measure. As 
with all therapy, if the desired goal is to be achieved, intelligent and precise 
professional supervision of every detail is essential. 
2. Scope of Penicillin Therapy. 
a. Penicillin is accepted as the best available antibacterial agent for 
gram-positive bacteria and gram-negative diplococci. It is ineffective for 
gram-negative bacilli. 322 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
b. Penicillin does not sterilize dead, devitalized or avascular tissue, nor 
does it prevent the septic decomposition of contaminated blood clot. There 
is no evidence that it can neutralize preformed bacterial exotoxins or inhibit 
the locally necrotizing bacterial enzymes in undrained pus. These limitations 
demand that surgical wound management retain the principles of excision of 
devitalized tissue, dependent drainage of residual dead space, evacuation of 
pus and delayed or staged closure of contaminated wounds (see Circular 
Letter Xo. 26, Office of the Surgeon, Hq. NATOUSA). 
c. The use of penicillin in an individual patient is based upon the 
decision that infection is probable or present. 
d. It is recommended that parenteral administration be the basis of 
penicillin therapy. The local or topical use of penicillin is a supplement to 
systemic therapy only in lesions of the central nervous system, serous cavities 
and joints. The diffusion of the drug into these areas appears slow and limited. 
3. Penicillin Therapy in Relation to Sulfonamide Therapy. 
a. Topical and oral administration of sulfonamides as first aid measures 
will be continued. 
b. Intravenous sulfonamide prior to initial surgery will be replaced by 
parenteral administration of penicillin (par. 6, a). 
c. At the conclusion of the initial wound operation, the decision will be 
made either to institute a postoperative course of penicillin therapy or to main- 
tain chemotherapy with sulfonamides. It is recommended that the agents be 
used individually and not concomitantly. If a course of penicillin is elected, 
topical frosting of the wound with sulfonamide is omitted. The following ob- 
servations will serve as a guide in this decision: 
(1) Clinical experience with penicillin has been greatest with wounds 
of the extremities and the thorax. The drug is recommended for these injuries. 
(2) The value of penicillin in craniocerebral wounds is well established, 
but an extensive experience has not been accumulated. 
(3) Cleanly debrided soft part wounds uncomplicated by fracture, 
extensive tissue destruction, or retained missiles are adequately handled by 
sulfonamide therapy. 
(4) Preliminary evaluation of penicillin therapy for fecal contamina- 
tion of the peritoneal cavity is encouraging but at the present time is inadequate 
for comparison with sulfonamide therapy. In view of the difficulties in main- 
taining a fluid intake adequate to safeguard sulfonamide therapy in this group 
of cases, substitution of penicillin may be made at the discretion of the surgeon. 
Forcing of fluids is not necessary solely because of penicillin therapy and in fact, 
reduces the effective concentration of the drug by rapid urinary excretion. 
4. Routes of Penicillin Administration. 
a. Intramuscular. This is the standard route for administration. The 
deltoid, gluteus and thigh muscles are recommended as the sites for injection. 
The same area may be used repeatedly. Subcutaneous administration is to 
be avoided. APPENDIX 
323 
b. Intravenous. The intravenous route is reserved for patients with 
shock or immediately life endangering infection. A single intravenous injection 
provides a therapeutic concentration of the drug that lasts for two hours. If 
intravenous therapy is indicated to span a longer period, the injection is 
repeated or constant drip administration instituted. 
5. Dosage. 
a. Systemic therapy. Current practice dictates a dosage of 200,000 
units in 24 hours, given as 25,000 units every three hours by the intramuscular 
route. Larger initial dosage or greater 24 hourly dosage have no demonstrable 
merit. Maintenance of full dosage schedules throughout the course of therapy 
is better than a graded terminal decrease in dosage. 
b. Local therapy. The powdered sodium salt of penicillin is slightly acid 
and provokes a burning pain and serous discharge if applied to an open wound. 
A solution containing 10,000 units per c. c. is well tolerated as an intramuscular 
injection but may produce headache, meningismus and pleocytosis of the 
spinal fluid after intrathecal injection. The maximal effective local concentra- 
tion is 250 to 500 units per c. c. The usual concentration employed clinically 
varies between 500 and 5,000 units per c. c. with predominate usage of a solution 
containing 1,000 units per c. c. The following dosage schedules are recom- 
mended for local instillation: 
(1) Intrathecal space 7,500 units 
(2) Pleural cavity 25,000 units 
(3) Peritioneal cavity 50,000 units 
(4) Knee joint 10,000 units 
Local instillation of penicillin may be repeated at intervals of 12 to 48 
hours in accordance with clinical indications. Needle aspiration and injection 
is preferable to inlying tubes. 
6. Use of Penicillin in Mobile Hospitals. The following recommendations 
are made on the basis of procedures that have been found practical in Evacua- 
tion Hospitals: 
a. Upon arrival in the shock or preoperative ward, the wounded will 
receive 25,000 units of penicillin intramuscularly, unless the wound is certainly 
of a trivial nature. If shock is present, an additional 25,000 units will be 
given intravenously. 
b. Preoperative dosage is continued at 3 hourly intervals. It is more 
practical to give penicillin to every patient in a preoperative ward at the same 
time, than to keep each pateint on a dosage schedule based on the time of 
arrival. There is no objection to a time interval of less than 3 hours between 
the first two injections. 
c. The decision to continue penicillin or to substitute sulfonamide in 
the postoperative period is made when the operation is concluded and the 
nature and extent of the injury evaluated (see par. 3 c). 324 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
d. No patient will be held in a mobile hospital solely for the purpose 
of continuing penicillin therapy. The usual criteria based on the conditioe 
of the patient will determine the suitability for evacuation. In general, thn 
drug is continued for 2 to 3 days beyond the period of clinical recovery from 
the hazard or subsidence of infection. A course of therapy may be associated 
with slight fever which disappears after the drug is stopped. Suitable 
periods of therapy are: 
(1) Soft part wounds 5 to 7 da}Ts 
(2) Compound fractures 10 to 12 days 
(3) Thoracic wounds 8 to 10 days 
(4) Abdominal wounds 8 to 10 days 
(5) Craniocerebral wounds 5 to 10 days 
(6) Joint wounds 7 to 14 daj^s 
e. Patients evacuated prior to completion of a course of therapy will 
carry a notation “On Penicillin” in the space provided under the designation 
“Special attention needed in transit, or other remarks” on the jacket of the 
Field Medical Record (Form 52d). This will indicate the need for continua- 
tion of therapy in holding stations, hospital ships and fixed hospitals, 
7. Use of penicillin in Holding Stations or Hospital Ships. 
a. Form 52d will be examined in each case upon admission to identify 
those patients receiving penicillin therapy (par. 5 e). 
b. 25,000 units of penicillin will be administered intramuscularly every 
3 hours to all such designated patients. 
8. Use of Penicillin in Fixed Hospitals. 
a. Patients designated as “On Penicillin” (par. 5 e) will have the course 
continued on admission to the hospital. Discontinuance of therapy will be 
the responsibility of a medical officer after he has reviewed the status of the 
patient. 
b. Secondary suture of cleanly debrided soft part wounds does not 
require penicillin therapy. Soft part wounds requiring debridement 
or secondary debridement or with established infection may properly receive 
penicillin. 
c. Reparative surgical procedures on wounds complicated by skeletal, 
joint, nerve, tendon or vascular injury require penicillin therapy. 
d. Established wound infection is an indication for penicillin therapy. 
e. Early secondary reparative operations through recently healed 
wounds require penicillin therapy. 
9. Surgical Disease. 
a. Acute or chronic infections such as furuncles, carbuncles, felons, 
desert sores, tenosynovitis, etc. should be treated with penicillin whenever it 
is judged that loss of time from duty can be shortened. APPENDIX 
325 
10. Burns. 
a. The local application of sulfonamide crystals or ointments contain- 
ing sulfonamides is not recommended. Fine mesh (bandage cloth) vaseline 
or boric acid gauze is preferable. Under no circumstances are tannic acid 
preparations or other escharotic agents to be used in this theater. 
b. Extensive burns or burns that may include areas of full thickness 
skin loss will be treated systemically with penicillin or if preferred, sulfa- 
diazine. 
c. See Circular Letter No. 26 regarding policy of early skin replace- 
men t. 
11. Anaerobic Infections. 
a. Clostridial myositis (gas gangrene). Early and adequate wound sur- 
gery remains the most effective preventive measure. Early diagnosis of this 
complication when it occurs, is essential to adequate treatment. Treatment 
utilizes surgery, penicillin, antitoxin and whole blood transfusion. It is recom- 
mended that penicillin be given in the following manner: Initial dosage of 
100,000 units intravenously, with 25,000 units intramuscularly at the same 
time. A course of 25,000 units intramuscularly every 3 hours day and night 
is instituted. Larger dosages and other regimens have not afforded any more 
satisfactory results. Sulfonamides are discontinued during penicillin admin- 
istration. 
b. Anaerobic cellulitis and other anaerobic infections. Penicillin ther- 
apy is used as with clostridial myositis (par. 10a). 
c. Amputation for anaerobic infection. 
(1) It is of prime importance to differentiate between clostridial 
myositis and other anaerobic wound infections to prevent the needless sacrifice 
of limbs on the basis of clinical findings of gas and putrid wound exudate. 
(2) In the management of clostridial myositis a limb need not be 
amputated solely as a measure designed to arrest the infection. If trauma, vascu- 
lar occlusion and advancing infection, acting singly or together, have so damaged 
the extremity that functional restitution is unlikely, amputation is performed 
as a ready and effective adjunct to the arrest of infection. 
(3) The early diagnosis of clostridial myositis and the employment 
of penicillin and other adjuncts to therapy, permit the management of the 
infection to be confined to the excision of involved muscles. If the excision 
of muscles judged necessary to eradicate the infection must be so extensive 
that functional restitution of the extremity is unlikely, amputation should be 
performed. 
(4) When amputation is performed as a part of the surgical treatment 
of clostridial myositis, the use of penicillin and other adjuncts to therapy allow 
other considerations than the eradication of infection to play a part in selecting 
the level for amputation. Provided all muscles invaded by the infection and 326 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
remaining in the stump are carefully excised, a more distal level of amputation 
may be selected if the ultimate function of the extremity is thereby conserved. 
For the SURGEON: 
(S) E. StaxDLEB 
E. STANDEES, 
Colonel, M.C., 
Deputy Surgeon. 
DISTRIBUTION: 
Surgeon, Fifth Army 600 
Surgeon, Seventh Army 300 
Surgeon, SOS NATOUSA 800 
Surgeon, AAFSC/MTO 600 
Surgeon, NATOUSA 300 
HEADQUARTERS 
NORTH AFRICAN THEATER OF OPERATIONS 
Office of the Surgeon 
APO 534 
29 August 1944 
CIRCULAR LETTER NO. 46 
SURGICAL MANAGEMENT OF THE WOUNDED III 
HI—SURGICAL MANAGEMENT OF THE WOUNDED. 
Note: The contents of this circular letter as well as Circular Letter Nos. 
26 and 36 are to be brought to the attention of every Medical Officer in the 
Theater who is assigned responsibility for the management of the wounded. 
7. Reparative Surgery of the Lightly Wounded. 
a. It is an eloquent tribute to the high standards that have been attained 
in forward surgery that the suture of wounds at the time of the first dress- 
ing at the base is established as a routine procedure. To maintain this stand- 
ard requires constant vigilance in techniques as described in Circular Letter 
No. 26. The lightly wounded combat soldier is the most valued military asset 
entrusted to the care of the Medical Corps. His treatment must be carried 
out or closely supervised by surgeons with mature judgement and experience. 
There are no “minor” wounds. 
b. Forward surgeons will indicate on the record or on the cast the extent 
of actual skin loss. At the time secondary suture is performed it is difficult APPENDIX 
327 
to distinguish between the gaping of a long incision that can be closed by 
approximation and the existence of a sizeable defect that will require skin 
graft. 
c. An increased use of splinting of soft part wounds following debride- 
ment is advisable. Circular plaster encasement if placed proximally on an 
extremity must be immediately bivalved to avoid constriction. 
d. In the closure of wounds, particularly those of the extremities, further 
refinements are desirable in techniques that have a direct effect on restoration 
of function and early return to duty. 
(1) Transversely divided muscle bundles may be closed by suture, 
staging the closure of the skin to a later date. 
(2) Very accurate approximation of the skin as in a plastic procedure 
is desirable. When drainage is required, this should be through a counter 
incision. 
(3) More use should be made of the principles of plastic surgery, viz., 
the advancement and rotation of skin flaps, zig-zag plastics and other tricks 
of closure that minimize scar contracture and limitation of motion. 
(4) Trauma to skin margins by rat tooth forceps and rough handling 
is productive of necrosis and imperfect healing. 
(5) Prolonged hospital neglect of unhealed wounds and skin defects 
must be stopped. It is recommended that the chief of surgical service per- 
sonally review cases of unhealed soft part wounds that remain in hospital 
longer than four weeks so that proper treatment can be expedited. 
8. Amputations. 
a. The most important phase in the management of amputations is the 
functional rehabilitation of the patient by the fitting of a prosthesis. Am- 
putation centers have been established in the Zone of the Interior for this 
purpose. It is the expressed desire of The Surgeon General that the early 
management of amputations in overseas theaters conform with policies that 
have been set forth in numerous Bulletins and Circular Letters. There will 
be no deviation from these policies in this theater. 
(1) Forward Area. 
(a) Level. Amputations will be performed at the lowest possible 
level except that a proximal amputation will be done in preference to a dis- 
articulation. 
(b) Technique. The properly performed flapless guillotine stump 
exhibits slightly concave open cross section of the extremity. A circular 
incision is made through the skin at the lowest level compatible with viable 
tissue and the skin allowed to retract; the fascia is then incised at the level to 
which the skin has retracted. The superficial layer of muscle is then cut at 
the end of the fascia and permitted to retract. At its point of retraction, the 
deep layers of muscle are cut through to the bone. After the deep muscles 
have retracted the periosteum of the bone is cleanly incised and the bone 
sawed through flush with the muscles. No cuff of periosteum is removed 
as in a closed amputation. Bone denuded of periosteum will sequestrate if 328 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
infection is present and a ring sequestrum often results when the periosteum lias 
been removed. It is important also that no periosteum be elevated or torn 
from the bone in the stump by rough handling. 
(c) Dressing and skin traction. The end of the stump is dressed 
with fine mesh gauze in such a manner that it does not overlap the skin edges. 
Skin traction is applied immediately. This may either be by a stockinette 
cuff attached with ace adherent or by adhesive tape. Traction is obtained 
preferably by a light plaster cast with a wire ladder banjo. The cast always 
incorporates the joint above the amputation, e. g., a spica for an amputated 
thigh. A. Thomas splint may be utilized as an alternative. When this is 
done in lower leg amputations, a posterior splint from midthigh to beyond 
the stump is provided to prevent flexion contracture of the knee. Medical 
Supply Item No. 36614—-Cord, Elastic, for Traction—is available and is 
preferable to plasma tubing for the elastic traction. Before evacuation, the 
traction is examined and if doubt exists as to its effectiveness, it is reapplied. 
(2) Base. 
(a) All thigh amputations and those of the leg at or near the site 
of election will be treated by continuous skin traction. Secondary suture or 
skin grafting of the terminal defect with or without revision will not be done. 
Removal of the cast or splint and maintenance of 6 to 10 pounds cf traction 
over a pulley at the foot of the bed is recommended. Traction is continued 
for several weeks (at least 6) until all layers of soft tissue have been firmly 
fixed by scar formation. Priority air evacuation to the Zone of Interior is 
available for amputation cases as soon as they are able to be transported. 
Traction during evacuation is provided for by stockinette and a banjo plaster. 
(b) Amputations in the lower third of the leg and of the upper 
extremity may be closed by secondary suture provided the wound is clean and 
a course of penicillin is instituted. If closure is not feasible, skin traction is 
maintained. 
(c) Amputations of the thigh or leg performed in fixed hospitals 
for trauma, vascular insufficiency or infection will be carried out in conformity 
with the above principles. In the upper extremity, modifications to secure 
primary or early secondary closure are permissible in individual cases. 
(d) Patients received with injuries that require amputation will 
benefit by an explanation of why the amputation is necessary prior to the 
operative procedure. About one in five patients will exhibit psychic reactions, 
often depressive in type, a few days after the operation. As soon as the 
patient is surgically comfortable and mentally receptive, an interview with a 
psychiatrist may be extremely helpful. Particular attention should be paid 
to what the patient may reasonably expect in the way of aid. The establish- 
ment of amputation treatment centers in the ZI may be explained, and assur- 
ance given relative to prosthetic appliances, and his potential economic and 
social status. Fortification of this type, before a patient becomes the target 
of a sympathetic family and friends, may tip the scales in favor of rehabilita- 
tion in contrast to life long disability and resentment. APPENDIX 
329 
9. Fractures of the Femur. 
The program of reparative surgery in fixed hospitals, improvements in 
skeletal traction techniques, and penicillin therapy are expected to result in 
improved apposition and alignment of the fractures and improved knee and 
muscle function, after the fracture has united. Therefore the following 
recommendations are made: 
a. Fractures treated by skeletal traction. 
(1) Knee flexion produces quadriceps stretch and predisposes to 
patellar fixation. As flexion increases quadriceps exercises become more 
difficult. While some knee flexion is necessary for comfort and to aid in 
reduction of the fracture it should be held to a minimum. For lower third 
fractures two-wire skeletal traction is recommended. By this method traction 
is made by a wire (or pin) in the tibial tubercle while a second wire through 
the lower femoral fragment permits vertical “lift”. Extreme knee flexion is 
avoided. 
(2) Quadriceps setting exercises and knee motion should be carried 
out several times daily as soon as wound management permits. Knee motion 
begun early produces less strain on the fracture site than that begun late after 
joint “stiffness” has set in. 
(3) Duration of traction. Traction in the great majority of cases 
must be continued until there is bony fixation clinically and roentgenologically. 
This will average about 10 to 12 wreeks. Prolonged traction permits an 
increasing range of knee motion and will prevent angulation in a cast during 
evacuation to the Z of I. 
(4) A low spica extending to the knee on the well side is the recom- 
mended splinting for transportation to the Z of I. Uncertainty of evacuation 
and because a spica is preferably applied at least 48 hours prior to transport- 
ing, have resulted in many fractures of the femur remaining in plaster for 
several weeks or months awaiting and during evacuation, thereby predispos- 
ing to restricted knee motion. Collaboration between the surgeon and the 
disposition officer permits the application of the spica 48 hours prior to evacu- 
ation. Fractured femurs immobilized after traction are excellent priority 4 
cases for air evacuation. 
b. Fractures Treated by Internal Fixation. 
(1) Wire loop fixation. Alinement should be protected by prolonged 
skeletal traction followed by a spica (see 9 a (3) (4)). 
(2) Plating or Multiple Screw Fixation. Postoperative immobiliza- 
tion in a Thomas splint with Pierson attachment permits early knee motion. 
Following wound healing and a period of knee motion and quadriceps exercises, 
a spica (see 9 a (3) (4)) is used for evacuation to the ZI. 
IV—DISASTER MANAGEMENT IN FIXED HOSPITALS. 
Any hospital in the theater, no matter how far removed from the Combat 
Zone suddenly may be called upon at any hour of the day or night to receive 
and care for large numbers of wounded or injured. It is essential, therefore, 330 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
that plans for such an emergency be made in advance and be clearly under- 
stood by both administrative and professional staffs. The following principles 
are important: 
1. Early recognition of what may be termed the “pattern of trauma” so 
that appropriate treatment may be instituted without delay. This is estab- 
lished by a careful examination of a representative sample of the injured and 
supplemented by inquiry regarding the source and nature of injury, the time 
elapsed since injury and the possible number of casualties to be admitted. 
Serious secondary effects may be masked by obvious primary manifestations: 
thus, the lethal effects of underwater blast may be masked by the effects of 
immersion; the inhalation of noxious fumes may pass unrecognized while 
superficial flash burns are treated. With explosions of ammunition ships or 
dumps in a theater of war, consideration must always be given to the possibility 
that agents of chemical warfare may have been released. 
2. Establishment of wards adjacent to the admitting ward for reception 
of patients is essential rather than distribution of the new patients throughout 
the hospital. 
3. Triage is established at the time of admission to sort three groups of 
patients: 
a. Those in immediate need of resuscitation, close preoperative super- 
vision and emergency operative procedures. 
b. Those that require surgery but will be transportable if and when 
it is necessary to reduce the backlog of cases awaiting operation by transfer 
to other hospitals for treatment. 
c. Lightly injured that will be discharged to duty after a short period. 
Patients in group a. will be sent to a “shock” ward where treatment is 
carried out under close supervision. They receive first priority X-ray and 
laboratory service. 
Group b. require ordinary ward supervision and second priority X-ray 
and laboratory service. Clinical records should be maintained and a tentative 
evacuation list prepared. 
Group c. should be fed and made comfortable, but professional attention 
postponed during the emergency period unless special indications arise. 
4. Surgical Management. 
Patients in group a. are assigned to operative teams who direct the pre- 
operative care, request necessary laboratoiy examinations and schedule the 
operation. One or more officers are assigned to the Shock Ward and remain 
on the ward. It is their duty to be familiar with the progress of each patient; 
what treatment has been ordered, and what examinations are in progress or 
have been completed. In addition they carry out resuscitation measures 
under surgical direction. 
After operation, if the patient is in precarious condition he should be 
returned to the Shock Ward or to an adjacent Postoperative Ward—but 
under no circumstances sent to some remote ward of the hospital. APPENDIX 
331 
5. Whole Blood Transfusion. 
Plans must include a well thought-out method of supplying whole blood 
in considerable quantity. Circular Letter No. 30 should be studied. Reli- 
ance cannot be based on securing blood from theater transfusion units, as the 
function of these installations is to supply blood to armies in combat. A 
supply of vacuum bottles, transfusion sets, refrigerator space and a donor 
list from the detachment will enable the laboratory to start a banked reserve. 
Immediate steps may be taken to supplement the donor list from organiza- 
tions in the immediate vicinity. Type specific blood should be used as most 
economical of donors. 
6. Reserve Surgical Supplies. 
Sufficient supplies must be kept on hand at all times to meet the demands 
of an emergency. Vaseline gauze, fine mesli gauze and other sterile supplies 
may be stored in sealed containers and resterilized as often as necessary. 
7. X- ray Service. 
Request for X-ray examinations should be based on the priority of the 
case, and the X-ray Department must not be flooded with examinations that 
can be postponed. Patients that may be transferred to another hospital for 
surgical operation need not be X-rayed unless necessary to the determination 
of transportability or disposition. 
A system for viewing wet films should be planned, and facilities made 
available for the films to accompany the patient to the operating theater. 
8. If doubt exists regarding the nature, source of circumstances surround- 
ing the incident, examination of casualties dead on arrival or dying in hospital 
may be of importance not only for official record but for treatment of the sur- 
vivors. 
For the SURGEON: 
(S) E. Standlee 
E. STANDLEE, 
Colonel, M. C., 
Deputy Surgeon. 
DISTRIBUTION: 
Surgeon, Fifth Army 600 
Surgeon, Seventh Army 300 
Surgeon, SOS NATOUSA 800 
Surgeon, AAFSC/MTO 750 
Surgeon, Replacement Command 50 
Surgeon, NATOUSA 300 332 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
HEADQUARTERS 
MEDITERRANEAN THEATER OF OPERATIONS 
UNITED STATES ARMY 
Office of the Surgeon 
APO 512 
10 March 1945 
CIRCULAR LETTER NO. 8 
SUBJECT: Notes on Care of Battle Casualties. 
The contents of several previous circular letters pertaining to the surgical 
management of the wounded are consolidated and in certain instances extended 
or modified in the following recommendations. 
1. The care of the wounded must always be shaped by conditions and 
circumstances that govern the tactical situation at the moment. It has been 
shown by this Theater that the surgery of war need not be molded by conces- 
sions to the need for haste and the confusion of caring for overwhelming numbers 
of patients. Military surgery is not a crude departure from accepted surgical 
standards, but a development of the science of surgery to carry out a specialized 
and highly significant mission. Modern surgical treatment employs many 
adjuvants to operative techniques, such as chemotherapy, fluid replacement 
therapy, the transfusion of whole blood and fractions of blood employed as 
substitutes, potent anesthetic agents and narcotics. These tools are as im- 
portant to the military surgeon as his scalpel, but are equally dangerous to the 
patient if used without expert precision. One of the major responsibilities of 
the military surgeon is to make fidl use of these and similar measures and at the 
same time to avoid the dangers that may attend their usage. 
The ever-present necessity for evacuation of the wounded to the rear is 
in fundamental conflict with idealsurgical management of the individual patient. 
To minimize this conflict, close coordination between the functions of adminis- 
tration and professional services is required. It is the responsibility of the 
medical officer charged with the surgical management of the patient to place 
technical procedures properly, both in time and in space, with due regard to 
the tactical situation on the one hand and to the welfare of the patient on the 
other. Unless the surgeon visualizes his position and the function of his hospital 
in relation to other surgeons and other hospitals, he may become confused in 
the mission he is to perform. Although some needed operation may be per- 
formed correctly, the military effort may be impeded and unforeseen harm done 
to the patient if the operation is done at the wrong time or in the wrong place. 
It is the responsibility of administrative officers charged with the establish- 
ment of evacuation and hospitalization policies to adapt the schedules of move- 
ment of patients to the maintenance of highest standards of surgical treatment. 
Priority of movement must be accorded to patients with certain types of injuries 
just as the duration of hospitalization in a given zone must be differentially 
adjusted to the urgent surgical needs of the patients. The term “nontrans- 333 
APPENDIX 
portable” as relating to the unfitness of battle casualties for interhospital trans- 
fer must, when military necessity permits, be extended beyond aetnal danger to 
life by a consideration of the likelihood of deformity, ultimate disability, and 
delay of recovery when these hazards exist. 
Just as the placement of various types of hospitals and consequently the 
provision of the facilities for surgery are determined by the geographic deploy- 
ment of a military force, phases of surgical management exist that in general 
will conform with military echelons. These phases of surgical management are: 
first aid measures, initial wound surgery, reparative wound surgery, reconstruc- 
tive surgery, and rehabilitation measures. 
First Aid Measures. Within the divisional area surgical management is 
limited to first aid measures and emergency resuscitation. Hemorrhage is 
controlled, splints and dressings applied, morphine administered for pain, 
plasma infused for resuscitation, a booster dose of tetanus toxoid is given, and 
chemotherapy initiated. 
Initial Surgery. Actual conditions of warfare will determine both the 
facilities provided for emergency wound surgery and their location with refer- 
ence to the combat area. In general, initial surgery is concerned with complete 
resuscitation so that surgery may be performed, and with surgical procedures 
designed to prevent or eradicate wound infection. Many of the seriously 
wounded casualties can be resuscitated only by a surgical operation in con- 
junction with transfusion and plasma therapy. For this reason, it is important 
that delays for the purpose of resuscitation ahead of an installation equipped for 
major surgery be kept at a minimum. Placement of the advance surgical 
hospital in physical proximity to the divisional clearing station accomplishes 
this end. 
Reparative Surgery. The general hospitals of the communications zone 
receive casualties from the hospitals of the forward area for further surgical 
management. As the initial wound operation is by definition a limited pro- 
cedure, nearly every case requires further treatment. Soft part wounds, 
purposely left unsutured at the initial operation, are closed by suture, usually 
at the time of the first dressing on or after the fourth day. Fractures are 
accurately reduced and immobilized until bony union takes place. 
Designed to prevent or cut short wound infection either before it is estab- 
lished or at the time of its inception, this phase in the surgical care of the 
wounded is concerned with shortening the period of wound healing and seeks 
as its objectives the early restoration of function and the return of a soldier to 
duty with a minimum number of days lost. In addition, it affords the return 
of patients to the United States at an earlier date and in better condition and 
minimizes the ultimate disability and deformity in the seriously wounded. 
The success of this important phase of surgery depends on the provision 
of an adequate period of hospitalization in addition to competent surgical care*, 
particularly in specialized fields. It is not to be confused with the reconstructive 
phase of surgery, which may be postponed until return to the Zone of the 
396961°—57 23 334 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Interior. The ideal time for the procedures of reparative surgery will be 
found between the fourth and tenth days after wounding. The patient then 
becomes “non-transportable” for a period of time which, in the case of fractures, 
may extend to eight or ten weeks. Transfer of patients between fixed hospitals 
within the zone of communications must be regulated with these considerations 
in mind, otherwise the objectives of this phase of surgical management may be 
sacrificed. The establishment of special centers within general hospitals for 
certain types of surgery during this phase is highly desirable, as the procedures 
are oftentimes of considerable magnitude and call for mature and experienced 
professional judgment. Advancement of general hospitals in close support of 
Army or utilization of air evacuation from Army to more remote fixed installa- 
tions are two measures that further the establishment of a program of 
reparative surgery. 
Reconstructive Surgery. Early evacuation to the United States is desirable 
for patients whose return to duty cannot be anticipated within the limits of the 
hospitalization policy of an overseas theater. The phases of reconstructive 
surgery and rehabilitation may then be integrated. 
2. Wound Management. 
a. Initial Wound Surgery. 
(1) X-ray. In the preoperative examination of a battle casualty 
X-ray examination is essential. 
(2) Adequate assistance and instruments, a good light, and access to 
the wound that is unhampered by faulty position of the patient are basic 
requirements. Ample preparation of a wide field by shaving the skin will 
allow for extension of the incision or counterincision. 
(3) Bold incision is the first essential step in an operation on a wound. 
Adequate exposure is necessary to carry out excision of devitalized tissues. 
On the extremity the line of the incision is placed parallel with the long axis ol 
the limb; elsewhere it follows the natural lines of skin structure. Only the 
devitalized skin of the margins of the wound is excised in a strip rarely wider 
than 2 to 3 mm. The creation of circular skin defects is avoided. 
(4) Incision and excision of the fascial layers is performed in the same 
manner to give free access to devitalized muscle. Unrestricted exposure of 
successive anatomic layers permits the complete excision of devitalized muscle 
and the removal of foreign bodies. 
(5) The surgeon must be familiar with the blood supply of muscles, 
particularly large groups like the gastrocnemius-soleus muscles of the calf and 
respect these vessels in his dissection. Deep recesses of the wound containing 
foreign bodies may be approached by counterincisions planned anatomically 
rather than by sacrificing normal muscle structures, 
(6) Use fine hemostats. Use the finest ligature compatible with the 
procedure. Include the smallest possible amount of tissue in ligating a bleeding 
point. Do not repeatedly bite the wound with tissue forceps. Sponge gently 
with pressure instead of wiping. Remaining devitalized tissue produced by APPENDIX 
335 
the missile or by the surgeon must slough before the wound can be closed by 
secondary suture. 
(7) Large wounds in regions of heavy muscles, particularly when 
complicated by comminuted fracture, require especial care. The depths of 
these wounds must be opened by a long incision with counterincision if necessary 
to allow free dependent drainage. 
(8) Only enough dry, fine, mesh gauze is used to separate the surfaces 
of the wound. It should be smoothly laid in the wound—not “packed”. 
(9) Ether, white soap, and benzene, have slight but definite necrotiz- 
ing effects on living muscles. Green soap and various other substances used 
as detergents have greater necrotizing effects. Physiological saline solution 
is relatively innocuous. In general, progress in wound management points 
away from the introduction of any agent into a wound, either for its supposed 
mechanical or antiseptic effect. 
(10) Old wmmds (48 hours or longer) are managed in accord with the 
same principles, except that in selected cases of established pyrogenic infection 
and anaerobic cellulitis with toxicity the general condition of the patient to 
withstand radical surgery may be improved byr immobilization, penicillin and 
repeated blood transfusions until an optimum time is selected for intervention. 
In postponement of surgery the advantage that accrues from the immediate 
drainage of septic hematomas, large masses of dead muscle, and fascial plane 
abscesses, is not to be forgotten. Postponement of surgery is not justified if 
clostridial myositis (gas gangrene) may be present. 
(11) Proper transportation splinting is provided for skeletal and 
joint injuries. Soft part wounds are supported by firm pressure dressings and 
may, if extensive, be advantageously enclosed in a light plaster. Care is taken 
to avoid any constricting action of a pressure dressing placed on an extremity. 
Plaster casts must always be padded and split or bivalved before the patient 
is returned to the ward. 
b. Reparative Wound Surgery. 
(1) On arrival at a hospital where bed care can be assured for a period 
of at least fifteen days (soft part w'ounds) the original dressing is removed in 
the operating room under aseptic precautions. X-ray films should be at hand. 
If the primary wound operation has been complete and has been properly done, 
all superficial wounds and many deep wounds may be closed by secondary 
suture at this time (4 to 10 day’s). Foreign bodies in soft parts adjacent to 
the wound are removed. Following suture, the part is immobilized, preferably 
by a light plaster, or if this is impractical, by bed rest. 
(2) The presence of residual dead tissue or established infection 
manifested by profuse discharge of pus, reddening and edema of the wound 
margins, persistent fever or toxicity is an indication for delay in secondary 
suture. When these manifestations are present but minimal, the wound is 
allowed to “clean up”. This process can be hastened by moist dressings or 
by additional surgical excision of devitalized fragments. Secondary suture 336 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
can then be performed in a few days. If established infection is severe, or if 
the patient is toxic and anemic from deep seated sepsis, a course of penicillin 
therapy and blood transfusions is instituted and followed by radical wound 
revision, and staged closure. 
(3) Wounds that have been laid open properly at the initial operation 
tend to gape widely and give the impression of extensive skin loss. This ap- 
pearance is actually due to loss of support of the deep fascia. Skin defects 
are more apparent than real in the majority of cases and closure of a defect is 
made from local tissue with suture in a straight line when possible. Under- 
mining with advancement or rotation of flaps provides sufficient skin in nearly 
all instances and is preferable to grafting. 
(4) Technical considerations that are important to the success of 
secondary wound closures are: 
(a) Atraumatic handling of tissue. 
(b) Avoidance of tension sutures. 
(c) Accurate approximation of skin margins. The epithelial 
bridge is the main support of the wound for a considerable period of time. 
(d) Obliteration of dead spaces by pressure dressings and im- 
mobilization. Stab wound drainage may be instituted when desired and is 
preferable to drainage through the suture line. 
(e) Leaving sutures in place for twelve days if stitch infection 
does not develop. 
(f) Suture in straight lines rather than the creation of sharp angles. 
(5) Preliminary bacteriologic analysis of the flora of a wound does 
not provide information pertinent to making the decision to perform secondary 
suture or allow the prediction of the result. If the suture is not successful 
because of infection, appropriate studies and corrective therapy is instituted 
before resuture is attempted. 
(6) The conditions that most often jeopardize results are: 
(a) Suture of a wound that is discharging pus. This usually 
means dead tissue in the depths. 
(b) Too early motion. (Wounds breaking down for this reason 
should be immediately resutured.) 
(c) Unrecognized foreign bodies adjacent to the wound, 
c. Closed Plaster Treatment. 
(1) The regimen of closed plaster management of war wounds is 
not considered as satisfactory as the method described above when field con- 
ditions permit the use of the latter. 
(2) While the necessity for the rapid turnover of large numbers of 
casualties might justify an adoption of the closed plaster method of manage- 
ment of compound fractures, a high penalty in the form of skeletal deformity 
would be the inevitable result. Results obtained by secondary suture do not 
justify the use of closed plaster for soft part wounds. 
(3) When it is desired to allow granulations to cover exposed bone 
in deep irregular wounds, the wound may be encased in plaster subject to in- APPENDIX 
337 
frequent changes. This is also an accepted method of management for estab- 
lished infection of bone, particularly when the wound has caused an extensive 
loss of overlying soft parts or there is a large bone defect. Before application 
of the plaster, all devitalized tissue and loose bone fragments are excised. 
There should be no pocketing or pooling of pus in the fracture site or adjacent 
fascial compartments. Small surfaces of bare cortical bone may be removed 
surgically when this permits closure of the defect by suture or skin graft. 
h. Amputations. 
(1) The most important phase in the management of amputations is 
the functional rehabilitation of the patient by the fitting of a prosthesis. Am- 
putation centers have been established in the Zone of the Interior for this 
purpose. It is the expressed desire of The Surgeon General that the early 
management of amputations in overseas theaters conform with policies that 
have been set forth in numerous Bulletins and Circular Letters and which are 
summarized below. 
(2) In the forward area, amputations will be performed at the lowest 
possible level except that a proximal amputation will be done in preference 
to a disarticulation. The technique for the performance of amputations is 
as follows: A circular incision is made through the skin at the lowest level com- 
patible with viable tissue and the skin allowed to retract; the fascia is then 
incised at the level to which the skin has retracted. The superficial layer of 
muscle is then cut at the end of the fascia and permitted to retract. At its 
point of retraction, the deep layers of muscle are cut through to the bone. 
After the deep muscles have retracted, the periosteum of the bone is cleanly 
incised and the bone sawed through flush with the muscles. No cuff of peri- 
osteum is removed as in a closed amputation. Bone denuded of periosteum 
will sequestrate if infection is present and a ring sequestrum often results 
when the periosteum has been removed. It is important also that no peri- 
osteum be elevated or torn from the bone in the stump by rough handling. 
The properly performed Hapless guillotine stump exhibits a slightly concave 
open cross section of the extremity. 
(3) The proper dressing of the stump is important. The end of the 
stump is dressed with fine mesh gauze in such a manner that it does not overlap 
the skin edges. Skin traction is applied immediately. This may either be 
by a stockinette cuff attached with ace adherent or by adhesive tape. Traction 
is obtained preferably by a light plaster cast with a wire ladder banjo. The 
cast always incorporates the joint above the amputation, e. g., a spica for an 
amputated thigh. The Army Hinged Half-Ring splint may be utilized as an 
alternative. Medical Supply Item No. 36614, Cord, Elastic, for Traction, 
is available and is preferable to plasma tubing for the elastic traction. Before 
evacuation, the traction is examined and if doubt exists as to its effectiveness, 
it is reapplied. 
(4) At the base areas, secondary closure of a circular guillotine ampu- 
tation stump is not indicated, as it is impossible to suture the inelastic fascia 338 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
without wasteful shortening of the bone. Bone length can be saved by con- 
tinuing the skin traction for an additional period of time—4 to 6 weeks. Closure 
of stumps by sliding flaps, plastic resection with sacrifice of bone length, or 
formal reamputation are procedures to be carried out in the Zone of the In- 
terior rather than in an overseas theater. Skin grafting is not indicated. 
Vertical incisions in the stump made for control of infection or as part of the 
initial debridement should be closed by secondary suture while skin traction 
is being maintained to cover the defect at the end. 
(5) In the Communications Zone continuous skin traction is main- 
tained in all cases. After removal of the cast or splint, maintenance of 4 to 6 
pounds in below-knee and 6 to 8 pounds in thigh stumps of traction over a 
pulley at the foot of the bed is indicated. Traction is continued until the 
wound is healed. Priority air evacuation to the Zone of Interior should be 
available for amputation cases as soon as they are able to be transported. 
Traction during evacuation is provided for by stockinette and a banjo plaster, 
i. Fractures. 
(1) The management of a compound fracture is divided into the 
following phases: first aid splinting in the field; debridement and the applica- 
tion of transportation splinting in a mobile hospital; final correction of the 
deformity and attainment of wound healing and bony union at a fixed hospital 
(reparative phase); reconstructive or corrective surgery (bone grafting, oste- 
otomy, sequestrectomy, etc.) in the Zone of the Interior. In every phase 
attention is directed to the ultimate Junction of the extremity which is dependent 
on muscles, nerves, blood vessels and joints as well as on skeletal integrity. 
(2) Transportation Splinting applied subsequent to initial wound 
surgery for evacuation from mobile to fixed hospitals is not designed to pro- 
vide anatomic reduction or prolonged fixation in suitable reduction. Except 
in rare instances it is by plaster of Paris. Plaster bandages are adequately 
padded and bivalved or split through all layers to the skin. Skeletal fixation 
by the incorporation of pins or wires into the plaster is not recommended. 
The only indication for the use of internal fixation in the forward area is to 
preserve the vascular integrity of the extremity. 
Methods of transportation splinting that have proved safe and com- 
fortable are: 
Femur: A low waisted “one and one half” plaster spica with the knee 
slightly flexed and minimal abduction. 
The Tobruk plaster and the Army leg splint with skin traction do not 
provide as adequate immobilization and should only be used as emergency 
measures when large numbers of casualties or multiple wounds in a single 
casualty demand concessions to operating time or for special indications such 
as the presence of a colostomy or suprapubic cystostomy. When restricted 
to lower third femoral fractures and knee joint injuries the Tobruk splint 
provides adequate immobilization. 
Humerus: A thoracobrachial plaster with the arm forward in internal 
rotation. APPENDIX 
339 
A plaster Velpeau bandage binding the arm to the trunk with the forearm 
flexed at a right angle and placed across the chest. 
The Army humerus splint designed for field (first aid) use is not suitable 
for postoperative transportation splinting. 
A hanging cast is both uncomfortable and ineffective as a method of 
transportation splinting. 
Forearm: 
A circular plaster bandage that extends to the midbrachial region with 
flexion of the elbow and extending only to the proximal palmar crease. 
Plaster slabs in the form of “sugar-tongs.” 
Tibia and Fibula: 
A circular plaster bandage from toes to groin. The knee is slightly (15 
degrees) flexed and the foot held in neutral position at 90 degrees to the axis 
of the limb. A plantar slab may extend beyond the toes to afford protection, 
but hyperextension is to be avoided. 
(3) Reparative Surgery of Compound Fractures. (See Wound Manage- 
ment, par. 2 c on Closed Plaster Treatment.) 
Reparative surgery in compound fractures is made necessary by leaving 
unsutured the large incisions made for debridement and the recognized fact 
that splinting suitable for transportation is inadequate for complete reduction 
and fixation of the fracture. The goal is functional restoration of the ex- 
tremity and demands treatment of muscle and nerve injury as well as skeletal 
damage. Observance of certain basic principles are important to the success 
of this phase of management. 
Preoperative correction of anemia by whole blood transfusion. Despite 
whole blood transfusion for resuscitation in the forward area, a high percentage 
of compound fracture cases will arrive at a fixed hospital in the Communica- 
tions Zone with low red cell volume (hematocrit) and hemoglobin. An ap- 
proximate estimate of the quantity of whole blood needed to restore red cell 
volume may be deduced from the rough rule of 500 cc blood for each 3 points 
of the hematocrit or 0.9 grams of hemoglobin. In the use of whole blood 
transfusion for correction of secondary anemia or hypoproteinema the total 
volume administered in a 24 hour period should not exceed 1000 cc except 
to replace blood lost at operative procedures. This is in contrast with the 
larger volumes that are administered for resuscitation when the total circu- 
lating blood volume may be greatly reduced. No correlation exists between 
the hematocrit or hemoglobin levels and circulating blood volume and care 
must be taken not to precipitate pulmonary edema by overtransfusion of a 
patient in whom the blood volume has been restored by dilution but who still 
shows a greatly reduced cell volume (hematocrit) and hemoglobin. 
The surgical elimination of residual necrotic tissue. No available chemo- 
therapeutic agent can “sterilize” an open wound containing devitalized tissue 
or blood clot. A properly managed clean wound requires no local antiseptic. 
The control of invasive infection by systemic chemotherapy. Systemic peni- 
cillin therapy in a dosage of 25,000 units every three hours is recommended 340 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
as a routine adjuvant for secondary operations on compound fractures. Treat- 
ment is continued post operatively until the likelihood of invasive infection 
is passed. 
Reduction or closure of soft tissue dejects. Exposed cortex of bone, nerves 
and tendons are vulnerable to the necrotizing effect of wound suppuration and 
are protected by the apposition of adjacent soft parts. Transversely divided 
important muscle groups are united by suture. Fascial compartments are re- 
stored to minimize scarring and improve muscle function. Certain of these 
procedures may be staged operations. Emphasis should not be placed on early 
or complete skin closure, as in most cases any remaining cutaneous defect will 
heal before bony union occurs. 
Provision of drainage for residual exudate. Severely comminuted fractures 
may require dependent drainage in association with the apposition of soft parts 
over exposed bone. Exteriorizing fascial plane incisions have proven superior 
to stab wounds or rubber drains. Upper extremity fractures rarely present a 
drainage problem. The thigh may be drained by a posterolateral incision be- 
tween the vastus lateralis and the biceps. An adequate posterior drainage 
route for the shaft of the tibia does not exist and such an injury may neces- 
sitate a period of “on the face” nursing. 
Internal fixation of battle fractures is not feasible commonly because of ex- 
tensive comminution. Further, the method demands further periosteal strip- 
ping and surgical trauma to the wound. Limitation of the use of this method 
to cases carefully selected by specialists fully experienced in the techniques and 
hazards of its usage is strongly advised. An example of sound usage is the 
employment of screws for restoration of the articular surface of a major joint. 
Reduction of the fracture is the goal of reparative surgery—not the use of 
internal fixation. 
Use of suspension traction. The application of suspension traction in the 
treatment of fractures, particularly those of the femur, is the safest and most 
satisfactory method of management. In fixed hospitals fractures of the femur 
should be treated by skeletal traction for ten to twelve weeks until enough 
union has been obtained to permit safe transportation to the Zone of the In- 
terior in a plaster spica. The use of suspension traction promotes the main- 
tenance of joint and muscle function and prevents angulation or over-riding 
deformity. 
Overpull and resulting distraction must be avoided at all times, particu- 
larly in cases associated with injury or division of the thigh muscles. Certain 
cases of this type require very expert attention and delay in the application of 
traction until firm fibrous union of muscles has been attained b}T suture, 
j. Joints. 
Early complete debridement is the keystone of success in the management 
of wounds that compound a joint. The wound of the soft part is excised and 
the bone and cartilage damage assessed through incisions that provide complete 
exposure. Comminuted fragments of bone and cartilage are removed from the 
joint and a careful search made for foreign material. Badly comminuted frac- APPENDIX 
341 
tures of the patella are excised completely as a step in the debridement of a 
knee joint wound. 
Every effort is made, after cleansing the joint cavity, to close the capsule. 
The skin is left unsutured. Closure of the joint is especially difficult in the 
face of extensive loss of soft parts. When it is impossible to close a joint by 
suture of synovia or capsule, an occlusive dressing is applied. On arrival at a 
fixed hospital, effort is directed toward closing the defect by advancement of 
a skin flap or other plastic procedure. 
Adequate exposure of the hip joint is a specialized procedure that requires 
precise anatomical orientation. The same principle of management must be 
applied to improve the results of this particular lesion. 
Penicillin is inserted into a joint at the end of the operation. In joints 
that are accessible to needle aspiration, accumulating exudate may be with- 
drawn and penicillin injected during the postoperative period. 
Wounds of the ankle joint with comminution of the os calcis or astragalus 
are peculiarly liable to sepsis. Initial debridement of comminuted bone frag- 
ments must be minimal if function is to be preserved and early efforts are made 
in the reparative surgical phase to reduce or close the skin defect with split 
thickness graft when necessary. When sepsis is established, subperiosteal ex- 
cision of necrotic bone fragments followed by wound closure by graft or suture 
should not be delayed. 
For the SURGEON: 
(S) E. Standlee 
E. STANDLEE. 
Colonel, M. C., 
Deputy Surgeon. 
DISTRIBUTION: 
Surgeon, PENBASE 300 
Surgeon, NORBS 20 
Hq. A/GofS 10 
Surgeon, Adriatic Base Command 100 
Surgeon, Fifth Army 600 
Surgeon, AAFSC/MTO 700 
Surgeon, Replacement Command 50 
Surgeon, Rome Area Command 25 
Surgeon, Hq. Command, AF 30 
Surgeon, MTOUSA 300 MEDICAL DEPARTMENT, UNITED STATES ARMY 
The volumes comprising the history of the Medical Department of the 
United States Army in World War II are divided into two series: (1) The 
administrative and operational series, which constitutes a part of the general 
series of the history of the United States Army in World War IT, prepared by 
The Surgeon General and published under the direction of the Chief of Military 
History; and (2) the professional, or clinical and technical, series, prepared by 
and published under the direction of The Surgeon General, This is one of 
the volumes published in the latter series. 
343 INDEX1 
Abduction of thumb— 
in splinting for carpal scaphoid fractures, 
292 
in splinting for radial-nerve paralysis, 47 
in testing for radial-nerve injury, 72 
Abscess formation in fractures of bones of 
leg, 163 
Abscesses; 
about fracture site, 93 
about lower femoral pin in external skeletal 
fixation, 205 
drainage of, 63, 72 
of fascial plane, 72, 139 
Accidents. See Noncombat orthopedic le- 
sions. 
Acetabulum, damage to articulating surfaces 
of, 237 
Adjutant General’s Office, MTOUSA, 280 
283 
Agents of wounding. See Wounding agents. 
Aidmen, medical, 32-33 
Air evacuation of amputees, 253, 257 
Alinement of fractures by— 
external skeletal fixation, 208 
internal fixation, 134, 198, 199-200, 202 
plaster immobilization, 40-41, 125, 165, 
182 
skeletal traction, 139, 149, 182 
Ambulation, after menisectomy, 286 
American Red Cross, 31 
Amputation, 245-270 
avoidance of, 130 
directives on, 7, 245, 247-249, 251-254, 
257, 259 
in fractures of— 
bones of foot, 183 
bones of leg, 166, 175-176 
femur, 139, 158 
in reparative-surgery program, 107, 197 
in wounds of knee joint, 216, 231, 235 
indication (s) for, 245, 246-247, 266-269 
disease as 247, 262-264 
infection as, 247, 249 
trauma as, 246, 264- 265 
trenchfoot as, 262 
vascular insufficiency as, 246, 249 
Amputation—Continued 
level of, 247-249 
multiple, 262, 270 
of arm, 261 
of leg, 253, 254 
of lower extremity, 261, 262, 269 
of thigh, 253, 254 
of upper extremity, 247-249, 254 
psychological considerations in, 245 
recommendations on, by consultant in 
orthopedic surgery, 7-8 
reparative surgery after, 253-257 
site of, 262 
statistics on, 260-270 
technique of, 251-253 
through long bones, 249 
timing of, 269 
traction after, 253, 256, 257 
traumatic, 246, 249, 262, 264, 265 
Amputation centers, in Zone of Interior, 245, 
253 
Amputation stump, 251-260 
closure of, 253-257 
healing of, 256-257 
revision of, 259-260 
Amputees: 
air evacuation of, 253, 257 
deaths of, 260 
Anatomic restoration, as factor in disposition 
of patients, 295 
Anemia, secondary, before reparative sur- 
gery, 82-83 
Anesthesia for reparative surgery, 83 
Angulation of fractures of— 
bones of foot, 182 
bones of leg, 167 
femur, 154-155 
humerus, 34, 125 
Ankle: 
disarticulations at, 261 
emergency splinting of, 35-39 
transportation splinting of, 51 
Ankle joint: 
arthrotomy of, 286-287 
involvement of, in fractures of bones of 
leg, 175 
1 Unless it is otherwise specified,ail references in this index are to (1) orthopedic surgery, (2) battle-incurred compound 
fractures, and (3) the Mediterranean (formerly North African) Theater of Operations. “Disposition of patients” refers 
to disposition from general hospitals of base sections. 
345 346 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Ankle joint—Continued 
loose bodies in, 286-287 
position of, in immobilization of fractures 
of bones of leg, 164 
resection of, 243-244 
use of external skeletal fixation after, 210 
wounds of: 
management of, 243-244 
suppurative arthritis in, 244 
Ankylosis, in wounds of hip joint, 214, 237, 
242 
Anomalies, congenital, disposition of patients 
with, 274 
Antibiotic therapy, 64, 72, 83. See also 
Penicillin. 
Anzio, 43, 63, 81, 138, 139, 186, 217 
Appliances, manuals on, 31-32 
Arch supports, use of, in management of 
painful feet, 275 
Arm. See Humerus. 
Army Air Forces: 
disposition of patients in, 276-277 
elective surgery policy in, 277 
hospitals supporting, 276, 280, 282 
Army half-ring leg splint. See Hinged half- 
ring leg splint. 
Arthritis: 
as factor in management of noncombat 
lesions, 274, 279 
suppurative: 
of hip joint, 237, 242, 243 
of knee joint, 214, 215, 217-219, 227, 236 
of smaller joints, 244 
traumatic, 293 
Arthrotomy of— 
ankle joint, 286-287 
elbow joint, 286-287 
knee joint, 231, 235-236 
contraindication for, 283-284 
disposition of patients after, 277-278, 
281, 282-283, 284, 286-287 
incision for, 223 
prognosis after, 284-285 
statistics on, 277, 280, 282, 286 
theater policy on, 279 
Articular cartilage: 
damage to— 
in fractures of humerus, 123 
in wrounds of hip joint, 241 
in wmunds of knee joint, 219 
necrosis of, in wounds of knee joint, 221 
removal of, 223, 243, 279, 286 
See also Semilunar cartilage. 
Articular surfaces: 
anatomic replacement of, 187 
damage to, in wounds of hip joint, 237 
damage to, in wounds of knee joint, 217 
defect in, as factor in diagnosis of joint 
mice, 286 
Aspiration-instillation regimen, in wounds of 
knee joint, 219-221, 231 
at initial surgery, 227 
at reparative surgery, 227, 235 
Astragalus, fractures of, 183 
Atrophy of muscles, as factor in diagnosis, 
283, 289 
Autofrance, Maj. Otto E., 160n 
Axillary contents, risk of injury to, in use of 
hinged full-ring arm splint, 34 
Axillary nerve, damage to, in fractures of 
humerus, 122 
Backs, painful, 271-275 
diagnosis of, 272-274 
disposition of patients with, 274-275 
management of, 274-275 
Bacterial count in wound closure, in World 
War I, 58-60 
Bacterial flora in war wounds, 59 
Bagnoli, 20 
Balanced-suspension skeletal traction— 
in fractures of femur, 139, 142-143, 149- 
155, 156, 159 
in wounds of knee joint, 227 
Bandages: 
Carlisle, 32, 34 
figure-of-eight plaster, 51 
manuals on, 31-32 
muslin, 40 
roller, 32, 34-35, 41 
triangular, 32, 34-35 
Banjo traction; 
after amputation, 251, 253, 257 
in fractures of bones of foot, 182 
Basswood splints, use of, in emergency splint- 
ing, 32, 34 
Battalion aid stations, 33, 34 
first aid in, 66-67 
Battlefield, first aid on, 66-67 
Bed rest— 
after fractures of bones of foot, 183 
as treatment for noncombat orthopedic 
lesions, 274, 275, 279, 288, 293 
Bed space, 271-272 
as consideration in elective surgery, 7 
waste of, caring for patients with chronic 
orthopedic, non combat lesions, 297 
Belgium, 212 INDEX 
347 
Belts, for painful backs, 275 
Biceps femoris muscle, 148 
BIP (bismuth subnitrate, iodoform, and 
paraffin), use of, in World War I, 53 
Bizerte, 4, 20 
Bladder, urinary, 237 
Blister formation in closed plaster method of 
fracture management, 55 
Blood, availability of, 63, 67 
Blood pressure in shock, 68, 70 
Blood replacement— 
in management of fractures— 
after initial surgery, 80 
after reparative surgery, 82-83 
before initial surgery, 68-70 
before reparative surgery, 82-83 
of bones of leg, 162-163 
of femur, 80, 138 
of upper extremity, 116-117 
in management of wounds of knee joint, 
219 
in reparative-surgery program, 63, 64 
Blood supply of bone fragments, 292, 293 
Blood transfusions. See Blood replacement. 
Blood vessels, 246 
injuries to, associated with wounds of hip 
joint, 237 
ligation of, at initial surgery, 74 
protection of, in fractures of upper ex- 
tremity, 117 
Body warmth, conservation of, before initial 
surgery, 67 
Bone and nerve surgery in fractures of— 
bones of leg, 161 
humerus, 128-129, 132 
upper extremity, 116 
Bone cortex: 
coverage of, at reparative surgery, 93-103 
excision of fragments of, at initial surgery, 
79 
exposure of, in fractures of bones of leg, 
160, 161 
fragmentation of, in fractures of tibia, 79 
Bone coverage, in fractures, 186 
after internal fixation, 87 
of bones of foot, 181 
of bones of leg, 163 
of humerus, 129 
of upper extremity, 116, 117 
Bone fragments: 
blood supply of, 292, 293 
displaced, 182 
distraction of, 201 
Bone fragments—Continued 
excision of, in carpal scaphoid fractures, 
293 
management of, in fractures, 198, 207 
at initial surgery, 78-79 
at reparative surgery, 84, 86, 87 
by delayed internal fixation, 134, 146, 
187, 199, 201, 207 
of bones of foot, 182 
of bones of forearm, 41, 134 
of bones of leg, 163, 165, 170 
of femur, 142, 149, 154 
of humerus, 128 
of upper extremity, 117 
policy on, 78-79 
role of, as bone grafts, 79 
Bone grafting— 
after fractures, 196, 199, 200, 201 
as factor in reparative surgery, 134, 165, 
166, 173, 207 
after wounds of knee joint, 237 
Bone injuries; 
data on, methods of accumulation of, 28 
disposition of patients with, 295-298 
initial surgery for, 64-81 
management of; 
administrative considerations, 3-28 
objectives of, 7 
personnel required for, in general hos- 
pitals, 26-27 
responsibility for, 25 
reparative surgery for, 81-114, 139-186 
See also specific bones, techniques, injuries. 
Bone loss, 87, 107, 185, 187, 199, 201 
after massive sequestration, 196, 199 
as indication for application of hip spica, 
156 
as indication for external skeletal fixation, 
207 
avoidance of, 79 
In fractures of— 
bones of forearm, 134-135, 202 
bones of leg, 160, 161, 165, 170, 173, 201 
femur, 144 
humerus, 116, 126-127, 201 
lower extremity, 245 
upper extremity, 116 
Bone-nerve injuries, in fractures of bones of 
forearm, 134-135 
Bone shortening, 187 
in fractures of— 
bones of forearm, 135 
bones of leg, 165, 201 
humerus, 126-127, 128 348 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Bone shortening—Continued 
in wounds of knee joint, 231, 236 
indications for, 87 
Bone tumors, disposition of patients with, 
274 
Boot plaster cast, 182, 183, 275 
Bou Hanifia, 19 
Boxing-glove type of plaster cast, 8 
Bracemakers, assignment and utilization of, 
15-20, 27 
Braces, for painful backs, 275 
Braceshops, 275 
equipment for, 15, 20 
Brachial artery, risk of damage to, in splint- 
ing, 34 
Brott, Capt. C. R., 245n 
Bruises, disposition of patients with, 295 
Burns associated with fractures, 209 
Butterworth, Maj. R. D., 168n 
Buxton, St. J. D., 250 
Cahen, Maj. Irvin, 137, 146, 149, 152 
Calcification, in carpal scaphoid fractures, 
293 
Calf, wounds of, 73 
Callus formation, after fractures, 81 
of metatarsal bones, 182 
Capillary attraction, drainage of wound 
exudate by, 78 
Capsule of hip joint, closure of, 241 
Capsule of knee joint. See Synovial mem- 
brane. 
Carlisle bandages, 32, 34 
Carpal scaphoid fractures, 271 
diagnosis of, 292 
disposition of patients after, 291, 293-294 
surveys on management of, 276, 290-294 
theater policy on mangement of, 290, 292 
union of, 293 
Carrel-Dakin method, 53, 211 
Cartilages, articular: 
damage to— 
in fractures of humerus, 123 
in wounds of hip joint, 241 
in wounds of knee joint, 219 
necrosis of, in wounds of knee joint, 221 
removal of, 223, 243, 279, 286 
See also Semilunar cartilages. 
Casablanca, 3 
Caserta, 63 
Cassino, 4, 43, 62, 139, 186 
Casts, plaster: 
banjo, 182, 251, 253, 257 
boot, 182, 183, 275 
boxing-glove type, 8, 9 
Casts, plaster—Continued 
hanging, 41, 27-31, 33, 117, 12:1-126, 127 
hip spica, 8, 48-49, 139, 154 
long arm, 41 
long leg, 49, 61, 170, 173, 216 
shoulder spica, 41, 43, 123, 125, 127 
U type, 43 
Velpeau, 41, 43 
See also Plaster immobilization, Plaster 
casts. 
Casualties. See Patients. 
Cellulitis, 72 
Certificate of Disability discharge, 237 
Chain of evacuation, 14 
role of, in reparative-surgery program, 62 
Chemotherapy, 57 
institution of, as first-aid measure, 67 
See also Sulfonamide therapy. 
Chiefs of orthopedic sections: 
classifications of, 26 
duties of, 26, 27 
role of, in accumulation of data, 28 
Chiefs of surgical services, responsibility of, 6 
Chip fractures of knee, 283 
Churchill, Col. Edward D. See Consul- 
tant in surgery. 
Circular amputations. See Open circular 
amputations. 
Circular letters: 
No. 13, Office of the Surgeon, NATOUSA, 
15 May 43—47n 
No. 16, Office of the Surgeon, NATOUSA, 
9 June 43—47n 
No. 36, Office of the Surgeon, NATOUSA, 
1 July 44—-10 
No. 46, Office of the Surgeon, NATOUSA. 
29 Aug 44—7, 8, 9, 245, 247-249, 251- 
254 
No. 48, Office of the Surgeon, NATOUSA, 
18 Nov 43—185, 203-204, 278-279. 
287, 289, 290 
No. 91, Office of the Surgeon General, 26 
Apr 43—247n 
Circular wounds, 74 
Circulatory status of extremities, determina- 
tion of, after initial surgery, 80 
Civilian orthopedic practice, 273 
knee disabilities in, 284-285 
wounds of joints in, 212-213 
Clary, Capt. Beverly B., 160n 
Clearing stations: 
first aid in, 66-67 
responsibility of, 14 
Cleveland, Col. Mather, 1 INDEX 
349 
Closed plaster method of fracture manage- 
ment, 53-58 
clinical observations on, 57 
discontinuance of use of, 58 
in fractures of bones of leg, 63, 178 
modification of, 56 
objectives of, 53 
results of, 53, 55-56 
Clostridial myositis— 
after amputation, 249, 256 
as indication for amputation. 247, 249, 267, 
269, 270 
in fractures of bones of leg, 178 
in fractures of femur, 139, 140 
Closure of amputation stump, 253, 254-257 
Closure of capsule of hip joint, 241 
Closure of knee joint, 216, 219 
Closure of synovial membrane in wounds of — 
knee joint, 216, 217, 219, 221, 223 
smaller joints, 243 
Closure of wounds. See Wound closure. 
Collecting stations, first aid in, 66-67 
Collom, Maj. Spencer A., Jr., 21 In, 137n 
Colostomy, 47 
Comminuted fractures, 87, 129, 134, 146, 159. 
165-170, 173, 175, 178-179, 186, 201, 207, 
208-209, 219, 223 
Comminution— 
as contraindication to internal fixation, 86, 
87, 122-123, 128, 186 
as indication for external skeletal fixation, 
207, 208-209 
Committee on Surgery, Division of Medical 
Sciences, National Research Council, 31 
Subcommittee on Orthopedic Surgery, 213 
Como, 3 
Condylar fractures, 198 
of femur, 87, 146 
of humerus, 87, 129 
Conference, Interallied Surgical, 1917, 211 
Congenital anomalies, disposition of patients 
with, 274 
Consultant (s): 
in neuropsychiatry, Fifth U. S. Army, 272- 
273 
in orthopedic surgery, 1, 4, 5, 63, 188, 189, 
238, 242, 277 
activities of, 7, 12. 238, 277 
mission of, 4, 6-7 
to field armies, advantages of appoint- 
ment of, 5. 13, 237 
to Fifth U. S. Army, 5 
Consultant (s)—Continued 
in surgery, 1, 4, 58, 65 
function of, 6, 7 
to Fifth U. S. Army, 5, 7, 8, 10 
to Seventh U. S. Army, 4, 5, 12, 51 
role of, in training of medical officers, 65 
Consultant system, evolution of, 3-5 
Continental Advance Base Section, 10-12 
Contraindications to— 
delayed primary wound closure, 59, 91, 103, 
163 
external skeletal fixation, 207 
internal fixation, 86, 186 
periosteal stripping, 86 
surgery for knee disabilities, 279, 283-284 
Trendelenburg position, in shock, 68 
Convalescent hospitals, 66, 279 
Copper sulfate hematocrit and serum protein 
determination, 82 
Counterincisions, utilization of, for— 
elimination of dead space, 77 
removal of foreign bodies, 73 
wound drainage, 74, 93, 103 
Cox, Col. Francis J., 137n, 148 
Crider, Capt. Russell J., 137n, 152, 155 
Crouch, Capt. Francis R., 115n, 160n 
Dead space, 57, 59, 93, 163-164, 166 
as surgical limitation to wound closure, 
59, 103 
drainage of, 186 
obliteration of, 77, 117, 142 
Deaths— 
after delayed internal fixation, 197 
in fractures of femur, 137, 139, 140, 158 
in reparative-surgery program, 107 
of amputees, in fixed hospitals, 260 
Debridement: 
at reparative surgery, 59 
in closed plaster method of fracture man- 
agement, 54, 55 
in wounds of— 
hip joint, 242 
knee joint, 216, 217, 219, 223-227, 235 
smaller joints, 243-244 
objectives of, 71 
See also Initial surgery 
Delayed internal fixation of fractures, 91, 
146, 155, 185-202 
about joints, 185, 187 
advantages of, 197 
comminution, as contraindication to, 186 
disadvantages of, 187 
hazards of, 195-196, 198-199 
indications for, 190-191, 197 
399661°—57 24 350 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Delayed internal fixation of fractures—Con. 
of bones of forearm, 185 
of bones of leg, 185, 199 
of femur, 197, 199 
of long bones, 187 
of upper extremity, 199 
results of, 186, 188-202 
techniques of, 187 
theater policy on, 185 
with segmental bone defects, 185, 187 
with soft-tissue loss, 185 
with unhealed wounds, 185, 186 
See also Screw fixation, Plating, and other 
specific techniques. 
Delayed primary suture of amputation 
stump, 256 
Delayed primary wound closure. See Wound 
closure, delayed primary. 
Delayed union in fractures, prevention of, 
198 
Delta Base Section, 11, 12 
Deltoid muscle, 122 
Dependent drainage, 77, 142, 143, 148, 161, 
163 
Devitalized tissue, 57 
drainage of products of, 91, 143, 148, 186 
excision of, 188 
as criterion for wound closure, 59 
at initial surgery, 73 
at reparative surgery, 84 
in closed plaster method of fracture 
management, 57 
in fractures, 63, 117, 142, 179-180, 181 
in wounds of joints, 219, 241 
effect of, on wound closure, 60, 149 
effect of, on wound healing, 112 
in fractures of femur, 142, 149 
inadequate excision of, 56 
sequestration of, 81, 107 
Diagnosis of noncombat orthopedic lesions, 
272-274 
in civilian orthopedic practice, 272 
of back, 274 
of carpal scaphoid fractures, 290, 292 
of knee, 283 
of shoulder, 287 
Dirty wounds: 
after incomplete initial surgery, 117 
extensive wound revision for, 103 
necessity of drainage in, 149 
reparative surgery in management of, 107 
restriction or avoidance of periosteal strip- 
ping in, 87 
Disarticulation, 261 
theater policy on, 247-249 
Disease, as indication for amputations, 247, 
262-264 
Dislocation (s) of— 
hip, in management of wounds of hip 
joint, 243 
humerus, 122 
patella, 278 
shoulder, 271-274, 276, 287-290 
Disposition boards in hospitals, 276, 279, 
287, 290, 294 
Disposition of patients. See Patients, dis- 
position of. 
Drainage— 
in fractures, 83 
after reparative surgery, 63, 91-103, 
107, 186, 188 
at initial surgery, 72, 74, 78 
in closed plaster method of fracture 
management, 53-58 
in external skeletal fixation, 204 
of bones of foot, 182 
of bones of leg, 161, 163-164, 175-178 
of femur, 142, 148-149, 201 
of upper extremity, 117 
in wounds of— 
hip joint, 237, 242 
knee joint, 216, 217, 219, 231, 235 
smaller joints, 244 
Drains: 
gauze used as, 103, 163 
rubber tissue, 77, 103, 163 
Drayer, Lt. Col. Calvin S., 272-273 
Dressing of stump, after amputation, 251 
Dressing of wounds: 
after initial surgery, 74, 77-78 
after reparative surgery, 103, 182 
Drilling, in carpal scaphoid fractures, 293 
Duncan, Lt. Col. George A., 115n, 137n, 
160n, 21 In, 295n 
Edema; 
in closed plaster method of fracture 
management, 55 
control of, 103, 183 
Elastic cord, use of, after amputations, 8, 
11, 253 
Elbow: 
arthrotomy of, 286-287 
disarticulations at, 261 
extension of, in hinged full-ring arm 
splint, 34 INDEX 
351 
Elbow—Continued 
fractures about, 122, 129-130 
delayed internal fixation of, 198 
emergency splinting for, 34 
transportation splinting for, 41, 43-44 
loose bodies in, 286-287 
protection of function of, in fractures of 
radius, 134 
resection of, 54 
wounds of, management of, 243-244 
Elective surgery: 
general discouragement of, 7 
in Army Air Forces, 277 
policy on, 278-279 
Elephant-tusk splint, 43 
Emergency splinting. See Splinting, emer- 
gency. 
England, 1 
Equipment: 
for braceshops, 15, 19-20 
for emergency splinting, 32, 34, 35, 37, 39 
for transportation splinting, 39, 41 
in communication zone, 14, 15 
in forward area, 14 
Evacuation: 
after amputation, traction during, 257 
after initial surgery of fractures, 80 
air, of amputees, 253, 257 
chain of, 14 
role of, in reparative-surgery program, 
62 
effect of, on patient, as consideration in 
disposition, 295 
Evacuation hospitals. See Hospitals, evacu- 
ation. 
Evacuation policies; 
as factor in management of noncombat 
orthopedic lesions, 279 
general principles of disposition and, 
295-298 
military considerations in, 64 
Ewino, Maj. William M., 137n 
Exercises, quadriceps, 150, 154, 279, 284, 286 
External skeletal fixation, 80, 156, 165, 170, 
203-210 
in closed plaster method of fracture man- 
agement, 53-58 
Extremities: 
circulatory status of, determination of, 
after initial surgery, 80 
nerve function in, determination of, at 
initial surgery, 72 
See also Lower extremity, Upper extrem- 
ity. 
Facilities in hospitals, 7, 271, 272, 295, 297 
in communications zone, 14-15, 19-20 
in forward areas, 14 
See also Equipment, Personnel. 
Falling-drop technique. See Copper sulfate 
hematocrit and serum protein deter- 
mination 
Fascia: 
coverage of, at reparative surgery, 93 
excision of, at initial surgery, 76 
incision of, at initial surgerv, 73 
sloughing of, in fractures, 91 
Fascia flaps, use of in wounds of knee joint, 
223 
Fascia lata, 76, 141-142 
Fascial plane; 
abscesses of, 72, 139 
drainage through, in fractures of femur, 
143,148 
Fat pad, excision of, in menisectomy, 285 
Feet: 
amputation of, 183, 262 
fractures of bones of, 180-183 
banjo traction in, 182 
disposition of patients with, 181, 296, 
298 
emergency splinting for, 35 
initial surgery of, 181 
manipulation in, 182 
plaster immobilization of, 182 
reparative surgery of, 181-183 
transportation splinting for, 40-41, 51 
painful, 271-272, 274 
diagnosis of, 272-274 
disposition of patients with, 275 
management of, 275 
See also Lower extremity. 
Femur: 
articulating surfaces of, damage to, 237 
fractures of, 137-159 
about joints, 221 
amputations in, 139, 158 
associated with wounds of thigh, 84 
balanced-suspension skeletal traction 
after, 139, 142-143, 149-155, 156, 159 
blood replacement in management of, 
68, 70, 80, 82, 138 
complications in, 140 
deaths in, 137, 139, 158 
disposition of patients with, 298 
drainage in, 148-149, 159 
duration of traction after, policy on, 9 
emergency splinting for, 39 352 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
F emur—Continued 
fractures of—Continued 
external skeletal fixation of, 156, 207, 
209 
hip spica in, 139, 156 
infection in, 139, 140, 156, 159 
internal fixation of, 87, 143-148, 155- 
156, 199, 201 
Kirschner wire in, 142 
knee motion after, 140, 153, 154, 197 
management of, 138-140 
nerve injuries associated with, 141 
operating time for initial surgery of, 138 
periosteal stripping in, 146 
quadriceps muscle tone after, 140 
reduction of, 139-140, 143-148, 150- 
157, 159 
reparative surgery of. 141-159 
operative position for, 142 
results of, 157-159 
scar formation in, 139, 140 
sequestration in, 159 
shock associated with, 138 
sinus formation in, 140, 158-159 
statistics on, 137-141, 158 
transportation splinting for, 47-48 
two-wire skeletal traction after, 149 
union of, 154-155 
wound healing in, 139, 140, 155, 159 
wound management in, 148-149 
Ferguson, Maj. William R., 115n, 137n, 
155, 160n 
Fibula, fractures of, 160-180 
blood replacement in management of, 68, 
162-163 
bone loss in, 160, 165-170 
closed plaster technique in management 
of, 163 
disposition of patients with, 164-165, 173 
drainage in, 161, 163-164 
external skeletal fixation of, 208, 209 
infection in, 160 
internal fixation of, 170-173, 199, 201 
manipulation in, 160 
nerve and bone surgery in, 161 
nerve injuries in, 162 
nonunion of, 161 
plaster immobilization of, 164, 165,166- 
170, 173 
reduction of, 57, 160, 161 
reparative surgery of, 162-180 
scar formation in, 160 
sequestration of, 160 
skeletal traction in, 160, 166-170 
Fibula, fractures of—Continued 
statistics on, 162, 175-178 
tissue loss in, 161 
transportation splinting for, 40-41, 51 
union of, 160-161 
wound closure in, 161, 163-164 
wound healing in, 160, 163 
wound management in, 162-164, 175-179 
Field hospitals. See Hospitals, field. 
Field manuals. See Manuals. 
Fifth U. S. Army, 4, 49, 51, 138, 261 
consultants to, 4, 7, 272-273 
Figure-of-eight plaster bandage, 51 
Fingers: 
determination of circulatory status of, 80 
motion of, in fractures of upper extremity, 
117 
motion of, in splinting for carpal scaphoid 
fractures, 292 
transportation splinting of, for radial- 
nerve paralysis, 43, 47 
First aid for fractures, 65-67 
First-aid splinting. See Splinting, emer- 
gency. 
Fixed Hospitals. See Hospitals, fixed. 
Flat feet, disposition of patients with, 275 
Flexion contracture of knee after amputa- 
tion, prevention of, 253 
Flexion of— 
elbow, in emergency splinting, 34 
hip joint— 
in hinged half-ring leg splint, 39 
in hip spica, 49 
knee— 
in balanced-suspension skeletal 
traction, 150, 152 
in emergency splinting, 39 
in transportation splinting, 40, 41, 49, 
52 
in immobilization after wounds of knee 
joint, 227 
thumb, in testing for ulnar-nerve injury, 72 
toes, in fractures of bones of leg, 164 
Flynn, Capt. James H., 115n 
Forearm. See Radius, Ulna. 
Foreign bodies: 
removal of, 63, 73, 84, 181, 223, 241 
retained, 68 
Forward hospitals. See Hospitals, forward. 
Fracture frames, 14, 15 
Fracture table, portable, 14, 39 
Fractures: 
about joints, 87, 185, 187, 221 
amputation after, 139, 158, 249 INDEX 
353 
F ractures—Continued 
avoidance of amputation in, 130 
blood replacement in management of, 68, 
70, 82-83, 116-117, 162-163 
bone fragments in, 78-79, 128, 134, 163 
bone loss in, 87, 126-127, 160, 165, 185, 187 
characteristics of, 65-66, 138 
closed plaster technique in management of, 
53-58, 163 
complications in, 140 
deaths in, 137, 139, 158 
delayed internal fixation of, 91, 146, 155, 
185-202 
displacement of, in plaster casts, 56 
disposition of patients with, 164-165, 173, 
181, 296, 298 
drainage in, 54, 91-103, 148-149, 161, 
163-164 
emergency splinting for, 31-39 
external skeletal fixation of, 128-129, 156, 
165, 203-210 
first aid for, 66-67 
functional restoration of extremity after, 
87, 129 
granulation in, 130, 132 
infection in, 57, 63, 123, 132, 134, 139-140, 
156, 158, 159, 160, 199, 236 
initial surgery of, 64-81 
internal fixation of, 86-91, 126-127, 129, 
130, 134, 143-148, 165, 170-173 
malposition of, prevention of, 159 
management of. See Management of 
fractures, 
manipulation in, 160, 182 
motion after, 153, 154 
nerve injuries in, 50, 116, 127-129, 130, 
132, 134-135, 141, 161, 162 
nonclosure of wounds in management of, 
74, 77 
nonhealing of wounds in, 192-202 
nonunion of, 192-202 
of ankle, 35, 51 
of astragalus, 183 
of bones of— 
forearm, 34, 41, 43, 47, 57, 68, 87, 115- 
117, 133-137, 185, 202, 207, 208, 
209, 298 
foot, 35, 51, 180-183, 298 
leg, 35, 37-39, 40-41, 51, 57, 68, 79, 
160-180, 199, 200, 201, 207, 209, 298 
of condyles of— 
femur, 87, 146 
humerus, 87, 129, 298 
F ractures—Continued 
of femur, 9, 39, 47-49, 68, 80, 82, 84, 137- 
159, 197, 199, 201, 207, 209, 221, 298 
of humerus, 34, 41, 43, 68, 87, 115-133, 201 
of long bones, 187 
of lower extremity, 245 
of olecranon process, 87, 134 
of patella, 219, 221, 223 
of upper extremity, 115-117, 199 
operating time for initial surgery of, 138 
operative position for reparative surgery 
of, 142 
osteomyelitis in, 132 
plaster immobilization of, 103, 122-127, 
133, 139, 156, 164, 165, 166-170, 173, 
182 
protection of function in, 134 
range of motion following internal fixation 
of, 197 
reduction of, 55, 56, 57, 63, 80, 86-91, 107, 
122, 123, 126, 129, 130, 133-134, 135, 
139-140, 142-148, 149-157, 159, 160 
reparative surgery of, 81-114, 122-133, 
162-173 
golden period for, 81, 141 
objectives of, 8, 137 
results of, 130-133, 135-137, 141-159, 
173-180 
scar formation in, 139, 140, 160 
sequestration in, 132, 159, 166 
shock in, 138 
sinus formation in, 132, 140, 158, 159 
skeletal traction in, 134, 139, 142-143, 
149-155, 156, 160, 166-170, 182 
soft-tissue loss in, 87, 130, 161, 197, 199 
splinting after reparative surgery for, 4, 
117, 150 
stabilization of, 64 
statistics on, 115, 137-138, 139-141, 161, 
162, 175-180 
tendon injuries in, 116 
transportation splinting for, 39-52 
union of, 79, 83, 126, 130, 132, 154-155 
after delayed internal fixation, 186, 
192-202 
unreduced, internal fixation of, 186 
vascular damage in, 80 
without bone loss, 123-126 
wound closure in, 74, 91-103, 123, 129, 
133, 161, 163-164 
wound healing in, 55, 57, 79, 116, 130, 
132-133, 134, 135, 139, 155-166, 163 
after delayed internal fixation, 92-202, 
186 354 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Fractures—Continued 
wound management in. See Manage- 
ment of wounds. 
Fractures, comminuted, 87, 129, 134, 146, 
159, 165-170, 173, 175, 178-179, 186, 201, 
207, 208-209, 219, 223 
Fractures, simple, 207, 271, 276, 290-294, 
296, 298 
France, 4, 9, 31, 51, 161, 204, 280, 291 
Frankatj, C. F. S., 215 
Full-ring hinged splint. See Hinged full- 
ring arm splint. 
Fusion of Joints, 215, 237, 244 
Gangrene, as indication for amputation, 246, 
268, 269 
Gas-bacillus infection, identification of, after 
initial surgery, 80 
Gastric lavage, before initial surgery, 68 
Gastrocnemius muscle, 52, 73 
General hospitals. See Hospitals, general. 
German prisoners of war, analysis of amputa- 
tions on, 261-270 
Glenoid process, 122 
Gluteus maximus muscle, 148 
Godfrey, Maj. Joseph D., 137n, 142, 152 
Golden period for reparative surgery, 81, 
141. See also Reparative surgery, timing 
of. 
Gottschalk, Capt. Robert B., 115n, 160n 
Grafting. See Bone grafting. 
Grafts. See Skin grafts. 
Granulation, wound healing by, in fractures, 
58, 59, 64, 91-103 
in closed plaster method of management, 
55, 57 
of bones of foot, 181 
of bones of leg, 160, 163, 175 
of femur, 139, 159 
of humerus, 130, 132 
Gross normal alinement of injured extremity, 
maintenance of, by splinting, 40 
Guillotine amputations. See Open circular 
amputations. 
Half-ring leg splint. See Hinged half-ring 
leg splint. 
Hallux valgus, disposition of patients with, 
275 
Hammertoes, disposition of patients with, 
275 
Hampton, Col. Oscar P., Jr. See Con- 
sultant in orthopedic surgery. 
Hamstring muscle, 148 
Hand: 
emergency splinting of, 34 
importance of function of, in management 
of fractures of upper extremity, 115 
Hand injuries: 
disposition of patients with, 296, 298 
management of, 8, 9, 74 
Hanging plaster cast, use of, in fractures of 
humerus, 117, 127 
advantages of, after reparative surgery, 
123-126 
inadequacy of, for transportation splinting, 
41 
Harris, Maj. Herbert W., 148, 203n, 211n 
Heel bone, fractures of, 181, 183, 245 
Hematocrit, copper sulfate determination of, 
82 
Hematocrit level, before reparative surgery— 
in fractures, 82 
of bones of leg, 162-163 
of femur, 138 
of upper extremity, 116-117 
in wounds of knee Joint, 219 
See also blood replacement. 
Hematomas, in fractures, 93 
elimination of, as criterion for wound 
closure, 59 
purulent decomposition of, 57 
septic, drainage of, 72 
Hemoglobin level, 82 
Hemorrhage, 82 
control of, at first aid, 66 
control of, before initial surgery, 67 
detection of, after initial surgery, 80 
Hemostats, use of— 
in first aid, 66 
in initial surgery, 73 
Hinged full-ring arm splint, use of— 
in amputation, 257 
in emergency splinting, 32, 34 
in transportation splinting, 41 
Hinged half-ring leg splint, use of— 
in amputation, 253, 257 
in balanced-suspension skeletal traction, 
150, 151, 152, 227 
in emergency splinting, 32, 35-39, 67 
in transportation splinting, 47, 51 
Hip Joint; 
capsule of, closure of, 241 
emergency splinting of, 35, 37, 39 
flexion of, 49 
transportation splinting of, 47-49 
wounds of, 237-243 
ankylosis in, 237 INDEX 
355 
Hip joint—Continued 
wounds of—Continued 
infection in, 237, 238-241, 242 
management of, 237, 242-243 
suppurative arthritis in, 237, 242 
wound healing in, 241 
Hip spica, use of— 
after thigh amputation, 253 
in fractures of femur, 139, 154, 156 
in transportation splinting, 48-49 
in wounds of hip joint, 242 
in wounds of knee joint, 8, 227 
Holding periods in hospitals; 
after elective arthrotomy, 279 
for accomplishment of reparative surgery, 
63, 65, 83 
for fractures of femur, 9 
for wounds of hip joint, 242 
in forward areas, 295 
theater policy on, as factor in disposition 
of patients with noncombat orthopedic 
lesions, 276 
Hopkins, Maj. George S., 245n 
Hospital(s): 
captured German military, 261 
convalescent, 279 
mission of, 66 
evacuation: 
8th—7 
9th—236 
16th—68, 138 
38th—7 
94th—7 
See also Hospitals, forward, 
field: 
33d—7 
See also Hospitals, forward, 
fixed: 
amputation at, 246, 260-261 
disposition of patients, 295-298 
management of— 
amputation stump at, 246, 253-256 
fractures at, 55-57, 138, 139-140, 187- 
188, 203-210 
noncombat lesions at, 272-294 
wounds of joints, 216-221, 227, 231, 
235-236, 242, 243, 244 
mission of, 63 
reparative surgery at, 81-114 
segregation of bone and joint injuries 
at, 25 
See also Hospitals, general; Hospitals, 
station. 
Hospital (s)—Continued 
forward: 
amputations at, 246 
assignment of general surgeons to, 12, 13 
assignment of orthopedic surgeons to, 
5, 12-13 
disposition of patients from, 295, 297 
facilities at, 14 
holding period at, 242, 295 
initial surgery at, 14, 67-81 
management of— 
fractures at, 55, 138, 163 
wounds of joints at, 231, 242 243 
mission of, 63 
screening of patients at, 272-273 
transportation splinting at, 39-52 
See also Hospitals, evacuation; Hos- 
pitals, field, 
general: 
disposition boards at, 276, 279, 287 
disposition of patients from, 295-298 
facilities at, 14-15, 19-20 
numbered; 
3d—11 
6th—9, 101-108 
12th—9, 148, 286-287 
17th—148, 219, 235 
2lst—10, 19, 82, 115, 121-138, 141- 
183, 186, 197, 219, 244 
23d—81, 82, 138, 142, 152, 186, 219 
24th—20, 140-183 
26th—280, 282-283 
33d—8, 9, 121-133, 140-183, 286 287 
36th—10, 11, 12 
43d—11 
45th—115, 133-137, 161-181, 215, 
219, 286-287, 297-298 
46th—10, 12, 19, 292 
64th—8, 140-183 
70th—236 
182d—291, 292 
300th—121-138, 141-183, 186 
outpatient dispensaries in, 27 
personnel required in, 26-27 
See also Hospitals, fixed, 
station: 
disposition boards at, 276 
numbered: 
35th—11 
70th—11 
73d—9 
78th—11 
80 th—11 
180th—10 356 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Hospital (s)—Continued 
station—Continued 
outpatients clinics in, 27 
See also Hospitals, fixed, 
supporting the Army Air Forces, 276, 280, 
282 
Zone of Interior, mission of, 64, 116 
Hospital administration, 25-27 
Hospital center for prisoners of war, 261 
Hospital disposition boards, 276, 279, 287, 
290, 294 
Hospital facilities, 7, 271, 272, 295, 297 
Hospitalization period: 
after arthrotomy of knee joint, 277-278, 
279, 281, 282 ' 
after carpal scaphoid fractures, 291-292,293 
after disabilities of knee, 280-281, 282 
after reparative surgery of fractures, 65 
of bones of foot, 183 
of femur, 157 
after shoulder dislocations, recurrent, 288 
Hospitalization policies, military considera- 
tions in, 64, 65 
Humerus: 
amputations of, 261 
dislocations of, 122 
fractures of, 115-133 
about elbow joint, 129-130 
about shoulder joint, 122, 126 
blood replacement in management of, 68 
disposition of patients with, 298 
emergency splinting for, 34 
granulation in, 130, 132 
infection in, 123, 129-130, 132 
internal fixation of, 87, 126-129, 201 
management of, 115 
nerve and bone surgery in, 128-129 
nerve injuries associated with, 116, 122, 
127-129, 130, 132, 134 
osteomyelitis in, 132 
plaster immobilization of, 123-127 
reduction of, 122-130 
reparative surgery of, 122-133 
sequestration in, 132 
sinus formation in, 132 
soft—tissue damage in, 130 
tendon injuries associated with, 116 
transportation splinting for, 41-46 
union of, 132 
with bone loss, 116, 126-127, 201 
without bone loss, 123-126 
wound closure in, 123, 129 
wound healing in, 130, 132-133 
wound management in, 122-124 
Improvised sacral rests, 39 
Improvised splinting. See Splinting, emer- 
gency, improvised. 
Incidence. See Statistics. 
Incisions: 
enlargement of, at reparative surgery, 84 
for amputations, 251 
for initial surgery— 
of fractures, 72, 73, 74—76, 163 
of wounds of knee joint, 223 
for menisecotomy, 285 
relaxing, for wound closure, 163 
Indications for— 
amputation, 245, 246-247, 266-269, 270 
arthrotomy, 277 
changes of cast in closed plaster method of 
fracture management, 54 
external skeletal fixation, 207-210 
hip spica, in fractures of femur, 156 
internal fixation of fractures, 87, 128, 134, 
173, 197 
elective, 191, 200, 201, 202 
obligate, 190-191, 200, 201, 202 
resection of knee joint, 231, 236 
Infection: 
after amputation, 256 
as indication for—- 
amputation, 247, 266, 269, 270 
reamputation, 270 
in fractures, 66, 80, 81, 84, 103, 107 
after external skeletal fixation, 204 
after internal fixation, 186, 188 
control of, 72, 199 
in closed plaster method of fracture 
management, 55-57 
in World War I, 53 
of bones of foot, 183 
of bones of leg, 160, 175, 178 
of femur, 87, 139, 140, 142, 146, 148, 
149, 154, 156, 158, 159, 201 
of humerus, 123, 129, 132 
of radius, prevention of, 134 
of upper extremity, 116 
in wounds of— 
hip joint, 237, 238-241, 242-243 
knee joint, 49, 216, 217-221, 227, 231, 
235-237 
smaller joints, 244 
prevention of, 57, 103, 183, 186 
by initial surgery, 71, 73 
by utilization of reparative-surgery 
program, 64 
See also Sepsis. INDEX 
357 
Initial surgery, 14 
amputations at, 246 
in wounds of— 
hip joint, 237, 241, 242 
knee joint, 223-227, 235-236 
smaller joints, 243-244 
of fractures, 64—81 
appraisal of wound at, 71-72 
blood replacement in, 138 
evacuation following, 80 
first aid preceding, 66-67 
fracture management at, 80 
general principles and practices of, 72- 
74 
management of bone fragments at 78- 
79 
objectives of, 71 
of bones of foot, 181 
of femur, 138 
postoperative regimen after, 80 
preoperative preparation for, 67-71 
technical considerations in, 74—78 
timing of, 64-66, 72 
role of, in prevention of amputation, 268 
See also Debridement, Staged manage- 
ment. 
Injuries. See Fractures, Wounds, and special 
wounds. 
Interallied Surgical Conference, 1917—211 
Internal fixation of fractures, 86-91, 107, 187, 
188 
advantages of, 86, 87 
contraindictations to, 86, 128 
disadvantages of, 87 
indications for, 87, 126 
of bones of forearm, 134 
of bones of leg, 165, 170-173, 178 
of femur, 142-148, 153, 155-156 
of humerus, 126-129 
See also Delayed internal fixation, Plating, 
Screw fixation, and other specific tech- 
niques. 
Intestines, involvement of, in wounds of hip 
joint, 241 
Intra-abdominal wounds, associated with 
wounds of hip joint, 237 
Inverted-cone stumps in amputation, 251 
Irrigation in wounds of joints, 216, 223, 227, 
243 
Italy, 3, 4, 8, 13, 19, 20, 26, 121, 133, 139, 140, 
236, 243, 261 
Jergesen, Maj. Floyd H., 5 
Joint(s): 
fractures about, 57, 87, 185, 187 
loose bodies in. See Joint mice, 
wounds of, 211-244 
data on, methods of accumulation on, 28 
disposition of patients with, 295-298 
in civilian orthopedic practice, 212-213 
in Spanish Civil War, 213 
in World War I, 211-212 
initial surgery for, 64-81 
management of: 
administrative considerations in, 3-28 
evolution of, 3, 63, 214-231, 242-243 
objectives of, 7 
personnel required for, in general 
hospitals, 26-27 
resection in, 213 
responsibility for, 25 
See also specific joints. 
Joint mice: 
disposition of patients with, 286 
survey on management of, 276, 286-287 
theater policy on management of, 278 
Joldersma technique of balanced-suspension 
skeletal traction, 151-152 
Jolly, D. W., 213 
Kirschner wire, 142, 149, 182 
Knee: 
arthrotomy of, 277-278, 281, 286-287 
disabilities of, 271-272 
diagnosis of, 272-274, 283, 284 
disposition of patients with, 277-278, 
279, 280-281, 282-284, 286-287 
management of, 276-286 
disarticulations at, 261 
flexion contracture of, after amputation of 
lower leg, 253 
position of, in— 
emergency splinting, 35, 37, 39 
skeletal traction, 150, 152 
splinting after reparative surgery, 164 
transportation splinting, 40, 41, 49-52, 
227 
resection of, 210, 216, 221, 231, 235-237 
suppurative arthritis of, 215, 217-219, 227, 
236 
wounds of, management of, 8, 214-237 
Knee motion after- 
fractures of femur, 140, 142, 150. 151, 154, 
159, 197 
wounds of knee joint, 216, 221, 227 
LaPanne, 212 358 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Leg; 
amputation of, 253, 254, 262 
wound closure after, 253 
emergency splinting of, 35, 37-39 
fractures of bones of, 160-180 
associated with bone loss, 245 
blood replacement in management of, 68 
disposition of patients with, 298 
external skeletal fixation of, 207 
inadequate reduction of, 185 
transportation splinting of, 51-52 
See also Tibia, Fibula. 
Leghorn, 8 
Ligaments of knee, injuries to, policy on 
management of, 278, 281 
Ligation of blood vessels, at initial surgery, 74 
Linch, Maj. Albert O., 151 
Litter, use of, as operating table, 71 
Long arm plaster cast, 41 
Long bones: 
amputations through, 249 
fractures of, 87, 187 
disposition of patients with, 297, 298 
external skeletal fixation of, 207 
hematocrit values in, 82 
internal fixation of, survey on, 188-202 
Long leg plaster cast, 49, 51, 170, 173 
in wounds of knee joint, 216 
Loose bodies in joints: 
disposition of patients with, 286 
survey on management of, 276, 286-287 
theater policy on management of, 278 
Lower extremity: 
amputations of, 261, 262, 269, 270 
emergency splinting of, 35, 37-39 
transportation splinting of, 47-52 
See also Femur, Tibia, Fibula. 
Lymphangitis, 72 
Lyons, Maj. Champ, 63, 83 
Malalinement in fractures, persistent, 207 
Malingerers, 283, 289 
Malposition in fractures, 80, 159 
Malunion of fractures, 57, 198 
Management of fractures, 53-114 
at initial surgery, 80 
at reparative surgery, 86-103 
by delayed internal fixation, 185-202 
by external skeletal fixation, 203-210 
by internal fixation, 86-90 
closed plaster method in, 53-58 
concept of, 58, 114 
functions of fixed hospitals in, 63 
functions of forward hospitals in, 63 
in World War I, 53 
Management of fractures—Continued 
of bones of foot, 182-183 
of femur, 141-159 
favorable factors in, 141-142 
results of, 139-140 
unfavorable factors in, 142 
of fibula, 160-180 
results of, 173-180 
unfavorable factors in, 160-161 
of humerus, 122-130 
results of, 130-133 
of radius, 133-134 
results of, 135-137 
of tibia, 160-180, 188-189 
results of, 173-180 
unfavorable factors in, 160-161 
of ulna, 133-134 
results of, 135-137 
of upper extremity: 
favorable factors in, 116 
objective of, 115 
principles of, 116-117 
problems of, 115-116 
Management of noncombat orthopedic le- 
sions, 271-294 
diagnosis in, 272-274, 283 
surveys on, 272-294 
Management of wounds; 
associated with fractures— 
at initial surgery, 71-78 
at reparative surgery, 84 
of bones of foot, 181-182 
of bones of forearm, 133 
of bones of leg, 162-164, 175-179 
of femur, 148-149 
of humerus, 122-123 
of upper extremity, 117 
closed plaster method in, 53-58 
concepts of, 58, 113-114 
of joints, 211-244 
evolution of 3, 63, 214-231, 242-243 
in civilian orthopedic practice, 212-213 
in Spanish Civil War, 213 
in World War I, 211-212 
of ankle, 243-244 
of elbow, 243-244 
of hip, 242-243 
results of, 237-241 
of knee, 215-231 
in fixed hospitals, 216-221, 227 
in World War I, 223 
results of, 231-236 
of shoulder, 243-244 
of wrist, 243-244 INDEX 
359 
Manipulation, in management of— 
fractures, 81, 91, 185, 199, 271 
in closed plaster method, 56, 57 
of bones of foot, 182 
of bones of leg, 160, 165 
knee with injuries of semilunar cartilage, 
279, 283-284 
Manpower: 
as factor in disposition of patients, 295, 296 
loss of, from noncombat orthopedic lesions, 
271, 274 
Manual (s): 
Bandaging and Splinting, FM 8-50, 
1944—32 
First Aid for Soldiers, FM 21-11, 1943—32 
Guides to Therapy for Medical Officers, 
TM-8-210, 1942—213 
Military Medical Manual, 31 
Orthopedic Subjects (Military Surgical 
Manual), 1942—31, 213 
Soldiers Handbook, FM 21-100, 1941—32 
Splints and Appliances, 1917—31, 39 
Splints, Appliances and Bandages, FM 
8-50, 1940—31, 32 
March fractures, management of, 275 
Mead, Maj. Newton C., 148, 151, 271n, 280 
Mechanic’s waste, use of in hand injury, 8, 9 
Median nerve, 117, 127-128, 134 
Medical aidmen, 32, 33 
Mediterranean Base Section, 19, 277 
Medullary canal, cortical fragments in, 79 
Menisci, injuries of, 280, 281, 283 
disposition of patients with, 280-282 
management of, 221, 223, 276, 279 
Menisectomy, 284-285 
postoperative management after, 285-286 
Merano, 261 
Metacarpals: 
fractures of, disposition of patients with, 
298 
position of, in transportation splinting, 47 
Metatarsals, fractures of, 181-182 
disposition of patients with, 298 
Meyerding sacral rests, 39 
Modlin, Capt. John., 137, 146, 149, 151, 
152, 153, 155 
Mollin, Capt. Edwin L., 203, 211 
Morphine, administration of, as first-aid 
measure, 66-67 
Muscle tension in fracture of femur, 207 
Muscles; 
atrophy of, 283, 289 
damage to, as consideration in amputa- 
tion, 249 
Muscles-—Continued 
deficits of, 87, 187 
excision of, 73, 76-77 
methods for determining viability of, 77 
See also specific muscles. 
Naples, 4, 20, 63, 132, 139, 153, 158, 217, 
219, 238 
National Research Council, Division of 
Medical Sciences, Committee on Surgery, 
31 
Subcommittee on Orthopedic Surgery, 213 
Navy technique of balanced-suspension 
skeletal traction, 151-152 
Necrosis, 57 
as factor in determining level of amputa- 
tion, 249 
avascular, 293 
in fractures of bones of forearm, 133 
in fractures of humerus, 123 
of articular cartilage, in wounds of knee 
joint, 221 
of tissue, in fractures, 91, 93, 107 
pressure, protection from, in emergency 
splinting, 39 
Nerve and bone surgery in fractures of— 
bones of leg, 161 
humerus, 128-129, 132 
upper extremity, 116 
Nerves; 
injuries of, 72, 87, 116, 127-129, 130, 132, 
134-135, 141, 187, 196 
protection of, in splinting, 34, 117 
See also specific nerves. 
Neuropsyclnatric-orthopedic consultation, in 
management of noncombat orthopedic 
lesions, 272-273 
90-90-90 technique of balanced-suspension 
skeletal traction, 142, 152 
Nodules, avascular, 286 
Nonclosure of wounds— 
after initial surgery, 74, 77 
after reparative surgery, 91-103, 122, 123, 
148, 163-164, 175, 231 
Noncombat orthopedic lesions, 162, 181, 215, 
271-294 
diagnosis of, 272-274, 283 
disposition of patients with, 274 275, 277- 
284, 286-290, 297, 298 
hospitalization period after, 277-278, 2S0- 
282 
surveys on management of, 276-294 
theater policy on management of, 278-279 360 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Xonhealing of wounds, in fractures— 
after internal fixation, 192-202 
of bones of leg, 79, 178 
Nonunion of fractures, 57, 107, 292, 293 
after internal fixation, 192-202 
of bones of leg, 161 
prevention of, 87, 198 
Obletz, Maj. Benjamin E., 137n, 142, 152 
Olecranon process, fractures of, 87, 134 
Open circular amputation, 247-270 
directives on, 245, 247-249, 251-254, 257 
level of, 227-250 
reparative surgery after, 253-257 
technique of, 251 
traction after, 253, 256, 257 
statistics on, 260-270 
Open reduction of fractures, 86, 91, 122, 155, 
185. See also Internal fixation. 
Operating room, in general hospitals, 14 
Operating table, litter used as, 71 
Oran, 4, 19 
Orr, H. Winnett, 53 
Orthopedic sections, chief of; 
Classification of, 26 
duties of, 26, 27 
role of, in accumulation of data, 28 
Os calcis, 181, 183, 245. 
Osteoarthritis, as contraindication to arthro- 
tomy, 284 
Osteochondritis dissecans, 276, 277-278, 283, 
286-287 
Osteomyelitis, 185 
following external skeletal fixation, 204 
in fractures of humerus, 132 
Oxygen, administration of, before initial 
surgery, 68 
Pain; 
after fractures of bones of foot, 182 
in backs, 271-275 
in feet, 271-274, 275 
in old carpal scaphoid fractures, 293 
in wounds of knee joint, 231 
relief of, 32, 34, 66 
Parker, Maj. Joseph M., 115n, 137n, 160 
Patella: 
fractures of, 219, 221, 223 
defects of, disposition of patients with, 286 
dislocations of, policy on management of, 
278 
Patients: 
chain of evacuation for, 14 
disposition of, 272-273, 295-298 
after arthrotomy of joints, 278, 281, 
282-284 
Patients—Continued 
disposition of—Continued 
as consideration in elective surgery, 7 
as factor in assignment of orthopedic 
personnel, 12 
categories of, 276, 296 
Army Air Forces, 276-277 
considerations in, 66, 272-274 
with carpal scaphoid fractures, 290, 
293-291 
with fractures, 296, 298 
of bones of foot, 181, 183 
of bones of forearm, 137, 298 
of bones of leg, 164-165, 173, 298 
with joint mice, 286-287 
with knee disabilities, 278-279,280-283, 
284 
with painful backs, 274-275 
with painful feet, 275 
with shoulder dislocations, recurrent, 
288-290 
Penicillin, use of— 
in amputation, 253, 268 
in wounds of hip joint, 243 
in wounds of knee joint, 8, 217-221, 223, 
227, 231, 235 
role of, in reparative-surgery program, 63 
theater policy on, 10 
See also Antibiotic therapy. 
Periosteal stripping, in internal fixation of 
fractures, 86, 87, 91, 187, 195, 198 
of bones of leg, 170, 188, 199 
of femur, 146, 199 
of humerus, 126, 127, 129 
Peroneal nerve, damage to, 141, 162 
Personnel: 
assignment and utilization of, 5, 12-13, 15 
problems of, in management of bone and 
joint injuries, 4, 5, 6, 65 
use of— 
for initial surgery, 73 
for transportation splinting, 39, 40, 41 
in general hospitals, 26-27 
See also Surgeons, orthopedic. 
Petrolatum-impregnated gauze, 9, 55, 56, 78, 
182 
Physical therapy, as treatment for noncom- 
bat orthopedic lesions, 273, 274, 275, 288, 
293 
Physiologic salt solution, in testing for nerve 
damage in fractures, 128 
Pierson attachment to hinged half-ring leg 
splint, 150-152, 227 INDEX 
361 
Plasma transfusion: 
as first-aid measure, 67 
before initial surgery, 68, 70 
Plaster casts, 253, 293 
bivalving of, 49 
policy on, 40 
changing of, 55 
indications for, 54-55 
timing of, 54-56 
molding of, around arch of foot, 51, 164 
records of wound data on, 40 
splitting of, 49 
policy on, 40 
windows in, 43, 103, 227 
Plaster immobilization: 
after open circular amputation, 253 
after reparative surgery, 117 
in carpal scaphoid fractures, 292-293 
in closed plaster method of fracture man- 
agement, 53-58 
in fractures, 185, 271, 275 
of bones of foot, 182-183 
of bones of forearm, 133 
of bones of leg, 164-170, 173, 178 
of femur, 139, 156 
of humerus, 123, 126 
use of, with external skeletal fixation, 
207-208, 210 
in transportation splinting, 39-52, 242 
in wounds of hip joint, 242 
in wounds of knee joint, 216-217, 221, 227 
in wounds of smaller joints, 244 
Plaster room, equipment for, in general 
hospital, 15 
Plaster spica, 210. See also Hip spica, 
Shoulder spica. 
Plaster Velpeau, use of, in transportation 
splinting, 41, 43 
Plating of fractures, 87, 187, 198, 199 
advantages of, 86 
of bones of forearm, 134, 135, 202 
of bones of leg, 170-173, 188, 197, 199, 202 
of femur, 146, 199, 201 
of humerus, 126-128, 201 
results of, 192-196 
Pool, Eugene H., 211-212, 223 
Popliteal artery, protection of, in fractures 
of femur, 39 
Popliteal space, protection of, in splinting, 
49 
Position, Trendelenburg, in shock, 68 
Postoperative management— 
after initial surgery of fractures, 80 
after menisectomy, 285-286 
Postoperative management—Continued 
after reparative surgery of fractures, 103 
of bones of foot, 183 
of femur, 129-157 
of upper extremity, 117 
for wounds of knee joints, 231 
Preoperative preparation— 
for initial wound surgery, 67-71 
for reparative surgery, 82-83, 116-117,187 
Pressure dressings, 9, 66, 285 
Pressure sores, in closed plaster method of 
fracture management, 55 
Primary suture, delayed. See Wound 
closure, delayed primary. 
Prisoners of war, analysis of amputations on, 
261-270 
Psychological considerations in— 
amputation, 245 
disposition of patients, 297 
management of noncombat orthopedic 
lesions, 272-273, 279, 285, 287, 290. 
294 
Quadriceps exercises: 
after fractures of femur, 150, 153, 154 
after knee disabilities, 279, 284, 286 
Radial deviation of wrist, in splinting for 
carpal scaphoid fractures, 292 
Radial-nerve injuries, associated with frac- 
tures: 
of bones of forearm, 134 
of humerus, 130 
splinting for, 117 
statistics on, 127-128 
testing for, at initial surgery, 72 
Radial-nerve paralysis, transportation splint- 
ing for, 43, 47 
Radius: 
fractures of, 87, 115-117, 133-137 
blood replacement in management of, 68 
disposition of patients with, 137, 298 
emergency splinting for, 34 
external skeletal fixation of, 207-209 
infection in, 134 
internal fixation of, 134, 202 
management of bone fragments in, 134 
nerve injuries in, 116, 134-137 
plaster immobilization of, 133 
protection of function in, 134 
reconstructive surgery of, 134, 135 
reduction of, 57, 133-135 
reparative surgery of, 133-137 
skeletal traction in, 134 
tendon injuries in, 116 
transportation splinting for, 41, 43, 47 362 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Radius—Continued 
fractures of—Continued 
wound healing in, 134, 135 
wound management in, 117, 133 
involvement of, in fractures of humerus, 
129 
Rawles, Maj. Benjamin W., 160n, 21 In, 
245n 
Reconstructive surgery of fractures, 64, 134, 
137, 175 
considerations of, at reparative surgery, 
165, 166 
Rectum, wounds of, associated with wounds 
of hip joint, 237 
Rectus femoris muscle, 73 
Red Cross, 31 
Redebridement, in wounds of hip joint, 243 
Reduction of fractures, 57. 63. 64, 80, 107, 
271 
by delayed fixation, 185-202 
by external skeletal fixation, 203-210 
by internal fixation, 86-90 
by manipulation, 81, 91, 199 
by skeletal traction, 91, 139, 142-143, 
149-156, 159 
in closed plaster method of fracture 
management, 55-56 
of bones of foot, 182-183 
of bones of forearm, 133-134, 135 
of bones of leg, 160, 161, 165-173, 175, 179 
of femur, 139-140, 142-148, 149-157 
of humerus, 122, 123, 126, 129, 130 
Rehabilitation of patients with noncombat 
orthopedic lesions, 273, 277, 284, 287, 290 
Reparative surgery: 
after open circular amputation, 253-257 
appraisal of wound at, 84 
concept of, 81 
delayed internal fixation at, 185-202 
drainage at, 91-103 
golden period for, 81, 141 
holding period after 9, 63, 65, 83 
internal fixation at, 86-91, 107, 187, 188 
nerve and bone surgery as part of, 128-129 
nerve repair in, 116 
objectives of, 137, 186 
of fractures, 59, 81-114 
of bones of foot, 182, 183 
of bones of forearm, 133-135 
of bones of leg, 162-173 
of femur, 141-159 
of humerus, 122-130 
of soft-tissue wounds, 58-60, 61 
of wounds of knee joint, 227, 231-237 
Reparative surgery—Continued 
postoperative management after, 103, 117 
preoperative preparation for, 82-83, 116- 
117, 187 
revision of wound at, 84 
splinting after, 117 
technical considerations in, 83-103 
timing of, 65, 81, 116-117, 141, 162, 163, 
227, 236, 241 
wound closure in, 91-103 
See also Staged management. 
Reparative-surgery program: 
application of, to fractures, 61-64 
application of, to soft-tissue wounds, 58 
application of, to wounds of joints, 63, 223 
development of, 58-60 
holding period required for, 9, 63, 65, 83 
objectives of, 64 
survey of, by consultant in orthopedic 
surgery 7-12 
Resection of joints, 213, 243, 244 
of ankle, external skeletal fixation after, 
210 
of hip, 243 
of knee, 216, 221, 231, 235-237 
external skeletal fixation after, 210 
indications for, 231, 237 
Resuscitation; 
in preparation for initial surgery, 68-71 
emergency splitting as part of, 32 
in fractures of femur, 138 
Roentgenologic examination, 68, 72, 73, 82, 
86, 122, 153, 274, 279, 283-284, 287, 289, 
291-292, 293 
Roller bandage, 32, 34, 35, 41 
Rome, 8, 158 
Rovane, Capt. John W., 115n 
Rubber-tissue drains, 77, 103 
Russell traction, 152-153 
Sacral rests, 39 
Salerno, 4 
Scar formation— 
after amputation, 253 
in closed plaster method of fracture man- 
agement, 57 
in fractures, 64, 188 
of bones of leg, 160 
of femur, 139, 140, 159 
Sciatic-nerve injuries, statistics on, 141 
Screw fixation of fractures, 87, 187, 198 
advantages of, 86 
of bones of forearm, 134 
of bones of leg, 170-173, 178, 199 
of femur, 146, 197, 199 INDEX 
363 
Screw fixation of fractures—Continued 
of humerus, 122, 127, 129 
results of, 192-196 
2d Auxiliary Surgical Group, 249 
II Corps, 4 
Secondary surgery, in closed plaster method 
of fracture management, 56 
Secondary suture of amputation stump, 253 
Sedatives, use of, as first-aid measure, 67 
Semilunar cartilage, injuries of: 
disposition of patients with, 277-278, 282- 
283 
management of, 276, 278-279, 282 
See also Articular cartilage. 
Sepsis: 
after inadequate debridement, 73 
consideration of, in delayed primary wound 
closure, 59 
in fractures of femur, 153, 159 
in wounds of knee joint, 216, 221 
See also Infection. 
Sequestration in fractures, 91, 93, 107 
after delayed internal fixation, 195-196, 
198-201 
after periosteal stripping, 86 
of femur, 159 
of fibula, 160 
of humerus, 132 
of tibia, 160, 175, 188 
Serum protein, copper sulfate determina- 
tion of, 82 
Seventh U. S. Army, 4-5, 12, 51 
Shock: 
in fractures of femur, 138 
prevention of, by emergency splinting, 32 
recurrence of, 71 
resuscitation in, 68-71 
Shorbe, Maj. Howard B., 21 In 
Shortening of bone— 
in fractures, 187 
indications for, 87 
of bones of forearm, 135 
of bones of leg, 165 
of femur, 135 
of humerus, 126-127, 128-129 
in wounds of knee joint, 231, 236 
Shoulder: 
disarticulations at, 261 
dislocations of, 271-272 
diagnosis of, 272-274, 287, 289-290 
disposition of patients with, 288-290 
management of, 287-290 
immobilization of, in fractures of humerus, 
122-123 
Shoulder joint: 
emergency splinting of, 34 
involvement of, with fractures of humerus, 
122-126 
transportation splinting of, 41-46 
wounds of, management of, 243-244 
Shoulder spica, use of— 
in fractures of humerus, 123-127 
in transportation splinting, 41-46 
Sicily, 4, 13, 26, 47 
Simple fractures, 207, 271, 276, 290 294, 
296, 298 
Sinus formation in fractures, 93, 107 
of bones of leg, 175, 179 
of femur, 140, 158, 159 
of humerus, 132 
Sixth Army Group, 12 
Skeletal traction, use of: 
in closed plaster method of fracture man- 
agement, 56, 57 
in fractures, 9, 91, 185, 199 
of bones of forearm, 134 
of bones of leg, 166-170, 178 
of humerus, 123 
in wounds of hip joint, 242 
See also specific types. 
Skin; 
devitalized, excision of, at initial surgery, 
73, 76 
excoriations of, in closed plaster method 
of fracture management, 55 
preparation of, at initial surgery, 73 
Skin defects: 
avoidance of, 73 
in fractures of bones of leg, 164 
management of, at reparative surgery, 107 
Skin deficits, management of, at reparative 
surgery, 59 
Skin flaps, use of, 59, 93 
in fractures of— 
bones of forearm, 133 
bones of leg, 163, 164 
humerus, 129 
in wounds of hand, 74 
in wounds of knee joint, 223 
Skin grafts, 84 
after amputation, 253, 255 
split-thickness, 59, 133, 164 
Skin traction— 
after amputation, 251-253, 255, 256, 257 
by use of elastic cord, recommendation 
on, 8, 11 
in management of knee disabilities, 279 
in wounds of hip joint, 242 364 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Skintight plaster casts, 40 
Sling(s), 32, 33, 34, 35, 47 
Snyder, Col. Howard E. See Consultant 
in surgery, Fifth U. S. Army. 
Soft tissue: 
damage to, in fractures of— 
bones of foot, 181 
bones of leg, 165 
humerus, 123, 130 
loss of, in fractures, 87, 103, 185, 197, 199 
loss of, in wounds of knee joint, 223 
role of, in determination of level of am- 
putation, 247-249 
wounds of, management of, 103 
closure in, 58-60 
recommendations on, by consultant in 
orthopedic surgery, 8 
Soleus muscle, 73 
Spanish Civil War, 39, 53, 125, 164, 213 
Spica, plaster, 210. See also Hip spica, 
Shoulder spica. 
Splint (s); 
basswood, 32, 34 
elephant tusk, 43 
hinged full-ring arm, 32, 34, 41, 257 
hinged half-ring leg, 15, 32, 35, 37, 39, 47, 
51, 67, 253, 257 
with Pierson attachment, 150, 151, 152, 
227 
improvised, 32, 33 
plaster of pans, 253 
removal of, after amputation, 253 
requirement for, in forward areas, 14 
Tobruk, 8, 47, 49-51, 221, 227 
wire ladder, 32, 34, 251 
Splinting: 
after reparative surgery of fractures: 
of bones of foot, 183 
of bones of leg, 164 
of femur, 154 
of upper extremity, 114 
classification of, 29 
in World War I, 31 
manuals on, 31-32 
objectivesof, 29 
Splinting, emergency, 31-39 
equipment for, 32, 33 
inspection of, before initial surgery, 67 
objectives of, 32 
regional, 34-39 
timing of, 33 
training in, 31-32 
Splinting, transportation, 39-52 
equipment for, 39, 41 
objectives of, 40 
personnel required for, 40, 41 
regional, 41-52 
use of plaster in, 39-52 
Split-thickness skin grafts, 59, 133, 164 
Spondylolisthesis, disposition of patients 
with, 274 
Sprains: 
disposition of patients with, 295, 298 
in diagnosis of carpal scaphoid fractures, 
292 
Staged management, 63 
concept of, 84 
evolution of program of, 3, 53-64 
See also Initial surgery, Reparative sur- 
gery. 
Statistics; 
amputations, 254-257, 259, 260-270 
balanced-suspension skeletal traction, 152- 
153, 155 
blood replacement at initial surgery, 68 
carpal scaphoid fractures, 291-294 
delayed primary wound closure, 60 
fractures of—■ 
bones of foot, 180-181 
bones of leg, 162, 173, 175-178 
femur, 139-141, 158, 159 
humerus, 122, 130 
upper extremity, 115 
external skeletal fixation, 204-206 
hematocrit levels before reparative sur- 
gery, 82 
internal fixation, 146, 165, 192 
joint mice, 286-287 
knee disabilities, 276-284 
nerve injuries, 127-128, 134, 141, 162, 196 
nonbattle injuries, 162 
refractures, 197 
shoulder dislocations, 287-290 
wounding agents, 141, 162 
wounds of hip joint, 241 
wounds of knee joint, 215, 231-236 
Steinmann pin, 202 
Stockinet, use of, after amputation, 251, 253, 
257 
Strains of back, disposition of patients with, 
275 
Streptococcus infection, 57 
Stump, amputation, 253-260 
Subcommittee on Orthopedic Surgery, Com- 
mittee on Surgery, Division of Medical 
Sciences, National Research Council, 213 INDEX 
365 
Sulfonamide therapy: 
in closed plaster method of fracture man- 
agement, 57 
in wounds of knee joint, 216, 285 
See also Chemotherapy. 
Suppurative arthritis— 
of hip joint, 237, 242, 243 
of knee joint, 214, 215, 217-219, 227-231, 
236 
of smaller joints, 244 
Surgeon (s): 
general, 12, 13, 25, 26 
of Delta Base Section, 11 
of Fifth U. S. Army, 261 
of NATOUSA (MTOUSA), 189, 204, 
238, 280 
orthopedic, 4, 5, 6-7, 12-13, 25, 26, 28, 40, 
79, 173, 204, 245, 253-254, 257, 268, 
286, 296 
See also Personnel. 
Surgeon General, The, 253-254 
Surgical Consultants Division, Office of the 
Surgeon General, 189 
Sutures: 
for initial surgery, 74 
for reparative surgery, 9, 93, 117 
Synovial membrane, closure of— 
in wounds of knee joint, 216, 217, 219, 
221, 223 
in wounds of smaller joints, 243. 
Synovitis, as factor in disposition of patients 
with knee disabilities, 282 
T-fractures of humerus, 129 
Tarsus, fractures of, 181-183 
Technicians, orthopedic, 20, 27 
Ten don (s); 
coverage of, at reparative surgery, 93 
coverage of, in fractures of bones of 
foot, 281 
injuries of, in fractures of upper extremity, 
116 
sloughing of, in fractures, 91 
Tendonitis, in shoulder dislocations, 290 
Tetanus toxoid, 67 
Thigh; 
amputation in, 245, 253, 254 
emergency splinting of, 35, 37, 39 
transportation splinting of, 47-49 
wmiinds of, 73, 84 
Thomas splint, 51. See also Hinged half- 
ring leg splint. 
Thoracentesis, 43 
Thrombophlebitis in fractures of femur, 140 
Thrombosis, as indication for amputation, 
247 
Through-and-through wounds, 77 
Thumb, position of: 
in splinting, 43, 47, 292 
in testing for nerve injuries, 72 
Tibia, fractures of, 160-180 
blood replacement in management of, 68, 
162-163 
bone fragments in, 163 
bone loss in, 160, 165-170 
bone shortening in, 165 
closed plaster technique in management 
of, 163 
disposition of patients with, 173 
drainage in, 161, 163-164 
external skeletal fixation of, 165, 208, 209 
exposure of bone cortex in, 160, 161 
infection in, 160 
internal fixation of, 91, 165, 170-173, 188- 
189, 199, 201 
loss of tissue in, 161 
manipulation in, 160 
nerve and bone surgery in, 161 
nerve injuries in, 162 
nonunion of, 161 
plaster immobilization of, 164-170, 173 
reduction of, 57, 160, 161 
reparative surgery of, 162-180 
scar formation in, 160 
sequestration of, 160 
skeletal traction in, 160, 166-170 
statistics on, 161-162, 175-178 
transportation splinting for, 40, 41, 51 
union of, 160-161 
wound closure in, 161, 163-164 
wound healing in, 79, 160, 163 
wound management in, 162-164, 175-179 
Tibial nerve, 141, 162 
Timelag, from— 
initial surgery to reparative surgery, 65, 
81, 116 
institution of first-aid measures to initial 
surgery, 65 
wounding to— 
initial surgery, 72, 217, 241 
institution of first-aid measures, 65 
reparative surgery, 81, 117, 141, 162, 
163, 227, 236, 241 
Tobruk splint; 
precaution in use of, 51 
use of, in transportation splinting, 47, 49, 
51 
use of, in wounds of knee joint, 8, 221, 227 
396961°—57 25 366 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Toes: 
avoidance of hyperextension of, 51 
circulatory status of, determination of, at 
initial surgery, 80 
flexion of, in fractures of bones of leg, 164 
fractures of bones of, 181-182 
Tourniquet, use of— 
after menisectomy, 285 
at initial surgery, 67, 223 
during first aid, 66 
Toxemia, associated with wounds of— 
hip joint, 237 
knee joint, 216 
Traction: 
in transportation splinting, 39 
with Tobruk splint, 51 
See also specific types. 
Traction hitch, 34, 67 
Traction ward, in general hospital, 14 
T raining— 
in emergency splinting, 31, 32 
in military management of bone and joint 
injuries, 5, 6, 7 
Transfixion pins, use of, in closed plaster 
method of fracture management, 55 
Transfusion. See Blood replacement. 
Transportability of patients: 
after initial surgery, 81 
as factor in disposition, 295 
as factor in early reparative surgery, 65 
military considerations in, 64 
Transportation splinting. See Splinting, 
transportation. 
Trauma: 
as indication for amputation, 246, 249, 
264-266, 269-270 
operative; 
at initial surgery, 74 
at wound closure, 163 
from internal fixation, 86, 87, 143-146, 
187 
in menisectomy, 285 
Traumatic arthritis, in carpal scaphoid 
fractures, 293 
Trenchfoot, as indication for amputation, 
247, 262, 269 
Trendelenburg position, in shock, 68 
Triangular bandages, 32, 34 
Trueta, J., 53, 54, 213 
Tuberculosis, as indication for amputation, 
247 
T umors; 
bone, disposition of patients with, 274 
malignant, as indication for amputation, 
247 
Two-pin plaster technique, in management 
of fractures, 165, 170 
Two-wire method of balanced-suspension 
skeletal traction, 149-151 
U-type plaster cast, 43 
Ulna; 
fractures of, 115-117, 133-137 
blood replacement in management of, 
68 
bone fragments in, 134 
disposition of patients with, 137, 298 
emergency splinting for, 34 
external skeletal fixation of, 207, 208 
internal fixation in, 133-135, 202 
management of, 15, 17, 133-134 
nerve injuries in, 116, 134-137 
plaster immobilization in, 133 
reconstructive surgery of, 135, 137 
reduction of, 57, 133-137, 185 
reparative surgery of, 133-137 
skeletal traction in, 134 
statistics on, 115 
tendon injuries in, 116 
transportation splinting for, 41, 43, 47 
wound management in, 117, 133 
wound healing in, 133, 185 
involvement of, in fractures of humerus, 
129 
Ulnar-nerve injuries 
in fractures of bones of forearm, 134 
statistics on, 127-128 
testing for, 72 
Ulnar-nerve palsy, 117 
in fractures of humerus, 130 
Union of fractures, 87, 292-293 
after internal fixation, 186, 192-202 
concept of, 79 
in closed plaster method of management, 55 
of bones of leg, 160-161 
of femur, 154-155 
of humerus, 132 
Upper extremity: 
amputation of, wound closure after, 253, 
254 
emergency splinting of, 34 
fractures of bones of, 115-137 
blood replacement in management of, 
116-117 
external skeletal fixation of, 207 INDEX 
367 
Upper extremity—Continued 
fractures of bones of—Continued 
internal fixation of, 199 
management of, 115-117 
nerve injuries in, 116 
splinting after reparative surgery of, 117 
tendon injuries in, 116 
wound healing in, 116 
wound management in, 117 
See also Humerus, Radius, Ulna, 
transportation splinting of, 41, 43, 47 
Urinary bladder, wounds of, associated with 
wounds of hip joint, 237 
Vascular impairment, determination of, after 
initial surgery, 80 
Vascular insufficiency, as indication for am- 
putation, 246, 249, 266-269, 270 
Vascular status, appraisal of, at initial 
surgery, 72 
Vaseline gauze. See Petrolatum-impreg- 
nated gauze. 
Vastus lateralis muscle, 148 
Velpeau plaster cast, use of, in transporta- 
tion splinting, 41, 43 
War of the Rebellion, 212 
Ward officers, 26-27 
Wards, orthopedic: 
management of, in general hospital, 14 
traction, desirability of, in general hospital, 
14 
Webbing strap, 37 
Weight bearing— 
after disabilities of knee, 279 
after march fractures, 275 
after menisectomy, 286 
Willems method, 212, 216, 244 
Window edema, prevention of, 103 
Wire ladder splints, use of— 
after amputation, 251 
in emergency splinting, 32, 34, 35 
Wire-suture fixation of fractures, 87, 187, 
198, 199 
of bones of forearm, 134, 202 
of bones of leg, 170-173, 178, 199 
of femur, 146, 156, 199, 201 
of humerus, 122, 126, 127, 129, 201 
results of, 192-196 
World War I: 
management of bone and joint injuries in, 
53, 211-212, 223 
delayed primary wound closure in, 58 
responsibility for, 25 
splinting in, 31, 39 
statistics on fractures of femur in, 137-138 
Wound(s): 
access to, 182, 209, 210 
appraisal of: 
at initial surgery, 71-72 
at reparative surgery, 59, 84 
before initial surgery, 67-68 
circular, 74 
closure of. See Wound closure, 
dressing of, after initial surgery, 77-78 
nonclosure of. See Nonclosure of wounds, 
of calf, 73 
of hands, 8, 9, 74, 296, 298 
of joints, 211-244 
of rectum, 237 
of thigh, 73, 84, 151, 152 
of urinary bladder, 237 
revision of, at reparative surgery, 84, 103, 
107 
saucerization of, at initial surgery, 77 
through-and-through, 77 
unhealed, delayed internal fixation of frac- 
tures with, 185, 186 
See also specific regions and wounds. 
Wound closure: 
delayed primary, 9, 58-60, 63, 91-103 
by approximation of soft parts, 117 
by skin flaps, 59, 74, 129, 133 
by skin graft, 175 
by split-thickness skin grafts, 59, 133 
concept of, 58-59 
criteria for, 59 
effect of excisional surgery on, 84 
effect of holding period on, 83 
in fractures, 117, 123, 133, 149, 161, 
163-164, 175, 181, 186, 188 
in World War I, 58 
in wounds of hip joint, 242 
in wounds of knee joint, 221, 227, 231, 
235 
in wounds of smaller joints, 244 
objectives of, 93, 148 
partial, 163, 175 
results of, 103-114 
statistics on, 60 
primary, 58 
timing of, 65, 81 
Wound healing: 
after delayed primary wound closure, 59, 
60 
after external skeletal fixation, 205-210 
after internal fixation, 91, 186, 192-202 
by granulation, 55, 57, 59, 64, 91, 103, 139, 
159, 163, 175, 181 
concept of, 79 368 
ORTHOPEDIC SURGERY IN MEDITERRANEAN THEATER 
Wound healing—Continued 
effect of excisional surgery on, 84 
effect of holding period on, 83 
in carpal scaphoid fractures, 293 
in closed plaster method of fracture man- 
agement, 57 
in fractures, 79, 91, 116, 126, 130, 132-133, 
134, 140, 142, 155-156, 159, 160, 166, 
171, 173, 175, 178, 179-180, 186 
promotion of, 83, 183 
in reparative-surgery program, 64, 103-114 
in wounds of hip joint, 241 
in wounds of knee joint, 216, 221, 231 
in wounds of soft tissues, 58, 59-60 
of amputation stump, 255-257 
Wounding agents: 
determination of sites of entry and exit 
of, 71-72 
in amputations, 261-266, 270 
in fractures, 65-66, 73, 141, 162, 181 
in wounds of knee joint, 215 
Wrist: 
disarticulations at, 261 
position of; 
in splinting for carpal scaphoid frac- 
tures, 292 
in transportation splinting, 41, 47 
sprains of, as factor in diagnosis of carpal 
scaphoid fractures, 292 
wounds of, management of, 243-244 
X-ray. See Roentgenologic examination. 
Z-shaped incision, use of, at initial surgery, 
76, 163 
Zone of Interior, 4, 9, 20, 29, 63, 126, 127, 
129, 130, 132, 156, 158, 159, 165, 166, 
170, 173, 181, 183, 221, 236, 242, 254, 
257, 259, 271, 272, 274, 275, 276, 278, 
279, 280, 281, 282, 283, 286, 290, 293, 
295, 296, 297, 298 
amputation centers in, 245, 253 
followup study on delayed internal fixa- 
tion in, 185-202 
hospitals in, function of, 64, 115, 175 
U. S. GOVERNMENT PRINTING OFFICE: 1957 
For sale by the Superintendent of Documents, U. S. Government Printing Office, Washington 25, D. C. 
Price $4 (Buckram)