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Ibo civilian casualties
Volume 2
Number 2
165
ABSTRACTS
half-way down the middle phalanx. These flaps are then turned through 180 ° and let into incisions made on the dorsum of the hand proximally from the interdigital web spaces. The donor defects on the fingers are then covered with thick split-skin grafts. The site and design of the flap allows good access to the metacarpophalangeal joint where capsulotomies and division of the collateral ligaments can be carried out as required under direct vision. The authors stress that local Z-plasties in the interdigital clefts are extremely unsatisfactory in dealing with scar contractures. They may indeed aggravate rather than relieve the local shortage of skirt and so prejudice severely any attempt at reconstructive work on the metacarpophalangeal joint itself. If more extensive resurfacing of the back of the hand and fingers is required the authors advise radical excision of all the scar and recovering of the hand and fingers with a cross-arm pedicle flap which is revolutionary in that the flap itself is deliberately made only as thick as a Wolfe graft (i.e., a full-thickness skingraft with no subcutaneous fat). The fact that such a flap cart give excellent results, without complications, is yet another example of science advancing by the death of dogma! According to the authors, and the clinical photographs confirm this, the skin-flap can stretch astonishingly and can easily permit immobilization of the metacarpophalangeal joints in flexion with the interphalangeal joints fully extended. The final results are excellent both from the functional and cosmetic standpoint. Any work needed in the interdigital clefts is done later by the method described in the earlier part of the paper. This is an important article, well illustrated, and deserves reading in the original. COt.SON, P., JANVIER, H., GANGOLPHE, M., and LAURENT, J. (1970), ' Burns on the Back of the Hand: Problems presented in the Secondary Repair of the Web Spaces ', Annls Chir. plast., 15, 14. Thumb Reconstruction This brief but interesting article from Portugal reviews the history and method of thumb reconstruction employed in the past, and describes 10 cases dealt with by tubed pedicle flap, bone-graft, and sensory island-flap. By doing this as a two-stage procedure the time for recovery has been shortened, and the results recorded are extremely good. Eight patients returned to their former occupation, 1 is still under treatment, and another is only engaged in light work. Sensibility was referred in 7 cases, but in 3 (including the recent one) sensibility was referred entirely to the donor finger. This is a brief but valuable paper, and well worth reading. DE OLrVEmA, J. C. (1970), ' Some Aspects of Thumb Reconstruction ', Br. J. Surg., 57, 85. Luxation of Extensor Tendons of the Hand According to the authors, dislocation of the extensor tendons over the metacarpophalangeal joints may be due to trauma, congenital anomalies, or degenerative processes. Two cases are described in which the subluxation was corrected by taking a strip from the radial margin of the extensor tendon, based proximally and looping this strip round the adjacent lumbrical tendon to correct the ulnar drift. Follow-up showed no return of symptoms of displacement in either case,
but the longest follow-up interval was only 20 months. Alternative methods of repair are reviewed. McCoY, F. J., and WINSKY, A. J. (1969), ' Lumbrical Loop Operation for Luxation of the Extensor Tendons of the Hand ', Plastic reconstr. Surg., 44, 142. Volkmann's Ischaemie Contracture after Seeonal Accidental self-administration of seconal intraarterially is reported in 3 drug addicts by Californian doctors. The clinical picture of severe burning pains in the forearm and hand along with swelling of the forearm is the same as occurs in intra-arterial injection of thiopentone in greater concentration than 2½ per cent solutions. The radial pulses were not affected. The severe painful swelling of muscles of the forearm with loss of function in the fingers and peripheral nerve palsies can be confused with cellulitis especially when a truthful history is not forthcoming at first. The pathology is believed to be due to the intense toxicity of the drug itself producing vasculitis in the arterioles with thrombosis. Early and extensive fasciotomy of the affected muscle compartments is indicated. MORGAN, N. R., and WAOGH, T. R. (1970), ' Volkmann's Ischaemic Contracture after Intraarterial Injection of Seconal ', J. Am. reed. Ass., 212, 476. An Artificial Finger-joint Artificial finger-joints at present in use are expensive, do not always possess a full range of movement, and sometimes lose their anchorage. A n artificial joint designed to overcome these disadvantages is described. It has been tried in dogs but not yet in man. CALNAN, J. S., and P~ls, N. D. (1968), ' T h e Development and Use of an Artificial Finger Joint ', Biomed. Engng, 3, 314.
WAR SURGERY Ibo Civilian Casualties The author dealt with 338 civilian casualties while working with the Child Medical Unit in Enugu. Communications were difficult, which meant that intervals of 2 or 3 days between wounding and admission to hospital were not unusual. The author summarizes his experience with the injuries of different parts of the body as well as describing the working conditions, which included widespread' subnutrition ' as he calls it. A mortality-rate of 6"3 per cent of all patients is a creditable performance in such conditions and reflects the high standard of care that included reliance on simple, well-tried remedies such as ' B i p p ' and Acriflavine, as well as internal fixation of open fractures in appropriate cases. Little blood was used because little was available; dextran and saline proved their worth and no patient was judged to have been lost for want of blood. Intravenous infusions needed more care than was always available. Anti-gasgangrene serum was not used and no gas gangrene was seen. Tetanus antitoxin was considered the most appropriate prophylactic agent in an unimmtmized population. Abdominal wounds, as usual, carried
166
INJURY-" THE BRITISH JOURNAL OF ACCIDENT SURGERY
the highest mortality--15 out of 72. The unsatisfactory attitude towards colostomy and ileostomy obliged the author to carry out primary closure of wounds of the colon, protected by washing out the belly with 1 litre of 20 per cent mercuric chloride, spraying Polybactrin liberally during closure and giving colistin, ampicillin, and erythromycin for 5 days afterwards. Three of 11 persons so treated died but not because of the way in which the colon was treated. A further interesting finding was that when the author was forced to use unabsorbable suture material the wounds healed at least as well as they did when catgut became available. This is an admirable record of fine work done in difficult circumstances. ODLING-SMEE, G. W. (1970), ' Ibo Civilian Casualties in the Nigerian Civil War ', Br. med. J., 2, 592.
Chest Injuries This study of a series of battle casualties proves to be very relevant to civilian trauma from modern high-speed cars and from stab wounds. Most problems of haemothorax, pneumothorax, and pulmonary contusion were successfully dealt with by closed tube thoracostomy and the advantages of this over thoracentesis are discussed. Open surgery was avoided in over 90 per cent of cases--the exception being uncontrollable bleeding. Unlike other war wounds, primary closure (with drainage) was advocated. Thoraco-abdominal wounds were treated by laparotomy plus closed tube thoracostomy rather than by a thoracotomy or a thoraco-abdominal incision. Treatment of the later stages (including the retained foreign body) is not discussed. VIRIGILIO, R. W. (1970), ' Intrathoracic Wounds in Battle Casualties ', Surgery Gynec. Obstet., 130, 609.
Amputation after War Wounds Of over 400 amputations, 60 per cent had been done primarily; 40 per cent were delayed. Factors influencing the decision to amputate in the delayed cases were, in order of frequency, infected wounds, the need for fasciotomy after vessel repair, missed injuries to vessels, failure to cover a vessel repair, primary closure of the wound, and late infection and haemorrhage at the site of a vascular repair. SCHMIa'r, J. H., jun., and ARMSTRONG, R. G. (1970), ' W o u n d s Causing Loss of Limb ', Surgery Gynec. Obstet., 130, 682.
Injury Oct. 197o
LIMB REPLACEMENT This is a quite outstanding article, and should be obligatory reading for all concerned in the management of trauma. The article reviews experimental work on limb replacement, and also reviews clinical work, with three tables, one of 15 replacements of complete amputations, one of 24 near-complete and physiological amputations, and another table of 12 limb replacement failures. The authors discuss the reasons for failure, classifying them as early due to shock, intermediate due to severe local infection, and late due to chronic infection, bone infection, muscle atrophy, contractures, and failure to restore sensation. The time lag between amputation and replacement must be less than 6 hours, unless there is prolonged cooling of the severed limb. The experimental work suggests that plasma loss in the sequestered limb was a potent cause of death, but this has not been proved clinically. The authors then proceed to generalizations on treatment, which are invaluable as a guide to those confronted with this emergency. They discuss in detail the technical problems of the operation, and divide them into phases : - 1. Shortening the limb. 2. Firm bone fixing. 3. Clearing circulation of distal limb. 4. Vein repair. 5. Arterial repair. 6. Nerve repair. 7. Soft-tissue approximation. 8. Skin closure. The w o r d ' d6bridement' is again incorrectly used to describe the excision of dead tissue, but otherwise this account would appear to be faultless. They discuss briefly the general management of the patient. The place of plasma, infusion, mannitol, low molecular dextran etc., and the importance of the elevation of the limb, fasciotomy if swelling and ischaemia appear, and early passive finger movements. They confine their observations to the upper limb, concluding that the replacement of the lower limb is not worthwhile except in rare occurrences, since prostheses are satisfactory, and the technical problems are almost overwhelming. They conclude with a case report with a successful outcome, but since the median and ulnar nerves were spared although abraded, the end-result was perhaps not typical. McNEILL, I. F., and WIt.SON, J. S. P. (1970), ' The Problems of Limb Replacement ', Br. J. Surg., 57, 365.
ERRATUM The Editor regrets that the review of Clinical Surgery, Volume 16: Neurosurgery published in INJURY,2, 73 was attributed to Mr. J. Potter but was in fact written by Professor Bryan Jennett.
Number 2
165
ABSTRACTS
half-way down the middle phalanx. These flaps are then turned through 180 ° and let into incisions made on the dorsum of the hand proximally from the interdigital web spaces. The donor defects on the fingers are then covered with thick split-skin grafts. The site and design of the flap allows good access to the metacarpophalangeal joint where capsulotomies and division of the collateral ligaments can be carried out as required under direct vision. The authors stress that local Z-plasties in the interdigital clefts are extremely unsatisfactory in dealing with scar contractures. They may indeed aggravate rather than relieve the local shortage of skirt and so prejudice severely any attempt at reconstructive work on the metacarpophalangeal joint itself. If more extensive resurfacing of the back of the hand and fingers is required the authors advise radical excision of all the scar and recovering of the hand and fingers with a cross-arm pedicle flap which is revolutionary in that the flap itself is deliberately made only as thick as a Wolfe graft (i.e., a full-thickness skingraft with no subcutaneous fat). The fact that such a flap cart give excellent results, without complications, is yet another example of science advancing by the death of dogma! According to the authors, and the clinical photographs confirm this, the skin-flap can stretch astonishingly and can easily permit immobilization of the metacarpophalangeal joints in flexion with the interphalangeal joints fully extended. The final results are excellent both from the functional and cosmetic standpoint. Any work needed in the interdigital clefts is done later by the method described in the earlier part of the paper. This is an important article, well illustrated, and deserves reading in the original. COt.SON, P., JANVIER, H., GANGOLPHE, M., and LAURENT, J. (1970), ' Burns on the Back of the Hand: Problems presented in the Secondary Repair of the Web Spaces ', Annls Chir. plast., 15, 14. Thumb Reconstruction This brief but interesting article from Portugal reviews the history and method of thumb reconstruction employed in the past, and describes 10 cases dealt with by tubed pedicle flap, bone-graft, and sensory island-flap. By doing this as a two-stage procedure the time for recovery has been shortened, and the results recorded are extremely good. Eight patients returned to their former occupation, 1 is still under treatment, and another is only engaged in light work. Sensibility was referred in 7 cases, but in 3 (including the recent one) sensibility was referred entirely to the donor finger. This is a brief but valuable paper, and well worth reading. DE OLrVEmA, J. C. (1970), ' Some Aspects of Thumb Reconstruction ', Br. J. Surg., 57, 85. Luxation of Extensor Tendons of the Hand According to the authors, dislocation of the extensor tendons over the metacarpophalangeal joints may be due to trauma, congenital anomalies, or degenerative processes. Two cases are described in which the subluxation was corrected by taking a strip from the radial margin of the extensor tendon, based proximally and looping this strip round the adjacent lumbrical tendon to correct the ulnar drift. Follow-up showed no return of symptoms of displacement in either case,
but the longest follow-up interval was only 20 months. Alternative methods of repair are reviewed. McCoY, F. J., and WINSKY, A. J. (1969), ' Lumbrical Loop Operation for Luxation of the Extensor Tendons of the Hand ', Plastic reconstr. Surg., 44, 142. Volkmann's Ischaemie Contracture after Seeonal Accidental self-administration of seconal intraarterially is reported in 3 drug addicts by Californian doctors. The clinical picture of severe burning pains in the forearm and hand along with swelling of the forearm is the same as occurs in intra-arterial injection of thiopentone in greater concentration than 2½ per cent solutions. The radial pulses were not affected. The severe painful swelling of muscles of the forearm with loss of function in the fingers and peripheral nerve palsies can be confused with cellulitis especially when a truthful history is not forthcoming at first. The pathology is believed to be due to the intense toxicity of the drug itself producing vasculitis in the arterioles with thrombosis. Early and extensive fasciotomy of the affected muscle compartments is indicated. MORGAN, N. R., and WAOGH, T. R. (1970), ' Volkmann's Ischaemic Contracture after Intraarterial Injection of Seconal ', J. Am. reed. Ass., 212, 476. An Artificial Finger-joint Artificial finger-joints at present in use are expensive, do not always possess a full range of movement, and sometimes lose their anchorage. A n artificial joint designed to overcome these disadvantages is described. It has been tried in dogs but not yet in man. CALNAN, J. S., and P~ls, N. D. (1968), ' T h e Development and Use of an Artificial Finger Joint ', Biomed. Engng, 3, 314.
WAR SURGERY Ibo Civilian Casualties The author dealt with 338 civilian casualties while working with the Child Medical Unit in Enugu. Communications were difficult, which meant that intervals of 2 or 3 days between wounding and admission to hospital were not unusual. The author summarizes his experience with the injuries of different parts of the body as well as describing the working conditions, which included widespread' subnutrition ' as he calls it. A mortality-rate of 6"3 per cent of all patients is a creditable performance in such conditions and reflects the high standard of care that included reliance on simple, well-tried remedies such as ' B i p p ' and Acriflavine, as well as internal fixation of open fractures in appropriate cases. Little blood was used because little was available; dextran and saline proved their worth and no patient was judged to have been lost for want of blood. Intravenous infusions needed more care than was always available. Anti-gasgangrene serum was not used and no gas gangrene was seen. Tetanus antitoxin was considered the most appropriate prophylactic agent in an unimmtmized population. Abdominal wounds, as usual, carried
166
INJURY-" THE BRITISH JOURNAL OF ACCIDENT SURGERY
the highest mortality--15 out of 72. The unsatisfactory attitude towards colostomy and ileostomy obliged the author to carry out primary closure of wounds of the colon, protected by washing out the belly with 1 litre of 20 per cent mercuric chloride, spraying Polybactrin liberally during closure and giving colistin, ampicillin, and erythromycin for 5 days afterwards. Three of 11 persons so treated died but not because of the way in which the colon was treated. A further interesting finding was that when the author was forced to use unabsorbable suture material the wounds healed at least as well as they did when catgut became available. This is an admirable record of fine work done in difficult circumstances. ODLING-SMEE, G. W. (1970), ' Ibo Civilian Casualties in the Nigerian Civil War ', Br. med. J., 2, 592.
Chest Injuries This study of a series of battle casualties proves to be very relevant to civilian trauma from modern high-speed cars and from stab wounds. Most problems of haemothorax, pneumothorax, and pulmonary contusion were successfully dealt with by closed tube thoracostomy and the advantages of this over thoracentesis are discussed. Open surgery was avoided in over 90 per cent of cases--the exception being uncontrollable bleeding. Unlike other war wounds, primary closure (with drainage) was advocated. Thoraco-abdominal wounds were treated by laparotomy plus closed tube thoracostomy rather than by a thoracotomy or a thoraco-abdominal incision. Treatment of the later stages (including the retained foreign body) is not discussed. VIRIGILIO, R. W. (1970), ' Intrathoracic Wounds in Battle Casualties ', Surgery Gynec. Obstet., 130, 609.
Amputation after War Wounds Of over 400 amputations, 60 per cent had been done primarily; 40 per cent were delayed. Factors influencing the decision to amputate in the delayed cases were, in order of frequency, infected wounds, the need for fasciotomy after vessel repair, missed injuries to vessels, failure to cover a vessel repair, primary closure of the wound, and late infection and haemorrhage at the site of a vascular repair. SCHMIa'r, J. H., jun., and ARMSTRONG, R. G. (1970), ' W o u n d s Causing Loss of Limb ', Surgery Gynec. Obstet., 130, 682.
Injury Oct. 197o
LIMB REPLACEMENT This is a quite outstanding article, and should be obligatory reading for all concerned in the management of trauma. The article reviews experimental work on limb replacement, and also reviews clinical work, with three tables, one of 15 replacements of complete amputations, one of 24 near-complete and physiological amputations, and another table of 12 limb replacement failures. The authors discuss the reasons for failure, classifying them as early due to shock, intermediate due to severe local infection, and late due to chronic infection, bone infection, muscle atrophy, contractures, and failure to restore sensation. The time lag between amputation and replacement must be less than 6 hours, unless there is prolonged cooling of the severed limb. The experimental work suggests that plasma loss in the sequestered limb was a potent cause of death, but this has not been proved clinically. The authors then proceed to generalizations on treatment, which are invaluable as a guide to those confronted with this emergency. They discuss in detail the technical problems of the operation, and divide them into phases : - 1. Shortening the limb. 2. Firm bone fixing. 3. Clearing circulation of distal limb. 4. Vein repair. 5. Arterial repair. 6. Nerve repair. 7. Soft-tissue approximation. 8. Skin closure. The w o r d ' d6bridement' is again incorrectly used to describe the excision of dead tissue, but otherwise this account would appear to be faultless. They discuss briefly the general management of the patient. The place of plasma, infusion, mannitol, low molecular dextran etc., and the importance of the elevation of the limb, fasciotomy if swelling and ischaemia appear, and early passive finger movements. They confine their observations to the upper limb, concluding that the replacement of the lower limb is not worthwhile except in rare occurrences, since prostheses are satisfactory, and the technical problems are almost overwhelming. They conclude with a case report with a successful outcome, but since the median and ulnar nerves were spared although abraded, the end-result was perhaps not typical. McNEILL, I. F., and WIt.SON, J. S. P. (1970), ' The Problems of Limb Replacement ', Br. J. Surg., 57, 365.
ERRATUM The Editor regrets that the review of Clinical Surgery, Volume 16: Neurosurgery published in INJURY,2, 73 was attributed to Mr. J. Potter but was in fact written by Professor Bryan Jennett.