Splints and casts in the treatment of war injuries

Splints and casts in the treatment of war injuries

SPLINTS AND CASTS IN THE TREATMENT INJURIES OF WAR BOARDMAN MARSH BOSWORTH, M.D. BRONXVILLE, NEW YORK 0 one will question that the availabiIity an...

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SPLINTS AND CASTS IN THE TREATMENT INJURIES

OF WAR

BOARDMAN MARSH BOSWORTH, M.D. BRONXVILLE, NEW YORK

0

one will question that the availabiIity and proper use of splints and casts in the treatment of war injuries are important factors affecting morbidity and mortaIity. It is aIso a fact that many of our doctors who in civi1 practice rareIy or never had occasion to appIy a splint became familiar with them in the course of their war experiences. What happened then as regards the use of casts and spIints becomes understandabIe. The suddenIy expanded medical corps had to Iearn the hard way, by tria1 and error. Mistakes occurred earIy in the game but with accumuIating experience they were avoided, much was eliminated by directive and graduaIIy a good dea1 of e&entiaI standardization crept in. During the course of four war years in the army medica corps I worked at different times as surgeon in a Clearing Station, FieId HospitaI, SurgicaI HospitaI, Evacuation Hospital and numbered and named General HospitaIs. I soon Iearned that I had to adapt my civiIian fracture experience to the pecuIiar exigencies of war surgery with its mass production methods, Iong chain of evacuation, segmented treatment and division of surgical responsibiIity. Methods of spIinting and cast appIication which had proven valuable at home with one patient under the contro1 of one doctor in one hospita1 throughout the period of treatment couId not in most instances be used for wounded soIdiers who were cared for by dozens of different doctors, who faced a Iong tedious journey which ‘was pretty rough in spots and whose fractures, wounds and extremities were very easiIy Iost sight of in the constant shuffle and change from one hospita1 to another. Safety, simpIicity and security were the

N

criteria by which proposed spIints and casts were judged. It was a matter of the greatest good for the greatest number and a few methods which couId be readiIy standardized and uniformIy practiced had to be chosen, regardIess of the training or preference of any one man. NaturaIIy the requirements in one theatre or portion of it differed from those in another and a good deal of ffexibiIity in the approach to the probIem had to be preserved. In view of this the subject of spIints and casts in the treatment of war injuries can perhaps best be taken up under three genera1 headings: Emergency SpIinting, Transportation SpIinting and Definitive SpIinting, according to the particuIar echeIon of command which is u*nder consideration. EMERGENCY

SPLINTING

(BATTALION

AID

STATION)

Here, right in the so-caIIed “front Iines,” where the injury was sustained and the wounded man received his first medica aid, there existed, theoreticaIIy at Ieast, the goIden opportunity to prevent further shock and tissue damage by the inteIIigent spIinting of a major wound. I say “theoreticaIIy ” for unIess one has actua1Iy served as a BattaIion Aid man or worked closeIy with them he can not possibIy comprehend the variety and extent of the obstacIes and diffIcuIties that have to be overcome. Such things as weather (wind, rain, snow, hai1, fog, heat and coId) and terrain (mud, sand, rocks, bogs, woods, rivers and mountains) merely add to and complicate the mortar hazards of mines, booby traps, barbed wire, strafing, she11 and smaI1 arms fire which BattaIion Aid workers had to face. Then there were such tactica factors as rapid movements forward or back, communica385

386

American

Journal

of Surgery

Bosworth-SpIints

FIG. I. Improvised shouIder spica for compound badly commmuted eIbow fracture. Patient ready for sixty miIe evacuation from cIearing station the morning after surgery. This iIIustrates an error in cast technic which was not uncommon in the early days of field operation. The forearm shoufd have been much Iower and cIoser to the body so as to avoid interference with an overhanging stretcher; Maktar, Tunisia, February, I!+&?.

tion, transportation and suppIy which were constantIy changing. It was one thing to find a wounded G.I. at night-for the Iargest pairt of this work had to be done under cover of darkness-and quite another to appIy an adequate spIint in the fieId and carry a 173 to 200 pound soIdier back to our own Iines. Now as a matter of fact reguIation army haIfring spIints were usuaIIy avaiIabIe in the BattaIion Aid Station. Our medica corps men were we11 trained and highIy proficient in their appIication, and they used them whenever it was humanIy possibIe to do so. Of course, there were occasions when, due to extraordinary circumstances, regulation spIints were not to be had in the fieId. In a number of instances cIever improvisation by BattaIion Aid men achieved effective spIinting. The soIdier?s riffe was sometimes tied aIongside his broken Ieg with his belt and strips torn from his cIothing; or a broken arm was swathed to the body with his bIouse. Sticks and boards were simiIarIy pressed into service in

and Casts

SEPTEMBER. 194.6

FIG. 2. A, GoIdthwaite frame improvised in the field from crates and spring Ieaves of a jeep; Arzew, AIgeria, November, 1942. B, streamIined version of same quickly weIded by an ordnance outfit from scrap meta in the Iield; Feriana, Tunisia, April, 1943.

emergencies. Th ese were recognized as pureIy stopgap and temporary expedients but they were preferabIe to no atttmpt at immobiIization and they reff ected credit on the stretcher bearers. PIaster was not empIoyed forward of CIearing Stations and FieId HospitaIs where the primary major surgery was done. Not onIy was it physicaI1y impracticabIe but it was beIieved that wounds shouId not be encased in pIaster unti1 they had been rendered surgicaIIy cIean. So in WorId War II our reguIation army haIfring splint (successor to the Thomas spIint) proved itself a God-send to men in the BattaIion Aid and CoIIecting Stations. They had it, they knew how to appIy it and they used it. There can be no doubt of the great number of Iives and Iimbs which were preserved by this simpIe apparatus. TRANSPORTATION SURGICAL

SPLINTING

(PRIMARY

INSTALLATIONS

In this war most of the primary surgery was done in SurgicaI, FieId or Evacuation HospitaIs and it was in these instaIIations that more adequate methods of splinting had to be devised for purposes of* transpor’tation. Here was the first opportunity to empIoy a materia1 which could readiIy be adapted and moIded to the needs of the individua1 case. When the pressure was on, patients with fractures were operated

Bosworth-SpIints

and Casts

American ~~~~~~~or surgery

387

B

simple fracture tIf Iower third of humerus after three attempts at cIosed reduction and I-. 1 _.~ 1.. r T’ _’ . .T 7 I-T.-1 1.~: external spnntrng. B, same axer open reauctmn arm mxernal splrnrmg in rne Lone 01 Lommumcatmn. FIG.

3.

A,

upon and evacuated within twenty-four to forty-eight hours and they were usuaIIy at a hospita1 in the Zone of Communication for more definitive treatment within an added three to five days. So the haIfring spIint was in most instances repIaced after surgery by some simpIe form of pIaster spIint. As it was reaiized that his cast wouId usuaIIy be removed upon the patient’s arriva1 at a hospita1 further back, it was not eIaborated upon nor was vaIuabIe time Iost in an attempt to secure anatomic reduction of a fracture. Great attention, however, was paid to certain fundamenta1 points. AI1 casts were required to be we11 padded, especiaIIy over bony prominences such as tuberosities, condyIes and maIIeoIi. As has been previousIy stressed,’ the unpadded cast technic, whiIe efficient in certain skilIed hands, has no pIace in freId surgery. A corollary to this ruIe was the requirement that a11 circuIar casts and circuIar dressings about an extremity be spIit right down to the skin immediateIy after appIication. The importance of this simpIe precaution was attested by severa extremities which came to amputation soIeIy as a resuIt of circuIatory interference from sweIIing and edemj beneath an unsplit circuIar dressing. A rough Iine drawing in indeIib1e penci1 on the cast outIining the fracture with a few pertinent notes as to times of injury and treatment, by whom treated and the presence of additiona injuries was of great

vaIue to physicians under whose care the patient subsequentIy came. X-rays and medica records were not infrequentIy Iost or separated from the patient, and the added time taken to record on the cast itseIf the essentia1 data mentioned was we11 spent. Fractures of the humerus were usuaIIy immobiIized in a shouIder spica with the arm down and forward across the chest so as not to obstruct the aisIe of a crowded hospita1 train, pIain or ship and not to bump against an overhanging bunk or and stretcher. (Fig. I.) SpeciaI apparatus equipment was frequentIy Iacking in these forward instaIIations and shouIder spicas were commonIy applied with the patient’s back, shouIders and head supported on a broomstick placed IongitudinaIIy on the tabIe or stretcher beneath his spine. A modified GoIdwaite frame, however, could easiIy be improvised (Fig. 2) and it facilitated the procedure considerabIy. Exceptions had to be made when chest compIications contraindicated the use of a shouIder spica. In such cases anteroposterior “elephant tusk” pIaster spIints were used. These extended the fuI1 length of arm and forearm and across the front and back of the chest. They were heId in place with bandages, swathes or a modified VeIpeau. The hanging cast and modifications of it, which were employed in fixed hospita1 instaIIations in the rear, were used early in the war by field units but were Iater discarded

388

American Journal of Surgery

Bosworth-SpIints

A

and Casts

B

SEPTEMBER,

1946

C

FIG. 4. A, half ring spIint with wire traction for supracondytar fracture of femur. B and c, same, showing improved position as the result of pressure bandages appIied in the half ring spliht.

in favor of the shouIder spica as* they provided insuffIcient immobiIization during transportation and patients compIained of pain and discomfort. A simpIe circuIar cast beIow the eIbow suffIcied for most fractures of the radius or ulna; if both bones were broken, the cast was run up high on the arm which was then pIaced in a sling. Fractured carand phaIanges were paIs, metacarpaIs evacuated either in a simpIe cast or with basswood spIint protection, aIthough occasionaIIy when work was not pressing a traction spIint of one form or another was appIied. PeIvic fractures were encased in a doubIe hip spica. Better immobiIization was obtained by extending this cast from the Iower chest a11 the. way to the toes, with hips and knees in I o to 15 degrees flexion. This made a heavy buIky cast but one in which the patient was safe and comfortabIe. Care was taken to window the abdomen and perineum wideIy to provide for possibIe distention and bedpan faciIity. Conventiona types of body casts were used for the transportation of spine injuries from forward instaIIations. Due to the frequency of associated injuries of chest, abdomen and extremities, however, many compromises in the choice and form of spIint had to be made.

In the North African campaign, due chieff y to British enthusiasm, considerabIe interest was evoked in the Tobruk spIint for fractures of the femur and knee. TheoreticaIIy, this type of spIint permitted more comfortabIe transportation than the hip spica for both the patient and his stretcher bearers. The patient couId sit up and the cast was reIativeIy Iight. AIso, it did not protrude beyond the Iimits of the stretcher. EssentiaIIy this method consisted of traction in a halfring spIint with a Iong posterior moId and a Iight pIaster she11 from toes to thigh.l However, after a reasonabIe tria1 by experienced personne1 it was discarded in favor of a we11 appIied spica. In my experience the spica provided far better immobiIization of the fracture and greater comfort to the patient. One type of spIint was about as easy (or hard) to apply as the other. The spica was kept.Iow on the peIvis by tying in the we11 Ieg above the knee. A transverse wood strut was wrapped into the cast just above the knees. This braced the spica and was aIso of great use in Iifting and turning the patient. It was pIaced on the back of the cast for greater soIidity and did not interfere with the bedpan since it was we11 beIow the perineum. Fractures of both bones of the Ieg were put in a circuIar toe-to-thigh cast with the knee in IO to 15 degrees ffexion and the

Bosworth-SpIints

and Casts

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Journalof Surgery

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FIG. 3. This shows the inadequacy of a haIf ring spIint in the definitive treatment of massive shattering fractures of the femoraI shaft; a spica is preferable.

foot at 90 degrees. A below-the-knee cast sufficed for most singIe fractures of either tibia or fibuIa, for ankIe and for foot fractures. WhiIe the vaIue of adequate spIints in the transportation of fractures has been taken as a matter of course, their importance in the protection of massive soft tissue injuries of the extremities without bone damage was sIow in attaining the genera1 recognition that it deserved. AvuIsion, Iaceration and destruction of Iarge skin areas and muscIe bundIes occurred not infrequentIy. Posterior molds, sugar tongs and circuIar casts proved invaIuabIe in putting these tissues at rest and protecting them from further insuIt during transit to the rear. In the earIy days, foIIowing amputation in the fieId, muscIe countertraction was maintained in a reguIation haIfring spIint during evacuation. Later, a much more comfortabIe and effective method was adopted. The proxima1 portion of the stump, we11 away from the wound, was

encased in a temporary Iight circuIar plaster cuff with a wire Iadder Ioop incorporated in it for muscIe stabilization and eIastic traction through a stockinette. DEFINITIVE COMMUNICATION

SPLINTING

(ZONE

AND

OF

ZONE

OF

INTERIOR)

In this are incIuded the numbered Genera1 and Station HospitaIs in the Zone of Communication and named Genera1 Hospitals in the Zone of the Interior. Zone of Communication. For most patients the treatment in these instaIIations was definitive and the methods of spIinting used were in many respects those empIoyed in civiIian practice at home. Due to the fact, however, that there were such numbers of cases of any one common type of fracture, a certain amount of standardization and mass production in treatment methods was not onIy practicabIe but imperative. This again meant in Iarge measure spIinting by directive rather than by choice.

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American Journal of Surgery

Bosworth-SpIints

and Casts

SBPTEMBER, ,946

FIG. 6. A and B, haIf ring spIint with Kirschner wire traction for fractured femur. c and D, circuIar cast used simukaneously for severe fractures of tibia and fibuIa in the same extremity.

The use of any form of interna spIint (plates, screws, pins) was frowned upon and discouraged. I am satisfied that this was a good genera1 ruIe, but I believe that it shouId have been more ffexibIe and that exceptions couId profitabIy have been made with greater frequency in individua1 cases in which the surgeon was we11 quaIified and the facilities for postoperative care and rehabiIitation adequate. It is doubtIess

true that the resuIts of inter.naI spIinting were not in many instances as happy as those obtained in civilian practice but few men experienced in traumatic surgery wiI1 question the advisabiIity, for instance, of an open reduction and interna fixation of a simpIe fracture of the Iower third of the humerus which is stuck in maIposition and caqnot be repIaced by cIosed reduction. (Fig. 3.)

VOL.

LXXII, No.

Bosworth-SpIints

3

and Casts

39’

I3

A

FIG. 7. A, combined use of circular cast and wire traction fibuta. B, it was possibIe moderate traction.

American Journal of Surgery

to improve

the alignment

P. T., aged twenty-one, a FieId ArtiIIery gunner, sustained a simpIe fracture of the Iower third of the humerus in a jeep accident October 8, 1944. He was treated with a traction cast and three separate attempts were made to improve the position of the fragments by cIosed reduction under anesthesia. AI1 were unsuccessfu1. Open reduction, correction of the deformity and interna fixation with a 4 screw VitaIIium pIate were done on November I I, 1944, in a numbered genera1 hospital in the United Kingdom. At operation, as expected, the fragments were found to be united soIidIy with abundant caIIus which had to be removed before reduction was secured.

By having an interna spIint appIied in the Zone of Communication instead of the Zone of Interior, this Iad was saved weeks or months of proIonged convaIescence and rehabiIitation and the army profited to that extent. Without correction and internal splinting he wouId have been a compIete Ioss to the services as we11 as permanentiy handicapped. So there was, in my opinion, a rea1 need of the interna spIint in seIected cases certainIy as far forward as the Zone of Communication.

for shattered tibia and doubIe fracture of by wedging the cast whiIe maintaining

In generaI, good resuIts were obtained in the Zone of Communication by treating fractured humeri with a hanging cast in which were incorporated tapes for suspension and traction or by Kirschner wire traction in a reguIation haIfring splint. After six to eight weeks the fracture was usuaIIy frozen suffIcientIy for remova of pIaster and institution of physiotherapy or for evacuation of the patient in a shouIder spica to the Zone of the Interior. In the defmitive treatment of hand fractures in the Zone of Communication the resuIts achieved seemed poorer than for any other common type of fracture. This was due principaIIy, I beIieve, to two things: In the first pIace, the importance of function as opposed to anatomic reduction was not suficientIy understood and generaIIy appreciated. Too much attention was paid to 3pIints and tob IittIe to earIy motion regardIess of some bone deformity visibIe on the x-ray. SecondIy, a11too often these injuries were regarded as minor matters and their treatment was deIegated to the Iess experienced members of the staff.

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American Journal of Surgery

Bosworth-SpIints

These smaII fractures are not dramatic unIess one makes them so in his ownmind; it was aJI too easy to appIy a cast or a spIint and forget about them for a period of weeks. Towards the end of the war, however, when poor resuIts began to coIIect in impressive numbers, a rea1 effort was made to institute more functiona methods of treatment and to make hospita1 staffs more finger conscious. SpIints were then used very sparingIy and sometimes not at aI1. In the treatment of fractured femora and knees the reguIation army haIfring spIint with Kirschner wire traction was wideIy empIoyed. Traction was thus maintained unti1 the formation of sufficient caIIus to permit evacuation of the patient in a doubIe hip spica to the Zone of Interior. This method of spIinting permitted the use of accessory measures such as countertraction and pressure bandages _to improve alignment and position. (Fig. 4.) It aIso aided in preserving the function of neighboring joints during the proIonged period of treatment. In some instances, however, comminution of the bone was so severe and extensive (Fig. 5) or the condition of the soft tissues was such that encasement in a plaster spica was mandatory. Severe fractures of femur, tibia and fibuIa in the same extremity posed diffIcuIt and not infrequent problems. Encasement of the Ieg in pIaster and the appIication of Kirschner wire traction on the femur in a haIfring spIint provided a satisfactory soIution in some cases. (Fig. 6.) OrdinariIy, fractures of both bones of the Ieg were treated with Kirschner wire tr’action in a halfring spIint or were immobiIized in a toe-to-thigh cast. OccasionaIIy, a combination of the two methods, permitting maintenance of traction and

and Casts

S?%X%lBBR, ,916

wedging of the cast to improve aIignment, was empIoyed. (Fig. 7.) Zone of the Interior. In the named Genera1 HospitaIs at home methods of spIinting cIoseIy approximated those of civiIian practice and therefore need no eIaboration here. As wouId be expected, interna spIints were more freeIy empIoyed. By the time the patient arrived in the United States his physica condition, IocaI and generaI, was often we11 stabiIized and his moraIe improved. FaciIities for treatment and after-care were in some respects more adequate and better organized, and certainIy not Ieast in importance was minimization of the time eIement as an essentia1 factor affecting the type of treatment chosen. SUMMARY

The use of spIints and casts in the treatment of war injuries varied according to the particuIar echeIon of command in which they were required. In general, emergency spIinting was effected with the reguIation army haIfring spIint. For transportation foIIowing primary surgery pIaster was aImost universaIIy empIoyed. Definitive splinting in the Zone of Communication was accompIished by useof the haIfring spIint or pIaster, frequentIy by a combination of the two. Internal spIinting was, for the most part, reserved for the Zone of the Interior. Two points deserve especia1 attention; the use of splints in the protection of extensive soft tissue injuries during transportation and the abuse of spIints in the treatment of fractures of the hand. REFERENCE I. BOSWORTH, B. M.

Treatment of fractures in the combat area. Am. J. Surg., 60: 342-349, 1945.