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Traumatic vasospasm and its relationship to wounds of the lower extremities
TRAUMATIC
VASOSPASM
TO WOUNDS
AND ITS RELATIONSHIP
OF THE LOWER JOHN
P.
HENRY,
hlercy
PENNSYLVANIA
T
HE casuaIties of modern war as we11 as the increased number of industria1 accidents in defense-booming mills and mines have stimulated renewed interest in the problem of wound heaIing. Gas gangrene, particularIy in wounds of the lower extremities, is one of the most dreaded complications of compound fractures. The struggle for its prevention, as well as for the control of other pyogenic infections of the soft tissues, of osteomyelitis and of deIayed and nonunion, has long called forth the best efforts of the finest medical minds. It is, therefore, with some reluctance, and only in view of existing world conditions, that I present the following conclusions at this time. Should this seem a premature report, I offer in mitigation the urgency of the moment and the hope that those interested in this fieId may receive it with sympathy and give it further study. It is my beIief that Iumbar sympathetic nerve block has a definite place in the routine treatment of compound fractures and severe wounds involving the Iower extremities. This conclusion is based on the reasonable supposition that any force sufficient to damage severeIy the tissues or to fracture heavy bones is sufficient to disturb the blood vesseIs, directIy or indirectly, by damaging the sympathetic nervous system and thus producing arterial spasms of varying degrees. Thus, I am convinced that many patients treated in the emergency rooms of large hospitaIs for compound fractures and other extensive wound the
Surgical Service and The before the annual meeting
VascuIar Clinic, of the Surgeons
M.D.
HospitaI
PITTSBURGH,
* From
EXTREMITIES*
damage to the extremities also suffer so7ne degree of traumatic vasospasm. Because of the importance of the visible injury, which may easiIy monopolize the attention of the physician at the time, such vasospasms have in the past gone unrecognized. My interest in the probIem of wound infection in traumatic cases has extended over a number of years. From 192; to 1936 at the Mercy Hospital a great number of such cases came to my attention; the majority were men who worked in coal mines. The incidence of gas gangrene among these injured miners was high, despite careful and studied attempts to prevent infection. More than fifty such cases came to my attention in that period. Our conclusion then was that best results could be obtained by early treatment of the wounds, carefu1 debridement, immediate fixation of fragments and immobilization of the part to prevent further destruction of muscle by sharp edges of the fractured bones. It was found that if the wounds were left open and packed loosely with gauze, infection was Iess likely to occur, and that when it did, it was less severe. Yet, despite these steps and an alertness to improve the technic whenever am1 wherever possible, it was obvious that the great problem of preventing infection was unsolved. The incidence of infection was still far too high for compIacency. Twelve vears of work in my clinic for vascular diseases of the lower extremities has made me acuteIy conscious of the various circulatory problems which confront the surgeon. It has been my experi-
hiercy Hospital, Pittsburgh, PennsyLvania. kxd Club, New Orleans, L.ouisiana, April 14, 1~~41.
19
in part
50
American.lournnlof Surgery
Henry-Traumatic
ence to see many severe cases of vascuIar spasm-severa the resuIt of direct trauma to Iarge vesseIs. It was not, however, unti1 one day when caIIed upon to treat a patient suffering from a compound fracture of the tibia and fibuIa in a hospital of a nearby town that the importance of traumatic vasospasm in reIation to traumatic wounds of the Iegs was cIearIy brought home to me. CASE I. I first saw the patient, a young adult, severa hours after the accident. He lay upon the operating table of the emergency room, suffering from a compound fracture of the tibia and fibula, with a large gaping wound extending from the knee to the ankle. AI1 muscIes were evuIsed and many structures exposed. The bones protruded from the wound. The skin was paIe and the tissues had a coId and cIammy feeI. The femora1 puIsations were present but faint. The popIitea1 puIsations were absent. There was no dorsaIis pedis puIse. The genera1 condition of the patient was fair; the degree of shock was sIight. After an intravenous injection of gIucose and saline, the patient was removed to the operating room. Sodium pentatho1 anesthesia was administered. After careful dkbridement of the destroyed tissue, the fractured bones were approximated and pIated. The wound was packed and IooseIy cIosed. LateraI pIaster spIints were appIied to the Ieg. The patient was then turned over, face down, and a paravertebra1 Iumbar sympathetic bIock was performed with 20 cc. of 2 per cent novoCaine. He was then sent to bed. Within about ten minutes, aIthough the exact time was not noted, the toes were quite pink, and the femoraI pulse was much more vigorous. (The popIitea1 puIse couId not be feIt because of the pIaster splints.) The patient made an entirely uneventful recovery. The fracture united in the norma length of time and the wound healed without complication.
In this case the traumatic vasospasm was obvious. However, the reIationship of the spasm to the wound, opened up to me a new Iine of thought. Was it not reasonabIe to suppose that in a11 serious wounds of the Iower extremities
Vasospasm
APRIL,1942
there is some degree of spasm, which, by diminishing the bIood suppIy to the part, gives the infecting organisms time to establish themseIves firmly? Such unrecognized vasospasms might be the reason why compound fractures of the extremities are so IikeIy to become infected. As Dr. Griffith’ points out, there is no better therapeutic “chemistry” to be introduced into a wound than that which nature produces from cIean muscIes and an adequate blood supply. Any procedure, within the reaIm of safety, which wouId increase the bIood suppIy to the injured part would be justified. By bIocking the sympathetic gangIia with novocaine, the vasomotor reff ex would be broken, the contraction of the artery released and the how of bIood to the part greatly accelerated. The technic of the Iumbar sympathetic bIock is comparatively simpIe, and if done carefuIIy can cause no possibIe damage to the patient. Ochsner and DeBakey2 perform it reguIarIy on out-patients when they wish to differentiate between arterial deficiencies due to organic disease and those due to vasospastic states. They point out that chemica1 bIock of the regiona sympathetic gangha is a conservative procedure in periphera1 vascuIar disease because of its efficacy, its simpIicity and its faciIity of performance. I was so stimuIated by the resuIts of the nerve bIock in the case described that when, Iess than a month Iater, a patient with soiI-contaminated compound fractures of both Iegs was admitted to my service I decided again to use the nerve block. CASE II. The danger of infection in this case was cIear since the patient, a boy seventeen years oId, empIoyed in a sIaughter-house, had been run over by a truck in the sIaughter-house yard. Not onIy had his cIothing been contaminated by the feces of the animaIs with which he worked, but portions of it had been ground into the wounds by the wheeIs of the truck. The patient’s left extremity suffered an extensive wound exposing Iarge groups of
NEW SERVES VOL. LVI, No. I
Henry-Traumatic
muscIe. The fracture was compound comminuted and a fragment of bone had been Iost. A compound fracture of the right leg was exposed by a wound Iess severe than the left. Both the limbs, as in the first case, were coId and clammy out of a11 proportion to the miId degree of shock which existed. The puIsations oft he femora1 vesseIs were weak and the popliteaIs and dorsalis pedes were not paIpabIe. This lad was taken to the operating room immediately. Both wounds were carefuIIy dtbrided and suIfathiazoIe was powdered over the extensive bvound on the left leg, whiIe none was used upon the wound of the right leg. The bones of the left leg were approximated and a Sherman bone pIate used to fix them in position. The fractured portions of the bone in the right leg were approximated but no pIate applied. Both wounds were lightly packed w-ith gauze and the wound edges Ioosely approximated. LateraI plaster spIints were appIied to both legs and in this instance the application of the splints was followed by a biIatera1 Iumbar sympathetic bIock. This boy made an uneventfu1 recovery. The wouncIs heaIed without any evidence of infection of soft tissue or bone. The boy left the hospita1 in I 20 days and five months afterward wxs able to walk without the aid of a crutch or cane. CASE III. A healthy young aduIt had faIIen thirty feet from a crane he was operating in a stee1 miI1. He suffered an extensive compound fracture involving the ankle joint. He was treated in preciseIy the same manner as in Case II namely, a carefu1 dkbridement within an hour after the accident, reduction of the fracture, loose closure of the wound, packing with dry gauze, appIication of pIaster spIints and a Iumbar sympathetic bIock. This patient also made an uneventfu1 recovery without infection. Several other compound fracture cases after these, although showing no marked evidence of arteria1 spasm, seemed to benefit by the paravertebra1 sympathetic block of the ganglia. It is a we11 recognized fact, as noted by both Kroh3 and Homans, that traumatic vasospasm is a definite entity. This vasospasm can exist, they point out, because of direct trauma to the vesseIs, or in many instances, as the result of disturbances to
Vasospasm
American Journal of Surgery
51
the IocaI vasomotor nerves which influence the functioning of these vessels. Perhaps the cause makes IittIe difference, since, in any case, a nervous mechanism in close relation to the vesse1 seems to have been set in motion. Homans aIso points out that traumatic arteria1 spasm may be brought on by a variety of injuries, incIuding fractures, blows, bullet wounds and stabs; and that although there is sometimes evidence of direct trauma to the arterial wall, almost as often the artery itself seems never to have been touched. Cases of acute arterial spasm resulting from fractures have been described by Montgomery and IreIandj and in these it was impossible to state whether the spasm was induced by direct trauma to the artery or whether by injury to the artery’s sympathetic nerve supply. It seems reasonabIe to contend that any force sufficient to damage severely the tissues or to fracture heavy bones is suflicient to disturb the blood vessels, directly or indirectIy, by damaging the sympathetic nervous system which controls the size of the Iumen and thus to produce arterial spasms of varying degrees, diminishing the bIood suppIy at the very time it is needed for healing of the wound. Spasms due to trauma Iast for hours, even for days. It is true that in a limb uncomplicated by an open Iesion or a fracture, there is as a rule, no complicated aftereffects from a traumatic vasospasm, although I have seen cases in which several toes became gangrenous and were lost as a resuIt of this type of injury. In compound fractures of the lower extremities, it appears that the vasospasm is a transitory thing and usually passes off itseIf in due time. However, the period of time necessary for nature automaticaIIy to release this spasm gives the infecting organisms time to estabhsh themselves firmly. The generaIized ischemia set up by the spasm promotes an excellent medium for bacteria1 growth. The nerve block
52
American Journal of Surgery
Henry-Traumatic
shortens the dangerous interim of diminished bIood suppIy by reIeasing a rich flow of bIood to the injured part at this critica time. Brown” has stated that wounds about the face invoIving bones that do not communicate with the ora cavity rareIy become infected. He attributes this rapid heaIing of bone in this region to the exceIIent bIood suppIy. Compound fractures invoIving the arm, whiIe they may become infected, do not present the same high incidence of infection as those of the Iegs; and again this may be attributed to a better bIood suppIy in that region. It seems to me, after observing and treating many compound fractures of the extremities, that reIease of the vasoconstrictor impuIses of the accompanying but usuaIIy unrecognized vasospasm may mean the difference between the successfu1 heaIing of wound and infection. I beIieve that many cases of osteomyeIitis, gas gangrene and other pyogenic infections of the soft tissues and possibIy aIso of deIayed and nonunion, couId have been prevented had we recognized the importance of traumatic vasospasm in its varying degrees of intensity in the extremities of those treated for serious wounds and compound fractures. AIthough the number of cases in this report is not great, the resuIts are so gratifying as to indicate that the Iumbar sympathetic nerve bIock has a definite pIace in effective therapeusis in compound fracture and severe wounds of the Iower extremities. TREATMENT
I suggest that adequate treatment of compound fractures of the Iower extremities is as foIIows: I. EarIy primary attention and a11 possibIe speed in getting the patient to the hospita1. As Kennedy7 states, “the Iength of time between the occurrence of the injury and the accompIishment of dkbridement is of aImost equa1 importance with the method empIoyed.” Satisfactory heaIing depends upon the treatment given a wound in the first few hours. There shouId
Vasospasm be carefu1 spIinting at the scene of the injury by the doctor in charge or by the first aid man. The best surgeons shouId be in the casuaIty cIearing stations and not behind the Iines, in the emergency rooms of hospitaIs and not beyond immediate caI1. Gone are the days when initia1 treatment consisted of a resident physician putting a steriIe dressing on the patient and sending him to bed to await the morning caI1 of the physician in charge. 2. CarefuI evaIuation of the patient’s genera1 condition and an estimate of the degree of shock. 3. If the patient’s condition permits, he shouId be taken to the operating room where, under the best avaiIabIe conditions, a11 destroyed tissue and extraneous materiaIs should be painstakingIy removed from the wound. The fracture shouId be approximated with as IittIe trauma as possibIe. We beIieve that a bone pIate shouId be used to fox the fragments in position unIess there is such digitation of the fracture ends that they can be approximated with a reasonabIe assurance that they can maintain their position. 4. At this point antiseptic drugs such as suIfathiazoIe may be sprinkIed into the wound. I, personaIIy, use SuIfathiazoIe, aIthough, as indicated in Cases I and II, in which one extremity served as a contro1, wounds seem to hea as we11 without it in compound fractures when the sympathetic nerve bIock is used. AIso, aIthough in treatment of open wounds the use of poIyvaIent anaerobic vaccines is common, I beIieve that they have no great importance and do not use them. 5. The wound shouId be very IooseIy cIosed and drainage insured by a packing of Ioose gauze. Permitting the air to enter the wound Iessens the chances of anaerobic growth. 6. Either a mouIded IateraI pIaster splint or a soIid cast shouId be appIied. I favor spIints as they enabIe the surgeon to examine the wound at wiI1 and do not necessitate the cutting of a window in the pIaster cast when such examination is
NI
\Y
SEHIES
VOL. 1.\‘1, No.
T
Henry-Traumatic
necessary. Also, as infIammation and swelling subsides, these lateral splints may be tightened and so maintain more complete fixation of the limb. As Eliaso$ points out, “a leg confined in a cast, after the swelling has subsided, very often rattles like a pea in a pod.” 7. The patient shouId then be turned on his side (the side opposite the fracture) and a novocaine bIock of the lumbar sympathetic ganglia performed. In cases of deep anesthesia, it is permissible to turn the patient upon his face. We feel that the vasospasm in compound fractures is a transient one and that 20 cc. of 2 per cent novocaine is sufficient to give the results sought. Technic of Lumbar Injection. A wheal is made about : cm. from the midIine opposite the second lumbar interspace. This faIIs close to the twelfth rib. Through this when1 more novocaine is injected into the muscular aponeurosis which is quite sensitive. A lumbar puncture needle or a No. 22 gauge needle shouId next be used. This is introduced at a right angle. Often it meets the tip of a transverse process. If so, it can be withdrawn and reinserted at a 45” angIe toward the \ertebraI body. If it strikes the body, it should be partialIy withdrawn and adjusted so as to pass the body completely t’or a distance of about two and one-half inches. There it should lie on the psoas muscle, just behind the aorta or inferior \.ena cava. At this point extreme care and caution should be used as it is possibIe to enter the vena cava. A carefuI pulling back of the plunger of the syringe wiI1 teI1 if it occurs. If this occurs (and it has happened to us), no difficulty follows. Twenty cc. of 2 per cent novocaine are infiItrated into the tissues at this point, which in itself should suffice. To be doubly sure, it is well to carry out the same procedure in the third interspace. In several of our cases I have injected 5 to IO cc. of go per cent alcohol
Vasospasm
American
Journal
of Surgery
53
with no results other than which we wished to obtain. SUMMARY I. The theory is advanced that some degree of traumatic vasospasm is suffered in all cases of compound fracture or serious wounds of the Iower extremities. 2. This theory is based on the supposition that any force sufficient to damage severely the tissues or to fracture heavy bones is sufficient to disturb the blood vessels, directly or indirectly, by damaging the sympathetic nervous system and thus producing arterial spasms of varying degrees. 3. Although the vasospasm passes off in due time, it is postulated that this period of diminished blood suppIy to the part gives the infecting organisms time to establish themseIves. 4. A Iumbar sympathetic nerve bIock, to prevent the interim of diminished blood suppI:\, is advocated as routine in the effective therapeusis of compound fractures and severe wounds of the lower extremities. 5. Several cases of severe compound fracture in which the nerve block was used with highly satisfactory results are described. REFERENCES
GRIFFITH, J. P. Surgical Lectures at University of Pittsburgh. DEBAKEY, MIWAEL. Pe2. OCHSNER, ALTON and ripheral vascular diseases. A critical survey of its SUr,~. conservative and radical treatments. Gynec. 4‘” Obst., 70: ro$$ 1940. 3. KROH, F. Quoted by Homans.’ Diseases of the Extrem4. HOMANS, JOHN. Circdatory ities. New York, 1939. The Macmillan Company. 5. MOWCOMERU, A. H. and IRELAW, J. Traumatic segmentary arterial spasm. J. A. :Lf. A., I 05: 1.
1741, 1935.
6. BROWN, JAMES BARRETT. Personal communication. ROBERT H. Present-day treatment of 7. KEWEDY, compound fractures. Ann. Surg., I 13: 942, 1941. Ixctures at University of 8. ELIASON, E. Surgicd Pennsylvania.
VASOSPASM
TO WOUNDS
AND ITS RELATIONSHIP
OF THE LOWER JOHN
P.
HENRY,
hlercy
PENNSYLVANIA
T
HE casuaIties of modern war as we11 as the increased number of industria1 accidents in defense-booming mills and mines have stimulated renewed interest in the problem of wound heaIing. Gas gangrene, particularIy in wounds of the lower extremities, is one of the most dreaded complications of compound fractures. The struggle for its prevention, as well as for the control of other pyogenic infections of the soft tissues, of osteomyelitis and of deIayed and nonunion, has long called forth the best efforts of the finest medical minds. It is, therefore, with some reluctance, and only in view of existing world conditions, that I present the following conclusions at this time. Should this seem a premature report, I offer in mitigation the urgency of the moment and the hope that those interested in this fieId may receive it with sympathy and give it further study. It is my beIief that Iumbar sympathetic nerve block has a definite place in the routine treatment of compound fractures and severe wounds involving the Iower extremities. This conclusion is based on the reasonable supposition that any force sufficient to damage severeIy the tissues or to fracture heavy bones is sufficient to disturb the blood vesseIs, directIy or indirectly, by damaging the sympathetic nervous system and thus producing arterial spasms of varying degrees. Thus, I am convinced that many patients treated in the emergency rooms of large hospitaIs for compound fractures and other extensive wound the
Surgical Service and The before the annual meeting
VascuIar Clinic, of the Surgeons
M.D.
HospitaI
PITTSBURGH,
* From
EXTREMITIES*
damage to the extremities also suffer so7ne degree of traumatic vasospasm. Because of the importance of the visible injury, which may easiIy monopolize the attention of the physician at the time, such vasospasms have in the past gone unrecognized. My interest in the probIem of wound infection in traumatic cases has extended over a number of years. From 192; to 1936 at the Mercy Hospital a great number of such cases came to my attention; the majority were men who worked in coal mines. The incidence of gas gangrene among these injured miners was high, despite careful and studied attempts to prevent infection. More than fifty such cases came to my attention in that period. Our conclusion then was that best results could be obtained by early treatment of the wounds, carefu1 debridement, immediate fixation of fragments and immobilization of the part to prevent further destruction of muscle by sharp edges of the fractured bones. It was found that if the wounds were left open and packed loosely with gauze, infection was Iess likely to occur, and that when it did, it was less severe. Yet, despite these steps and an alertness to improve the technic whenever am1 wherever possible, it was obvious that the great problem of preventing infection was unsolved. The incidence of infection was still far too high for compIacency. Twelve vears of work in my clinic for vascular diseases of the lower extremities has made me acuteIy conscious of the various circulatory problems which confront the surgeon. It has been my experi-
hiercy Hospital, Pittsburgh, PennsyLvania. kxd Club, New Orleans, L.ouisiana, April 14, 1~~41.
19
in part
50
American.lournnlof Surgery
Henry-Traumatic
ence to see many severe cases of vascuIar spasm-severa the resuIt of direct trauma to Iarge vesseIs. It was not, however, unti1 one day when caIIed upon to treat a patient suffering from a compound fracture of the tibia and fibuIa in a hospital of a nearby town that the importance of traumatic vasospasm in reIation to traumatic wounds of the Iegs was cIearIy brought home to me. CASE I. I first saw the patient, a young adult, severa hours after the accident. He lay upon the operating table of the emergency room, suffering from a compound fracture of the tibia and fibula, with a large gaping wound extending from the knee to the ankle. AI1 muscIes were evuIsed and many structures exposed. The bones protruded from the wound. The skin was paIe and the tissues had a coId and cIammy feeI. The femora1 puIsations were present but faint. The popIitea1 puIsations were absent. There was no dorsaIis pedis puIse. The genera1 condition of the patient was fair; the degree of shock was sIight. After an intravenous injection of gIucose and saline, the patient was removed to the operating room. Sodium pentatho1 anesthesia was administered. After careful dkbridement of the destroyed tissue, the fractured bones were approximated and pIated. The wound was packed and IooseIy cIosed. LateraI pIaster spIints were appIied to the Ieg. The patient was then turned over, face down, and a paravertebra1 Iumbar sympathetic bIock was performed with 20 cc. of 2 per cent novoCaine. He was then sent to bed. Within about ten minutes, aIthough the exact time was not noted, the toes were quite pink, and the femoraI pulse was much more vigorous. (The popIitea1 puIse couId not be feIt because of the pIaster splints.) The patient made an entirely uneventful recovery. The fracture united in the norma length of time and the wound healed without complication.
In this case the traumatic vasospasm was obvious. However, the reIationship of the spasm to the wound, opened up to me a new Iine of thought. Was it not reasonabIe to suppose that in a11 serious wounds of the Iower extremities
Vasospasm
APRIL,1942
there is some degree of spasm, which, by diminishing the bIood suppIy to the part, gives the infecting organisms time to establish themseIves firmly? Such unrecognized vasospasms might be the reason why compound fractures of the extremities are so IikeIy to become infected. As Dr. Griffith’ points out, there is no better therapeutic “chemistry” to be introduced into a wound than that which nature produces from cIean muscIes and an adequate blood supply. Any procedure, within the reaIm of safety, which wouId increase the bIood suppIy to the injured part would be justified. By bIocking the sympathetic gangIia with novocaine, the vasomotor reff ex would be broken, the contraction of the artery released and the how of bIood to the part greatly accelerated. The technic of the Iumbar sympathetic bIock is comparatively simpIe, and if done carefuIIy can cause no possibIe damage to the patient. Ochsner and DeBakey2 perform it reguIarIy on out-patients when they wish to differentiate between arterial deficiencies due to organic disease and those due to vasospastic states. They point out that chemica1 bIock of the regiona sympathetic gangha is a conservative procedure in periphera1 vascuIar disease because of its efficacy, its simpIicity and its faciIity of performance. I was so stimuIated by the resuIts of the nerve bIock in the case described that when, Iess than a month Iater, a patient with soiI-contaminated compound fractures of both Iegs was admitted to my service I decided again to use the nerve block. CASE II. The danger of infection in this case was cIear since the patient, a boy seventeen years oId, empIoyed in a sIaughter-house, had been run over by a truck in the sIaughter-house yard. Not onIy had his cIothing been contaminated by the feces of the animaIs with which he worked, but portions of it had been ground into the wounds by the wheeIs of the truck. The patient’s left extremity suffered an extensive wound exposing Iarge groups of
NEW SERVES VOL. LVI, No. I
Henry-Traumatic
muscIe. The fracture was compound comminuted and a fragment of bone had been Iost. A compound fracture of the right leg was exposed by a wound Iess severe than the left. Both the limbs, as in the first case, were coId and clammy out of a11 proportion to the miId degree of shock which existed. The puIsations oft he femora1 vesseIs were weak and the popliteaIs and dorsalis pedes were not paIpabIe. This lad was taken to the operating room immediately. Both wounds were carefuIIy dtbrided and suIfathiazoIe was powdered over the extensive bvound on the left leg, whiIe none was used upon the wound of the right leg. The bones of the left leg were approximated and a Sherman bone pIate used to fix them in position. The fractured portions of the bone in the right leg were approximated but no pIate applied. Both wounds were lightly packed w-ith gauze and the wound edges Ioosely approximated. LateraI plaster spIints were appIied to both legs and in this instance the application of the splints was followed by a biIatera1 Iumbar sympathetic bIock. This boy made an uneventfu1 recovery. The wouncIs heaIed without any evidence of infection of soft tissue or bone. The boy left the hospita1 in I 20 days and five months afterward wxs able to walk without the aid of a crutch or cane. CASE III. A healthy young aduIt had faIIen thirty feet from a crane he was operating in a stee1 miI1. He suffered an extensive compound fracture involving the ankle joint. He was treated in preciseIy the same manner as in Case II namely, a carefu1 dkbridement within an hour after the accident, reduction of the fracture, loose closure of the wound, packing with dry gauze, appIication of pIaster spIints and a Iumbar sympathetic bIock. This patient also made an uneventfu1 recovery without infection. Several other compound fracture cases after these, although showing no marked evidence of arteria1 spasm, seemed to benefit by the paravertebra1 sympathetic block of the ganglia. It is a we11 recognized fact, as noted by both Kroh3 and Homans, that traumatic vasospasm is a definite entity. This vasospasm can exist, they point out, because of direct trauma to the vesseIs, or in many instances, as the result of disturbances to
Vasospasm
American Journal of Surgery
51
the IocaI vasomotor nerves which influence the functioning of these vessels. Perhaps the cause makes IittIe difference, since, in any case, a nervous mechanism in close relation to the vesse1 seems to have been set in motion. Homans aIso points out that traumatic arteria1 spasm may be brought on by a variety of injuries, incIuding fractures, blows, bullet wounds and stabs; and that although there is sometimes evidence of direct trauma to the arterial wall, almost as often the artery itself seems never to have been touched. Cases of acute arterial spasm resulting from fractures have been described by Montgomery and IreIandj and in these it was impossible to state whether the spasm was induced by direct trauma to the artery or whether by injury to the artery’s sympathetic nerve supply. It seems reasonabIe to contend that any force sufficient to damage severely the tissues or to fracture heavy bones is suflicient to disturb the blood vessels, directly or indirectIy, by damaging the sympathetic nervous system which controls the size of the Iumen and thus to produce arterial spasms of varying degrees, diminishing the bIood suppIy at the very time it is needed for healing of the wound. Spasms due to trauma Iast for hours, even for days. It is true that in a limb uncomplicated by an open Iesion or a fracture, there is as a rule, no complicated aftereffects from a traumatic vasospasm, although I have seen cases in which several toes became gangrenous and were lost as a resuIt of this type of injury. In compound fractures of the lower extremities, it appears that the vasospasm is a transitory thing and usually passes off itseIf in due time. However, the period of time necessary for nature automaticaIIy to release this spasm gives the infecting organisms time to estabhsh themselves firmly. The generaIized ischemia set up by the spasm promotes an excellent medium for bacteria1 growth. The nerve block
52
American Journal of Surgery
Henry-Traumatic
shortens the dangerous interim of diminished bIood suppIy by reIeasing a rich flow of bIood to the injured part at this critica time. Brown” has stated that wounds about the face invoIving bones that do not communicate with the ora cavity rareIy become infected. He attributes this rapid heaIing of bone in this region to the exceIIent bIood suppIy. Compound fractures invoIving the arm, whiIe they may become infected, do not present the same high incidence of infection as those of the Iegs; and again this may be attributed to a better bIood suppIy in that region. It seems to me, after observing and treating many compound fractures of the extremities, that reIease of the vasoconstrictor impuIses of the accompanying but usuaIIy unrecognized vasospasm may mean the difference between the successfu1 heaIing of wound and infection. I beIieve that many cases of osteomyeIitis, gas gangrene and other pyogenic infections of the soft tissues and possibIy aIso of deIayed and nonunion, couId have been prevented had we recognized the importance of traumatic vasospasm in its varying degrees of intensity in the extremities of those treated for serious wounds and compound fractures. AIthough the number of cases in this report is not great, the resuIts are so gratifying as to indicate that the Iumbar sympathetic nerve bIock has a definite pIace in effective therapeusis in compound fracture and severe wounds of the Iower extremities. TREATMENT
I suggest that adequate treatment of compound fractures of the Iower extremities is as foIIows: I. EarIy primary attention and a11 possibIe speed in getting the patient to the hospita1. As Kennedy7 states, “the Iength of time between the occurrence of the injury and the accompIishment of dkbridement is of aImost equa1 importance with the method empIoyed.” Satisfactory heaIing depends upon the treatment given a wound in the first few hours. There shouId
Vasospasm be carefu1 spIinting at the scene of the injury by the doctor in charge or by the first aid man. The best surgeons shouId be in the casuaIty cIearing stations and not behind the Iines, in the emergency rooms of hospitaIs and not beyond immediate caI1. Gone are the days when initia1 treatment consisted of a resident physician putting a steriIe dressing on the patient and sending him to bed to await the morning caI1 of the physician in charge. 2. CarefuI evaIuation of the patient’s genera1 condition and an estimate of the degree of shock. 3. If the patient’s condition permits, he shouId be taken to the operating room where, under the best avaiIabIe conditions, a11 destroyed tissue and extraneous materiaIs should be painstakingIy removed from the wound. The fracture shouId be approximated with as IittIe trauma as possibIe. We beIieve that a bone pIate shouId be used to fox the fragments in position unIess there is such digitation of the fracture ends that they can be approximated with a reasonabIe assurance that they can maintain their position. 4. At this point antiseptic drugs such as suIfathiazoIe may be sprinkIed into the wound. I, personaIIy, use SuIfathiazoIe, aIthough, as indicated in Cases I and II, in which one extremity served as a contro1, wounds seem to hea as we11 without it in compound fractures when the sympathetic nerve bIock is used. AIso, aIthough in treatment of open wounds the use of poIyvaIent anaerobic vaccines is common, I beIieve that they have no great importance and do not use them. 5. The wound shouId be very IooseIy cIosed and drainage insured by a packing of Ioose gauze. Permitting the air to enter the wound Iessens the chances of anaerobic growth. 6. Either a mouIded IateraI pIaster splint or a soIid cast shouId be appIied. I favor spIints as they enabIe the surgeon to examine the wound at wiI1 and do not necessitate the cutting of a window in the pIaster cast when such examination is
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necessary. Also, as infIammation and swelling subsides, these lateral splints may be tightened and so maintain more complete fixation of the limb. As Eliaso$ points out, “a leg confined in a cast, after the swelling has subsided, very often rattles like a pea in a pod.” 7. The patient shouId then be turned on his side (the side opposite the fracture) and a novocaine bIock of the lumbar sympathetic ganglia performed. In cases of deep anesthesia, it is permissible to turn the patient upon his face. We feel that the vasospasm in compound fractures is a transient one and that 20 cc. of 2 per cent novocaine is sufficient to give the results sought. Technic of Lumbar Injection. A wheal is made about : cm. from the midIine opposite the second lumbar interspace. This faIIs close to the twelfth rib. Through this when1 more novocaine is injected into the muscular aponeurosis which is quite sensitive. A lumbar puncture needle or a No. 22 gauge needle shouId next be used. This is introduced at a right angle. Often it meets the tip of a transverse process. If so, it can be withdrawn and reinserted at a 45” angIe toward the \ertebraI body. If it strikes the body, it should be partialIy withdrawn and adjusted so as to pass the body completely t’or a distance of about two and one-half inches. There it should lie on the psoas muscle, just behind the aorta or inferior \.ena cava. At this point extreme care and caution should be used as it is possibIe to enter the vena cava. A carefuI pulling back of the plunger of the syringe wiI1 teI1 if it occurs. If this occurs (and it has happened to us), no difficulty follows. Twenty cc. of 2 per cent novocaine are infiItrated into the tissues at this point, which in itself should suffice. To be doubly sure, it is well to carry out the same procedure in the third interspace. In several of our cases I have injected 5 to IO cc. of go per cent alcohol
Vasospasm
American
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with no results other than which we wished to obtain. SUMMARY I. The theory is advanced that some degree of traumatic vasospasm is suffered in all cases of compound fracture or serious wounds of the Iower extremities. 2. This theory is based on the supposition that any force sufficient to damage severely the tissues or to fracture heavy bones is sufficient to disturb the blood vessels, directly or indirectly, by damaging the sympathetic nervous system and thus producing arterial spasms of varying degrees. 3. Although the vasospasm passes off in due time, it is postulated that this period of diminished blood suppIy to the part gives the infecting organisms time to establish themseIves. 4. A Iumbar sympathetic nerve bIock, to prevent the interim of diminished blood suppI:\, is advocated as routine in the effective therapeusis of compound fractures and severe wounds of the lower extremities. 5. Several cases of severe compound fracture in which the nerve block was used with highly satisfactory results are described. REFERENCES
GRIFFITH, J. P. Surgical Lectures at University of Pittsburgh. DEBAKEY, MIWAEL. Pe2. OCHSNER, ALTON and ripheral vascular diseases. A critical survey of its SUr,~. conservative and radical treatments. Gynec. 4‘” Obst., 70: ro$$ 1940. 3. KROH, F. Quoted by Homans.’ Diseases of the Extrem4. HOMANS, JOHN. Circdatory ities. New York, 1939. The Macmillan Company. 5. MOWCOMERU, A. H. and IRELAW, J. Traumatic segmentary arterial spasm. J. A. :Lf. A., I 05: 1.
1741, 1935.
6. BROWN, JAMES BARRETT. Personal communication. ROBERT H. Present-day treatment of 7. KEWEDY, compound fractures. Ann. Surg., I 13: 942, 1941. Ixctures at University of 8. ELIASON, E. Surgicd Pennsylvania.