WAR WOUNDS OF THE EXTREMITIES*

COLONEL B. NOLAND CARTER anp MAJOR MICHAEL E. DEBAKEY,
MeEpIcaL Corps, UNITED STATES ARMY

Surgery Division. Office of the Surgeon General, United States Army, Washington, D. C.

Bees. a medico-military point of view, wounds
of the extremities are of great significance.
This is true primarily because they constitute
65 to 70 per cent of all wounds seen in Army Hos-
pitals in combat areas. In this connection, it is
interesting to note that the incidence of wounds of
the extremities in the Civil War was 70.8 per cent;
in World War I, 76.4 per cent; and thus far in World
War II, 73 per cent. Although the incidence of
wounds of the extremities in these wars are nearly
identical, in World War II such injuries, especially
to the lower extremities, are usually more severe.
This is due in part to the more violent explosives
used in this conflict, but it is particularly due to the
widely used land mine which causes extensive dam-
age when exploded by the tread of the soldier’s foot.
The extremity is literally pulpified by the terrific
explosion and can often be treated only by amputa-
tion. It is not uncommon to see patients with both
lower extremities seriously damaged. The fact that
a wounded man constitutes much more of a hindrance
to an army than a dead one further emphasizes the
military significance of these wounds. Wounds of
the extremities will be discussed under the headings
(1) soft tissues, (2) blood vessels, (3) nerves, (4)
bones and joints, and (5) wound infection.

SOFT TISSUES

While the fundamental principles of treatment of
war wounds are identical with those of all wounds,
certain conditions. in war preclude the use of some
surgical measures and necessitate modification of
certain others. All surgeons who have had ex-
perience in this war subscribe to the basic principle
of thorough debridement of wounds. The proper
performance of this procedure is the most important
step in the treatment of war wounds, certain reports
to the contrary notwithstanding. The heavier the
contamination of the soil of the battlefield, the more
important adequate debridement becomes. On the
other hand, wounds occurring in a relatively clean
environment, such as on shipboard or in airplanes,
may require less extensive debridement. In civil
life, the surgeon can spend as much time as is re-
quired to do the most thorough and meticulous
wound revision. When the press of work is not
great, the military surgeon can do likewise; however,
when casualties are heavy and the litter cases ac-
cumulate outside the operating room, the dictum of
the ‘greatest good for the greatest number” de-
mands a more expedient but perhaps less ideal de-
bridement. Having accomplished this important

fundamental in the surgical care of a wound in the
most approved manner, the civilian surgeon fre-
quently closes the wound by primary suture, be-
cause he has operated within the short time follow-
ing injury, has had access to a well appointed op-
erating room with adequate assistance, and can keep
his patient in one hospital for close supervision by
him and his staff for as long as is necessary. Under
such circumstances, primary closure is proper. Con-
sider the situation confronting the military surgeon
who, even under the best conditions, sees his patients
several hours after wounding and frequently not
until many hours have elapsed since the injury was
received; all wounds are contaminated ; the operating
room, though well equipped with instruments, may
be in a tent or in an improvised shelter; and the
patient, except in unusual instances, will not remain
long under supervision in the forward hospital,
since, in order to make room for incoming casualties
and to maintain mobility of such forward installa-
tions, he must be evacuated promptly to a hospital
farther back. The dangers of primary closure under
these circumstances are obvious and the principle of
leaving ail war wounds open after debridement is
sound and proper. Although a certain percentage of
war wounds can be closed successfully by primary
suture, the large number of disastrous complications
which will and do ensue after routine closure of these
wounds make it imperative to follow the rule of “no
primary closure of war wounds,” and yet this prin-
ciple of war surgery is too often not applied by sur-
geons recently arrived in battle areas, and they have
to observe the disastrous results following primary
closure to be convinced of their errors in judgment.

Certain facts concerning debridement have been
learned from the experiences of this war and deserve
emphasis. Tissue damage is frequently more exten-
sive than is apparent on the surface and, although the
wound looks innocent from the outside, there may
be considerable shattering and destruction of tissues
in its depths. For this reason, all wounds must be
thoroughly explored. This means adequate incisions
in skin and fascial planes in order that access may
be had to all parts of the wound. It does not mean
over-excision of skin, which is a common fault in
technique. When a wound is thus explored, it is
common to find beneath the small wound of en-
trance, foreign bodies, bits of clothing, hematomas,
devitalized muscle, and not infrequently, damage to
a major vessel. All devitalized and soiled tissue
having been excised, hemostasis is effected, and
vaseline gauze dressings are laid loosely in the wound.

*The subject “‘War Wounds of the Extremities” was presented by a representative of the Medical Corps, United States Army, at each of the twenty-
one War Sessions of the American College of Surgeons which were held in February, March, and April, 1944. The names of these representatives

and the War Sessions in which they participated are given on page 78 of this BULLETIN.
II7
118

Tight packing of a wound is comparable to primary
closure and must be avoided for this reason as well
as on account of its ‘‘tourniquet effect.’’ It has been
found wise to splint the part even in the absence of
fractures.

BLOOD VESSELS

Peripheral vascular injuries, especially those in-
volving major vessels, are particularly significant
complications of wounds of the extremities and oc-
cur much more frequently than is commonly real-
ized. This is shown by the fact that in one of the
vascular centers the number of operations now done
for traumatic aneurysm averages about twelve per
month. Various forms of injuries may occur, includ-
ing laceration of the vessel, partial or complete
severance, thrombosis, acute reflex vasospasm, false
aneurysm, and the subsequent development of ar-
teriovenous aneurysm. It is important to recognize
that the vasospasm is a natural response to those
forms of trauma which directly or indirectly affect
vascular structures, and it is therefore a common
occurrence in most of these injuries. Depending upon
a number of factors, it may involve only a small part
of the vessel, may spread to neighboring vessels of
the entire extremity, or may be generalized to involve
even larger areas of the body. Although it may be
considered a compensatory mechanism under certain
conditions, if continued it may lead to undesirable
and hazardous consequences. In cases in which the
actual traumatism to the tissues has already serious-
ly impaired their vitality, this vasospasm may be the
deciding factor upon which the life of the limb de-
pends. An additional consideration is the fact that,
in some cases, the resultant ischemia may be a con-
tributing factor in the development of gas bacillus
infection.

In.cases in which there is direct injury to major
vessels with laceration, partial or complete sever-
ance, or thrombosis, ligation will usually be neces-
sary. The repair of these injured vessels in such a
way as to maintain blood flow through them is rarely
feasible because of the conditions under which they
occur and must be handled, and because of the
character of the injury. Cleanly incised longitudinal
wounds which may be most successfully sutured, or
even incised transverse wounds which may be repaired
by end-to-end anastomosis or preferably by non-
suture tube techniques are only occasionally observed
in war injuries. For these reasons, the more prac-
tical and realistic procedure of ligation must usually
be employed. This should be done not by ligation
in continuity but by placing non-absorbable ligatures
well above and below the site of injury with excision
of the intervening damaged segment in order to
eliminate the dangers of secondary hemorrhage,
thrombosis and vasoconstrictor influences. Other
cases with thrombosis should be similarly ligated
following excision of the thrombosed segment. These
cases must be distinguished from localized seg-
mental spasm of the artery. In cases manifesting
this phenomenon, the limb is cold, pale, and pulse-

AMERICAN COLLEGE OF SURGEONS

less but evidence of hemorrhage or hematoma in-
dicating that the vessel has been lacerated may not
be present. This type of reflex vasospasm has ap-
peared in cases in which the site of the trauma was
remote from the vessels. Thus, a case has been
observed in which a shell fragment produced a wound
of entrance and exit on the lateral aspect of the right
calf at its midpoint. Although at operation the
wound track was found to be from 5 to 8 cm. from
the posterior tibial artery, complete spasm of this
vessel was observed. In some cases in which the
wound was immediately adjacent to the vessel,
which revealed no grossly visible injury, the artery
has been found in complete spasm. Still other cases
have been observed in which spasm has developed
following minimal manipulation of a simple frac-
ture. The degree of vasospasm varies considerably
from localized constriction with consequent minimal
ischemia to a more extensive and generalized involve-
ment, especially of the collateral circulation, with
sufficient ischemia to produce actual gangrene.
Moreover, the vasospasm may persist for periods as
long as or even longer than 48 to 72 hours.
Rational treatment in these cases is directed to-
ward counteracting vasospasm and producing maxi-
mum vasodilatation in the involved extremity. Since
the disturbance is apparently due to the develop-
ment of a vasomotor reflex initiated in the trauma-
tized tissues, and since vasoconstrictor impulses are
transmitted by way of the sympathetic nerve fibers,
interruption of these impulses in the circuit prevents
vasospasm and permits vasodilatation. This inter-
ruption may,be accomplished by debridement of
surrounding traumatized tissue, periarterial sympa-
thectomy, or procaine hydrochloride block of the
regional sympathetic ganglia. The last procedure is
considered the most effective method of producing
maximum vasodilatation in these cases and should
be employed in all types of peripheral vascular in-
juries accompanied by manifestations of vaso-
spasm. It may be necessary to repeat the sympa-
thetic block at least once or twice daily for several
days. Close observation is essential in cases with
injury of the major peripheral vessels and, for this
reason, these patients should be evacuated as soon
as possible after injury to installations with facilities
for the proper surgical care described above. They
should not be moved from these installations and
should not have plaster-of-Paris cast applied until
the danger of ischemia is past. Three vascular centers
have been established in General Hospitals in the
United States for the specialized treatment required
in the management of serious problems and com-
plications, such as traumatic aneurysms, associated
with peripheral vascular injury and disease. All
cases of this nature are sent to these centers, which
are especially staffed and equipped for this purpose.

NERVE TRUNKS

Injury to major nerve trunks occurs in from 12 to
15 per cent of all extremity wounds in this war. The
relative frequency, the protracted management, the
WAR WOUNDS OF

crippling effects, and the not too satisfactory results
of treatment of these injuries emphasize their im-
portance. The possibility of this complication should
always be considered and efforts directed toward
early diagnosis in order to facilitate proper evacua-
tion and the necessary early treatment. While it is
recognized that under war conditions primary
anastomosis of severed peripheral nerves is not gen-
erally feasible, it should be attempted if the nerve
ends are readily accessible and can be approximated
without tension. This should be done as an end-to-
‘end anastomosis with the ends to be united cut
at exactly right angles with a sharp scalpel. During
the suture, axial rotation should be avoided. Fine
silk or tantalum wire sutures should be employed
and the ends of the nerve coapted by simultaneously
pulling taut all the sutures which have been passed
through the epineurium only of both stumps. If
primary anastomosis is not possible, the injured
nerve ends should be identified and a sling suture of
fine stainless steel wire placed between them, or they
should be anchored with similar suture material to
the surrounding tissue in order to prevent retraction.
Metal suture material is advocated here because it
facilitates roentgenographic identification preceding
subsequent repair. In order to minimize the irrepar-
able degenerative changes that occur in the end-
plates of severed nerves, early repair of those nerves
is essential. For this reason, every effort is made to
evacuate these patients as soon as possible to the
neurosurgical centers in General Hospitals in the
United States where operative repair and the neces-
sary postoperative physiotherapy can be instituted.
At present, 18 neurosurgical centers are strategically
located, equipped, and staffed to provide the best
treatment available for these cases. Recent ex-
perience has shown that operative repair can be done
within a week to ro days after the wound has healed,
which is much earlier than was formerly thought
possible. This is particularly desirable since the
earlier the operation can be done, the better the end
result is likely to be. The use of tantalum wire for
suture material and tantalum foil for wrapping the
anastomosed nerve end is considered especially valu-
able because this metal element is relatively inert
and therefore produces minimal tissue reaction and
protects against intraneural and invading scar tissue
formation. Recent experience with the use of fibrin
film suggests that it may be more valuable for this
purpose. Because of the protracted recovery period
in these cases, careful postoperative care and follow-
up observations are essential in their proper manage-
ment and study. A program of this nature permit-
ting prolonged observation has been instituted in
the neurosurgical centers.

BONES AND JOINTS
Bone and joint involvements in wounds of the
extremities are among the most important com-
plications because of the protracted hospitalization
and disabilities which they cause especially if early
treatment has been inadequate. The difficulties in

THE EXTREMITIES 119

the ideal management of these cases are greatly in-
creased under war conditions. Moreover, the highly
destructive, shattering fractures with great loss of
bone substances commonly observed in such cases
emphasize further the problems encountered in their
treatment. For these reasons, efforts have been
directed toward prompt and proper management
along principles which, under war conditions, have
given the most satisfactory end results. In the for-
ward echelons the essential problem in the manage-
ment of wounds of the extremities is concerned
principally with the most expedient and comfortable
method of immobilization during evacuation. It
must provide adequate fixation for ambulance or
jeep transport over rough roads and, at the same
time, assurance that circulation of the extremities
will not be jeopardized or that additional soft part
injury will not be incurred. For fractures of the
femur about the knee and both bones of the leg
above the ankle, these desiderata are best met by
the use of the Army half-ring splints with the litter
bar, ankle strap, and five triangular bandages. Trac-
tion is effected for a short period of time by the ankle
strap or hitch about the ankle with the shoe on, but
prolonged use of this method is dangerous as it pro-
duces skin necrosis. Skin traction with the shoe off
is much safer, and this method has been found the
most satisfactory for evacuating these cases from the
first and second echelons to the Evacuation Hospital
or even to the General Hospital. Skeletal fixation
and skeletal traction in patients who are to be trans-
ported have resulted in much discomfort and in bone
infection in the pin wounds. These procedures may
rarely be used in the management of these cases in
the forward echelons when skin traction cannot be
used because of destruction of skin by burns or
trauma. Following adequate debridement in the
Evacuation Hospital, patients with fractures of the
shaft of the femur or tibia and fractures involving
the hip or knee joints are evacuated to the General
Hospitals in the Army half-ring splint with skin or
skeletal traction or in a padded plaster spica. In
this connection, the so-called “Tobruk” splint has
received favorable comment and is applied as fol-
lows: by means of traction, preferably skin traction,
the extremity is pulled down, a plaster cast is ap-
plied over the traction to the thigh and leg, a half-
ring splint is applied to which the traction is made
fast, the extremity and splint are wrapped by several
turns of plaster, and the cast is completely split.
Padded posterior and lateral wire ladder splints are
considered best for evacuating patients with frac-
tures of the ankle and foot. In transporting patients
with fractures of the humerus from the forward
echelons to the first hospital installation such as the
Evacuation Hospital, the Thomas arm hinged splint
with skin traction or the immobilization of the arm
to the side of the chest with a sling or Velpeau
bandage incorporating a padded external splint have
been found satisfactory. For evacuation from this
hospital to one further to the rear such as the Gen-
eral Hospital, the best method consists of a U-shaped
120

moulded plaster splint extending from the axilla
around the elbow and up the outer surface of the
arm and shoulder to the neck, supported by bandages
and a sling. For fractures of the elbow and upper
third of the forearm, immobilization is best effected
with the elbow flexed by the use of a posterior wire
ladder or moulded plaster splint extending beyond
the wrist and supported by a sling.

In the management of compound fractures in for-
ward echelons, adequate debridement is imperative
and the principles described above are followed.
Whereas internal metallic fixation is at times a
valuable procedure in the definitive treatment of
simple fractures, its application in the emergency
surgical treatment in these echelons is followed by
frequent complications and failures. For these rea-
sons, the more conservative principles of careful
debridement are advocated— leaving the wound open
and covering it with loosely placed fine mesh vase-
line gauze, followed by cast or splinting with skin
traction. The importance of properly padding and
completely bivalving all casts of the extremities
prior to evacuation is emphasized.

Penetrating wounds of the joints are also treated
by adequate debridement, removal of all loose
bone fragments, irrigation of the joint cavity, and
closure of the synovial membrane. The soft tissue
wound down to the sutured synovial membrane is
left open and is covered with loosely placed gauze.
Immobilization is obtained as previously described.

Because of the highly destructive and shattering
injuries incurred in this war, particularly from land
mines, cases requiring amputation have been rela-
tively frequent. In the performance of amputations
under war conditions, there has been an unfortunate
lack of familiarity with the principles of open am-
putation. The most common errors of judgment
have been concerned with unnecessary sacrifice of
tissue and with closure of the stump resulting in
osteomyelitis, gas gangrene, or other serious infec-
tions, or with a resulting stump that is too short for
satisfactory prosthetic fitting. All emergency am-
putations for trauma or infection should be per-
formed at the lowest level possible which permits
removal of all devitalized and contaminated tissue
regardless of stump length. Revision of the stump
in accordance with prosthetic considerations may be
subsequently performed. The open (guillotine) cir-
cular method, with severance of successive layers at
the level of retraction of the preceding layers is the
procedure of choice, and it should be kept in mind
that skin should not be needlessly sacrificed in order
to give a neat stump. The wound must be left open
and a vaseline dressing used. Skin traction to the
stump must always be immediately applied follow-
ing the amputation and must be continued until
healing occurs. The short flap-type open amputa-
tion may be done only in cases in which early evacua-
tion is not contemplated and subsequent closure at
the same installation is deemed possible, such as in
a General Hospital. As early as practicable after the
primary amputation, all major amputees are sent to

AMERICAN COLLEGE OF SURGEONS

General Hospitals designated as amputation centers
for revision of stump or fitting of prosthesis. Before
discharge from the Army, these patients are fitted
with a proper prosthesis and taught how to use it
and how otherwise to care for themselves.

WOUND INFECTIONS

All war wounds may be considered contaminated.
The degree of infection varies from minimal surface
involvement to actual invasive infection with re-
gional or generalized extension. Whereas the fre-
quency cannot be estimated accurately, the incidence
of serious infection, it is believed, has not been high.
The prevention and treatment of these infections
consist in the application of well-established prin-
ciples which have been repeatedly emphasized. In
this connection, the exact status of chemotherapy
has not been completely established. It may be
justifiably stated, however, that in the sobering
light of recent critical studies and more extensive
experience the widely heralded and perhaps over-
enthusiastic concept regarding the value of the sul-
fonamides in wound infection, which was expressed
earlier in the war, must now be considerably modi-
fied. Whereas many surgeons continue to frost the
wound with sulfanilamide, the beneficial effects of
the drug, when applied locally, are questioned by
careful observers. The critical surgeon, in our Army
and in the British Army, is beginning to veer away

‘from the local use of the sulfonamides and to rely

on their systemic effect to prevent general sepsis and
spreading infection. For this reason, it is recom-
mended that sulfadiazine, which is considered the
drug of choice, be administered by oral or parenteral
means at the earliest opportunity after injury and
continued postoperatively. At present, penicillin
appears to be the most promising bacteriostatic
agent in the control of wound infection and seems to
have great potentialities in military surgery. The
immunization program with tetanus toxoid and
the routine administration of a stimulating or
“booster”? dose immediately after wounding have
effectively controlled the occurrence of tetanus in
the United States Army. No case of tetanus has oc-
curred in American soldiers who have been properly
immunized and have received these tetanus toxoid
injections.

The most serious infection and the one which con-
tinues to be a grave problem is gas gangrene. Indeed,
the general incidence of gas gangrene thus far in this
war closely approximates that of the last war. On
the basis of extensive studies of anaerobic infections
of war wounds mong the British troops in the Mid-
dle East, MacLennon found that “neither in preven-
tion nor treatment has much advance been made in
the last 25 years’’ despite the fact that in this period
“the potency of antisera has at least been doubled
and the whole group of sulfonamide drugs intro-
duced.” Similarly, the incidence and mortality of
gas gangrene among our wounded have been in ac-
cord with these findings. These startling observa-
tions serve to emphasize the importance of this
WAR WOUNDS OF

problem especially in view of the increased possi-
bilities of anaerobic infection as fighting on the
highly fertilized soil of the European Continent
progresses. Since the mortality (40 to 50 per cent)
and the morbidity in established gas gangrene are so
high, the prevention of this complication is of the
greatest importance. Effective prophylaxis depends
upon an adequate realization of the factors and con-
ditions under which the disease is particularly liable
to develop. Since the underlying factor contributing
to the development of this grave infection is the
presence of anaerobic environment and spore-bearing
bacilli of the Clostridium group and of devitalized
tissue, preventive measures should be designed to-

THE EXTREMITIES 121

ward the removal of all tissue in which the circulation
is lost or dangerously impaired, the avoidance of
procedures that jeopardize the vascularity of the
affected part, such as unpadded, unsplit casts, tight
plugging of wounds, circular bandages, and tourni-
quets, and the provision for adequate drainage of the
wound. The prophylactic value of polyvalent gas
gangrene antitoxin has not been established clini-
cally, and its use is not recommended. The treatment
of established gas gangrene is directed toward con-
trolling the infection and combatting the toxemia.
This is best accomplished by the combined use of
surgery, antitoxin, sulfonamides, penicillin, and sup-
portive measures.