Downloaded from http://jramc.bmj.com/ on March 20, 2017 - Published by group.bmj.com
J R Army Med Corps 1919;32:29–42
This paper describes the outcomes of 155 patients sustaining gunshot injuries to the femur and describes injury factors and management strategies which the authors believed affected the outcome of the injury. In this series, 22 patients died, there were 21 cases of gas gangrene, 14 injuries were intra-articular and 35 had sustained other wounds. Fifteen amputations were performed and 18 patients died from gas gangrene. This mortality is what we would have considered until very recently a surprisingly low rate, and is noteworthy because this paper was published the year after the introduction of the Thomas splint into military service in 1917. Sir Henry Gray estimated the mortality from compound femoral fractures earlier in the war to be around 80% but in 1917, he described a death rate of 15.6% in 1009 patients after the splint’s introduction.1 It is an interesting piece to read as it outlines the epidemiology and management strategies of these injuries at the closing stages of the war—by 1918, a great deal had been learned and medics, casualty clearing station doctors and field hospital doctors had evolved a standard of practice based on comprehensive exposure to war trauma. A minimally operative strategy is outlined; comprehensive descriptions of various forms of splintage are given with photographs, and a great deal of consideration is given to optimum reduction of the fractures sustained. The authors suggest skeletal traction as an aid to reduction, preferring calliper-type devices over Schanz pins, but also note the place of internal fixation and external fixation in fractures where skin traction or splintage are inadequate.
SUBSEQUENT INFLUENCE ON OPINION
equivocal3–5 but for a long time the dysfunction associated with sciatic nerve palsy was believed to mandate primary amputation.
The beam trammel was an early modern external fixator and its use as described in this paper upholds many of the principles adhered to today—spanning the zone of injury and ensuring aseptic pin placement, for example, remain mainstays of modern treatment. The description of this device as a reduction aid, seen alongside its picture, will be instantly recognisable to orthopaedic surgeons as the femoral distractor on today’s orthopaedic sets.
In terms of immediate management, it is no less appropriate now to apply a Thomas splint with traction. This is an effective means of controlling blood loss at the fracture site and reducing pain, both of which have a concomitant beneficial effect on cardiovascular stability.
The identification of sciatic nerve or femoral artery damage as a predictor of poor outcome and an indication for early amputation is a theme which developed and was expanded on throughout the century. Later on, Gustilo and Anderson would go on to classify open fractures with associated neurovascular compromise into the most severe group,2 recognising the poor outcomes associated with this. More recently, the argument over limb reconstruction versus amputation has become more
i18
This demonstrates recognition of an intrinsic principle of treating patients with multiple injuries; fixing limbs to improve the chest. A patient forced to remain supine or semirecumbent for weeks is likely to develop either venous thromboembolism or chest infections, and in an era without antibiotics, anticoagulation or advanced ventilation techniques this would have been rapidly fatal. Appreciating the balance of these factors is a question facing the trauma surgeon today—is this patient too sick to operate on or too sick not to be operated on? The emphasis on minimising internal fixation also continues today—open reduction and internal fixation entails soft tissue
Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
Downloaded from http://jramc.bmj.com/ on March 20, 2017 - Published by group.bmj.com
stripping, something the already compromised soft tissue environment can ill afford. Internal fixation would go on to be increasingly popular some decades later as surgeons such as Danis pioneered osteosynthesis, but the pendulum later came a long way back as the Arbeitsgemeinschaft für Osteosynthesefragen organisation produced an evidence base for when and how to use such techniques.
WHAT DO WE DO DIFFERENTLY NOW? It is timely to ask this question with two recent enduring operations involving many of these injuries and, at home, the adoption of the joint British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons standards for the management of open fracture care.6
preparing the intramedullary canal for nail insertion involves reaming, which provides a significant biological ‘jumpstart’ for fracture healing, and bone transport is possible over the nail if segmental loss needs to be addressed. Should a patient be left with a substantial bone defect, a number of options are available to the modern surgeon. The Masquelet technique10 is a two-stage procedure, the first of which is inserting an antibiotic-eluting spacer into a debrided wound and covering it, often with some form of flap. A pseudomembrane is allowed to form, creating a more biologically amenable environment, into which cancellous bone graft is implanted on explantation of the spacer. Circular frame management of bone loss also permits a number of strategies—in the 1970s, Western surgeons became aware of a surgeon from Belarus who was using external fixators to manage complex fractures to great effect. Ilizarov’s frames became more commonly used as surgeons visited to learn the techniques, and later the Taylor spatial frame joined the fold to offer even more flexible geometric corrections. Both these techniques offer either acute shortening with cortical distraction or segmental bone transport as a means of replacing a lost segment of bone.11 12
CONCLUSION An improved understanding of ballistics means that we would no longer be reassured by a high-velocity bullet injury—these entail a larger kinetic energy transfer, wider zone of injury and hence more disruption to the biological processes involved in fracture healing. The concept of an open fracture being merely a broken bone within an extensive soft tissue injury means that less splintered bone is significantly less relevant than the microvascular implications of high energy rounds on soft tissue. Something else done differently now relates secondarily to this approach— as the requirement for wider debridement and wound assessment has become appreciated, the defects left by surgery have necessarily become larger. Open management of open fractures has led to the development of a number of plastic surgical techniques to cover such defects, and more recently these have been accompanied by the use of vacuum-dressing systems to enhance drainage from the surgical site, maintain a clean environment and allow soft tissues time to settle prior to definitive coverage.
The esquillectomy described here refers to radical debridement of fragments of bone within the periosteal envelope. Modern thinking dictates preserving viable fragments—the ‘tug test’ permits removal of all devitalised fragments which are unlikely to contribute to healing and may serve as a nidus of infection but ensures retention of any fragments which may have a blood supply, and hence the resultant bone defect is no larger than it needs to be. Irrigation with brilliant green, a topical antiseptic agent, was mentioned in this article and written up separately by Massie for the Lancet in 1918,7 when he was in charge of a surgical team at a casualty clearing station—there exists now a consensus that continuous irrigation is unnecessary, and when performed with antibiotics potentially harmful.8 One of the workhorses of open fracture management is the intramedullary nail,9 beneficial on several fronts. The insertion point can be made outside the zone of injury, permitting access through healthy tissues and hence greater healing potential and less distorted anatomy. This also means the soft tissue envelope around the fracture site can be left undisrupted. The process of
This article gives the reader a snapshot of the routine management of gunshot wounds to the thigh, and an insight into limb reconstruction practices of the day. It is clear that, although practice has evolved, many core concepts were already well on the way to being understood. A better understanding of ballistic science completes this picture, and goes a long way to explain the shift away from bone and towards soft tissue when planning the management of high-energy open fractures.
THE AUTHORS Little can be traced of the authors of this article—Robert Massie FRCS Edin was gazetted as a temporary lieutenant on 20th August 1915, promoted to captain in August 1916, granted the acting rank of major in 1918 and by 1919 had been awarded the OBE. It appears from another gazette entry that he was serving with No. 47 General Hospital at the time this article was published, which was based in Le Tréport, near Dieppe in northern France. After the war, he appears to have gone into practice in Richmond, Surrey, as a notice of the dissolution of his partnership with Dr R Johnson was published in 1923. George Swanson graduated MB from Glasgow University and was promoted to captain shortly before the publication of this paper, in January 1918. Piers Page Correspondence to Maj Piers Page, Brighton and Sussex University Hospitals, Eastern Road, Brighton BN2 5BE, UK; [email protected] The original article can be found online as supplementary file. To view please visit the journal online (http://dx.doi.org/10.1136/jramc-2014-000292). Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
REFERENCES
Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
1
Robinson PM, O’Meara MJ. The Thomas splint—its origins and use in trauma. J Bone Joint Surg Br 2009;91:540–4.
i19
Downloaded from http://jramc.bmj.com/ on March 20, 2017 - Published by group.bmj.com
2
3
4 5
6
i20
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg 1976;58:453–8. Giannoudis PV, Harwood PJ, Kontakis G, et al. Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury 2009;40:213–19. Soni A, Tzafetta K, Knight S, et al. Gustilo IIIC fractures in the lower limb: our 15-year experience. J Bone Joint Surg Br 2012;94-B:698–703. MacKenzie EJ, Bosse MJ, Castillo RC, et al. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg 2004;86-A: 1636–45. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br 2006;88:351–7.
7 8
9 10 11 12
Massie R. Note on the treatment by brilliant green of recently inflicted gunshot wounds. Lancet 1918;191:635–6. Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds: a prospective, randomized study. J Bone Joint Surg 2005;87:1415. Chapman MW. The role of intramedullary fixation in open fractures. Clin Orthop Relat Res 1986;212:26–34. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthopedic Clinics of NA 2010;41:27–37. Dagher F, Roukoz S. Compound tibial fractures with bone loss treated by the Ilizarov technique. J Bone Joint Surg Br 1991;73:316–21. Rozbruch SR, Pugsley JS, Fragomen AT, et al. Repair of tibial nonunions and bone defects with the Taylor Spatial Frame. J Orthop Trauma 2008;22: 88–95.
Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
Downloaded from http://jramc.bmj.com/ on March 20, 2017 - Published by group.bmj.com
Piers Page J R Army Med Corps 2014 160: i18-i20
doi: 10.1136/jramc-2014-000292 Updated information and services can be found at: http://jramc.bmj.com/content/160/Suppl_1/i18
These include:
Supplementary Supplementary material can be found at: Material http://jramc.bmj.com/content/suppl/2014/05/20/160.Suppl_1.i18.DC1 References Email alerting service
This article cites 12 articles, 0 of which you can access for free at: http://jramc.bmj.com/content/160/Suppl_1/i18#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
J R Army Med Corps 1919;32:29–42
This paper describes the outcomes of 155 patients sustaining gunshot injuries to the femur and describes injury factors and management strategies which the authors believed affected the outcome of the injury. In this series, 22 patients died, there were 21 cases of gas gangrene, 14 injuries were intra-articular and 35 had sustained other wounds. Fifteen amputations were performed and 18 patients died from gas gangrene. This mortality is what we would have considered until very recently a surprisingly low rate, and is noteworthy because this paper was published the year after the introduction of the Thomas splint into military service in 1917. Sir Henry Gray estimated the mortality from compound femoral fractures earlier in the war to be around 80% but in 1917, he described a death rate of 15.6% in 1009 patients after the splint’s introduction.1 It is an interesting piece to read as it outlines the epidemiology and management strategies of these injuries at the closing stages of the war—by 1918, a great deal had been learned and medics, casualty clearing station doctors and field hospital doctors had evolved a standard of practice based on comprehensive exposure to war trauma. A minimally operative strategy is outlined; comprehensive descriptions of various forms of splintage are given with photographs, and a great deal of consideration is given to optimum reduction of the fractures sustained. The authors suggest skeletal traction as an aid to reduction, preferring calliper-type devices over Schanz pins, but also note the place of internal fixation and external fixation in fractures where skin traction or splintage are inadequate.
SUBSEQUENT INFLUENCE ON OPINION
equivocal3–5 but for a long time the dysfunction associated with sciatic nerve palsy was believed to mandate primary amputation.
The beam trammel was an early modern external fixator and its use as described in this paper upholds many of the principles adhered to today—spanning the zone of injury and ensuring aseptic pin placement, for example, remain mainstays of modern treatment. The description of this device as a reduction aid, seen alongside its picture, will be instantly recognisable to orthopaedic surgeons as the femoral distractor on today’s orthopaedic sets.
In terms of immediate management, it is no less appropriate now to apply a Thomas splint with traction. This is an effective means of controlling blood loss at the fracture site and reducing pain, both of which have a concomitant beneficial effect on cardiovascular stability.
The identification of sciatic nerve or femoral artery damage as a predictor of poor outcome and an indication for early amputation is a theme which developed and was expanded on throughout the century. Later on, Gustilo and Anderson would go on to classify open fractures with associated neurovascular compromise into the most severe group,2 recognising the poor outcomes associated with this. More recently, the argument over limb reconstruction versus amputation has become more
i18
This demonstrates recognition of an intrinsic principle of treating patients with multiple injuries; fixing limbs to improve the chest. A patient forced to remain supine or semirecumbent for weeks is likely to develop either venous thromboembolism or chest infections, and in an era without antibiotics, anticoagulation or advanced ventilation techniques this would have been rapidly fatal. Appreciating the balance of these factors is a question facing the trauma surgeon today—is this patient too sick to operate on or too sick not to be operated on? The emphasis on minimising internal fixation also continues today—open reduction and internal fixation entails soft tissue
Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
Downloaded from http://jramc.bmj.com/ on March 20, 2017 - Published by group.bmj.com
stripping, something the already compromised soft tissue environment can ill afford. Internal fixation would go on to be increasingly popular some decades later as surgeons such as Danis pioneered osteosynthesis, but the pendulum later came a long way back as the Arbeitsgemeinschaft für Osteosynthesefragen organisation produced an evidence base for when and how to use such techniques.
WHAT DO WE DO DIFFERENTLY NOW? It is timely to ask this question with two recent enduring operations involving many of these injuries and, at home, the adoption of the joint British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons standards for the management of open fracture care.6
preparing the intramedullary canal for nail insertion involves reaming, which provides a significant biological ‘jumpstart’ for fracture healing, and bone transport is possible over the nail if segmental loss needs to be addressed. Should a patient be left with a substantial bone defect, a number of options are available to the modern surgeon. The Masquelet technique10 is a two-stage procedure, the first of which is inserting an antibiotic-eluting spacer into a debrided wound and covering it, often with some form of flap. A pseudomembrane is allowed to form, creating a more biologically amenable environment, into which cancellous bone graft is implanted on explantation of the spacer. Circular frame management of bone loss also permits a number of strategies—in the 1970s, Western surgeons became aware of a surgeon from Belarus who was using external fixators to manage complex fractures to great effect. Ilizarov’s frames became more commonly used as surgeons visited to learn the techniques, and later the Taylor spatial frame joined the fold to offer even more flexible geometric corrections. Both these techniques offer either acute shortening with cortical distraction or segmental bone transport as a means of replacing a lost segment of bone.11 12
CONCLUSION An improved understanding of ballistics means that we would no longer be reassured by a high-velocity bullet injury—these entail a larger kinetic energy transfer, wider zone of injury and hence more disruption to the biological processes involved in fracture healing. The concept of an open fracture being merely a broken bone within an extensive soft tissue injury means that less splintered bone is significantly less relevant than the microvascular implications of high energy rounds on soft tissue. Something else done differently now relates secondarily to this approach— as the requirement for wider debridement and wound assessment has become appreciated, the defects left by surgery have necessarily become larger. Open management of open fractures has led to the development of a number of plastic surgical techniques to cover such defects, and more recently these have been accompanied by the use of vacuum-dressing systems to enhance drainage from the surgical site, maintain a clean environment and allow soft tissues time to settle prior to definitive coverage.
The esquillectomy described here refers to radical debridement of fragments of bone within the periosteal envelope. Modern thinking dictates preserving viable fragments—the ‘tug test’ permits removal of all devitalised fragments which are unlikely to contribute to healing and may serve as a nidus of infection but ensures retention of any fragments which may have a blood supply, and hence the resultant bone defect is no larger than it needs to be. Irrigation with brilliant green, a topical antiseptic agent, was mentioned in this article and written up separately by Massie for the Lancet in 1918,7 when he was in charge of a surgical team at a casualty clearing station—there exists now a consensus that continuous irrigation is unnecessary, and when performed with antibiotics potentially harmful.8 One of the workhorses of open fracture management is the intramedullary nail,9 beneficial on several fronts. The insertion point can be made outside the zone of injury, permitting access through healthy tissues and hence greater healing potential and less distorted anatomy. This also means the soft tissue envelope around the fracture site can be left undisrupted. The process of
This article gives the reader a snapshot of the routine management of gunshot wounds to the thigh, and an insight into limb reconstruction practices of the day. It is clear that, although practice has evolved, many core concepts were already well on the way to being understood. A better understanding of ballistic science completes this picture, and goes a long way to explain the shift away from bone and towards soft tissue when planning the management of high-energy open fractures.
THE AUTHORS Little can be traced of the authors of this article—Robert Massie FRCS Edin was gazetted as a temporary lieutenant on 20th August 1915, promoted to captain in August 1916, granted the acting rank of major in 1918 and by 1919 had been awarded the OBE. It appears from another gazette entry that he was serving with No. 47 General Hospital at the time this article was published, which was based in Le Tréport, near Dieppe in northern France. After the war, he appears to have gone into practice in Richmond, Surrey, as a notice of the dissolution of his partnership with Dr R Johnson was published in 1923. George Swanson graduated MB from Glasgow University and was promoted to captain shortly before the publication of this paper, in January 1918. Piers Page Correspondence to Maj Piers Page, Brighton and Sussex University Hospitals, Eastern Road, Brighton BN2 5BE, UK; [email protected] The original article can be found online as supplementary file. To view please visit the journal online (http://dx.doi.org/10.1136/jramc-2014-000292). Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
REFERENCES
Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
1
Robinson PM, O’Meara MJ. The Thomas splint—its origins and use in trauma. J Bone Joint Surg Br 2009;91:540–4.
i19
Downloaded from http://jramc.bmj.com/ on March 20, 2017 - Published by group.bmj.com
2
3
4 5
6
i20
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg 1976;58:453–8. Giannoudis PV, Harwood PJ, Kontakis G, et al. Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury 2009;40:213–19. Soni A, Tzafetta K, Knight S, et al. Gustilo IIIC fractures in the lower limb: our 15-year experience. J Bone Joint Surg Br 2012;94-B:698–703. MacKenzie EJ, Bosse MJ, Castillo RC, et al. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg 2004;86-A: 1636–45. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br 2006;88:351–7.
7 8
9 10 11 12
Massie R. Note on the treatment by brilliant green of recently inflicted gunshot wounds. Lancet 1918;191:635–6. Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds: a prospective, randomized study. J Bone Joint Surg 2005;87:1415. Chapman MW. The role of intramedullary fixation in open fractures. Clin Orthop Relat Res 1986;212:26–34. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthopedic Clinics of NA 2010;41:27–37. Dagher F, Roukoz S. Compound tibial fractures with bone loss treated by the Ilizarov technique. J Bone Joint Surg Br 1991;73:316–21. Rozbruch SR, Pugsley JS, Fragomen AT, et al. Repair of tibial nonunions and bone defects with the Taylor Spatial Frame. J Orthop Trauma 2008;22: 88–95.
Page P. J R Army Med Corps 2014;160(Supp 1):i18–i20. doi:10.1136/jramc-2014-000292
Downloaded from http://jramc.bmj.com/ on March 20, 2017 - Published by group.bmj.com
Piers Page J R Army Med Corps 2014 160: i18-i20
doi: 10.1136/jramc-2014-000292 Updated information and services can be found at: http://jramc.bmj.com/content/160/Suppl_1/i18
These include:
Supplementary Supplementary material can be found at: Material http://jramc.bmj.com/content/suppl/2014/05/20/160.Suppl_1.i18.DC1 References Email alerting service
This article cites 12 articles, 0 of which you can access for free at: http://jramc.bmj.com/content/160/Suppl_1/i18#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
