Fracture care of friend and foe during World War I

Background:  In the early years of trench warfare, compound lower limb fractures caused by gunshot missiles prompted the ­questioning of traditional splintage techniques and established evacuation methods. These prejudiced recovery and delayed surgery, often by many days, causing a high mortality rate especially for open femoral fractures. Importantly, battle weaponry was modified by differences in climate and terrain in Mesopotamia, Gallipoli, the Alps and the Northern European plain, to manifest differences in wound pathology. In Flanders, the static situation limited simple bullet wounds and launched a high percentage of jagged shell ­fragment injuries complicated by tissue destruction, in-driven clothing and metal contaminated with mud, lethal bacteria and spores. From no-mans-land, soldiers with arm fractures scrambled back unaided, with tibial fractures they might hobble between two comrades, but with femoral fractures they were helpless unless stretcher bearers arrived. Often they did not, or only after a lull in fighting, by which time death from blood loss or exposure supervened. Even on a stretcher, poor fracture immobilization and long arduous carries added to shock and mortality. Remedies to these deficiencies and observations by Australasian, Austrian, British, Canadian, French, German, South African and American surgeons are noted.

Conclusions:  Trained to treat bullet wounds in open terrain, many military medical organizations were slow to adjust to the novel challenges associated with trench warfare. However, from 1917 well-trained stretcher bearers, efficient application of the Thomas splint, better control of haemorrhage and more rapid evacuation with motorized ambulances reduced deaths, amputation rates and long-term disability significantly.