Noe, A. (2006). Extremity injury in war: A brief history. Journal of the American Academy of Orthopaedic Surgeons, 14(10), S1-S6.
No matter what your thoughts are about the war in Iraq or your political persuasion, an understanding of some of the orthopaedic injuries faced by our young men and women overseas is an enlightening experience. The first article in this supplemental series discusses the history of extremity injury in war. Several other articles in this group are worth your attention. Some of the pictures are graphic, but they reveal the wonderful advances that have been made in treating our wounded. The current enemy has become cleaver, especially with the use of improvised explosive devices (IEDs), which create extensive tissue damage and resulting pain.
This article briefly chronicles the history of injuries to the extremities from the earliest times where the seeds developed for the science of orthopaedic surgery to the modern wars and conflicts. Dr. Noe presents an overview of developing care for extremities beginning in early times with amputations as life-saving measures to the more sophisticated use of external devices for transportation, wound stabilization, and hemostatic benefits. In addition, she discusses the beginnings of the military hospital conceived back in Roman times with its important proximity to the battle site for care of the wounded. Even as long ago as 1500, the Spanish army developed the first military medical hospital, and the role of the military surgeon was established. She notes that in the 1700s, surgical methods included management of soft-tissue injuries, splinting, fracture alignment, repair of tendons and muscles, and reduction of dislocations. Napoleon's personal physician, Jena Larrey, was responsible for initiation of the casualty support system that remains a part of the current military medical system. This system highlighted rapid transportation of the wounded to the closest facility for treatment.
During the Civil War, Dr. Noe reports that understanding the time interval between injury and treatment became an important way to reduce mortality. Jonathan Letterman who was the medical director of the Army, instituted what would become the forerunner of the mobile field hospitals and the transportation of wounded from the front line. During World War I, triage became a standard practice and extremity wounds were no longer exclusively treated with amputation. World War II saw the development of antibiotics and the use of blood products and substitutes to save lives. The subsequent conflicts saw medical evacuations proliferate, especially with helicopters, as the goal was surgical intervention within 2-4 hours of injury.
Dr. Noe believes the future challenges for extremity injuries are treatment of high-velocity blasts with the "battlefield band-aids" (chitosan-described in Combat Orthopaedics: A View from the Trenches) and pain management techniques for rapid surgery and quick transportation. Agents, such as chitosan are hemostatic dressings that control bleeding, are cost effective and vital in preventing death on the battlefield.
As orthopaedic nurses, we need to know about the developments for orthopaedic injuries in these austere environments. These individuals will be our patients stateside in the future. Other interesting articles appear in this series by Bagg, Covey, & Powell (2006) and Covey (2006).
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