APPLICATION OF TOBRUK SPLINT

Technique for application of Tobruk splint (New Zealand pattern) for transportation of fractured femurs and gunshot wounds of knee:

1.	When the operation is completed shave the leg, apply a felt or gamgee collar round the malleoli and the heel, and traction elastoplast up to as near the wound as possible.
2.	Apply a Thomas splint, bent 10 degrees at the knee, with 4–inch flannel slings to support the limb, a firm pad of appropriate size inside the outer part of the ring, and ample gamgee and wool in front of and at the sides of the limb.
3.	Fix the extension to the end of the splint and insert a rod of wood or other material to act as a windlass.
4.	Apply a plaster slab from the back of the ring behind the slings to three inches above the ankle. Then encircle the splint and limb with plaster bandages covering the same area and incorporating the ring pad. Then squeeze the plaster bandage round the bars to provide a grip.
5.	The foot is supported in mid position by a foot-piece, padded both on the dorsum and the sole, and fixed with plaster bandage at right angles. The plaster is carried on the flat forward beyond the toes on the sole, but the dorsum is left free for toe movement.
6.	The lower end of the Thomas splint is firmly fixed to the suspension bar and the bar to the stretcher.
7.	In fractures of the upper third of the femur a second suspension bar at the level of the ring, to which the ring should be fixed, is advisable.

STATISTICS OF CASES INVALIDED TO NEW ZEALAND

It has been possible to analyse the records of patients invalided to New Zealand from 2 NZEF MEF and CMF, and to produce statistics showing the type and location of fractures, the associated injuries, the complications, the date of medical boarding, and the missile responsible for the wound.

Type and Location of Fractures in Battle Casualties: The involvement of the contiguous joints is seen to be common, 20 per cent of the fractured femur cases having involvement of the knee joint, but only 4 per cent page 296 having involvement of the hip. In fractures of the tibia 12 per cent had knee-joint involvement, while in fractures of the humerus 26 per cent had elbow-joint involvement.

Associated Injuries: Injuries to the main nerves are seen to be common and are of particular importance in regard to the eventual function of the limb. They are more common in arm injuries, the musculo-spiral nerve being affected in 20 per cent of fractured humerus cases, and the sciatic nerve in 8 per cent of the fractured femur cases. Vascular injuries were not so frequent but were of considerable importance.

Complications: These were fortunately relatively uncommon, only three cases of purulent arthritis of the knee being recorded in the group of fractured femur cases, 61 of which had involvement of the knee joint. Serious after-effects such as mal-union and non-union were sometimes seen in returned prisoners of war.

Date of Boarding: This gives a good idea of the severity and number of casualties sustained in the different years of the war. They show the largest numbers in 1944. The figures for 1941 do not show the prisoners of war, many of whom were not boarded until their release in 1945.

Missile causing Injury: The figures show clearly the marked predominance of shell injuries in all the groups. Rifle and machine-gun bullets caused many wounds of the femur, humerus, and forearm. Mine wounds caused a large proportion of the fractures of the legs and feet. A high incidence of accidental injuries is shown, especially in the latter part of the war.

Admission to Hospitals: The figures show clearly, as one would expect, that practically all the men sustaining major fractures were invalided back to New Zealand.

Fractured Femurs Invalided FROM 2 NZEF

	Group A (BCs)	Goup B (BCs)	Group C (AIs) Compound	Simple	Totals
Shaft	142	52	9	13	216
Involving hip	12			1	13
Involving knee	61		4	1	66
Incomplete	21	7			28
Simple	2				2
Both femora			1		1
	——	——	——	——	——
	236	61	29		326

Particulars Referring TO THE 236 Cases In Group A

associated injuries same leg—
Fracture tibia involving knee	4
Fracture tibia	2
Fracture fibula	1
Fracture patella	2
Fracture tibia, fibula, and patella	3
Fracture tibia and fibula	1
Fracture tibia and patella	1
Injury ext popliteal nerve	7
Injury femoral vein	1
Injury post-tibial artery	1
Arterial haematoma	1
Arterio-venous aneurysm femoral	1
Arterio-venous aneurysm popliteal	2
Injury sciatic nerve	12page 297
complications-
Purulent arthritis hip	3
Purulent arthritis knee	3
Secondary haemorrhage	1
Osteomyelitis (PW)	1
Osteitis	1
Anuria (transfusion)	1
Fibrous ankylosis knee (PW)	1
Shortening (PW)	1
Deformity	1

date of boarding—
	Group A.	Group C
PW	12
1941	8 (PW)
1942	60	7
1943	45	3
1944	79	10
1945	40	9
?PW	5

missiles causing—
Shell	99
Gunshot	47
Mortar	23
Machine-gun	21
Mine	14
Bomb	14
Rifle	7
Other	6

Fractured Tibias and Fibulas Invalided from 2 NZEF

	Group A (BCs)	Group B (BCs)	Compound	Group C (AIs) Simple	Undefined	Totals
tibia and fibula—
Shaft	72	24	38	41	18	193
Both legs	2			13	3	6
Simple	7	4				11
Involving knee	6	4		2		12
Involving ankle	10	2	1	1		14
	——	——	——			——
	97	34	105			236
tibia—
Shaft	90	48	8	18	4	168
Both legs	3					3
Incomplete	10					10
Simple	8	2				10
Involving knee	25		3	10		38
Involving ankle	18		2	4		24
	——	——	——			——
	154	50	49			253
fibula—
Shaft	56	26	7	12		101
Incomplete	1					1
Involving ankle	5					5
Simple		2				2
Fibula and os calcis				1		1
	——	——	——			——
	62	28	20			110
——	——	——	——			——
Totals	313	112	174			599

associated injuries—	Group A (313)	Group C (174)
Ant tibial artery and vein	3
Ant tibial artery	4
Post tibial vessels	8	1
Popliteal artery and vein	2	page 298
Gas gangrene		1
Post tibial nerve	11	1
Ant tibial nerve	1
Peroneal nerve	13	2
Musculo cutaneous nerve	1
Fracture tarsus	8
Fracture patella	2	3
Fracture ankle	1
complications—
Amputation (late), below knee	1
Suppurative arthritis, ankle	1
Arthritis, ankle	1
Bony ankylosis, ankle	1
Mai-union (PW)	1
missiles causing—
Shell	138
Mine	49
Gunshot	31
Mortar	27
Machine-gun	16
Grenade	3
Other	12

date of medical boarding—	Group A	Group C
PW	16
1941 (PW)	9
1942	82	16
1943	54	18
1944	120	49
1945	40	55
1946		5
?PW	7

Admissions to Hospital, 19411–45

	Compound	Simple
Fract tibia and fibula	166	20
Fract tibia	220	23
Fract fibula	115	8

Fractured Humeri Invalided from 2 NZEF

	Group A.(BCs)	Group B(BCs)	Group C(AIs)	Totals
Shaft	101	66	25	192
Involving shoulder	44			44
Involving elbow	64	15		79
Both humeri	2		1	3
Simple fracture	5			5
	216	81	26	323

Particulars referring to Group A (216 cases)

ASSOCIATED FRACTURES SAME ARM-
Scapula	16
Clavicle and scapula	2
Radius and ulna	14
Radius	7
Ulna	11
Simple radius and ulna	1
Disorganisation shoulder	3

page 299

ASSOCIATED NERVE INJURIES—
Musculo-spiral	43
Musculo-spiral and ulnar	1
Musculo-spiral and ulnar and median	2
Musculo-spiral and median	2
Posterior interosseous	3
Median and ulnar	2
Median	7
Circumflex	1
Brachial plexus	1
Ulnar	14
Ligature brachial artery	1
Ligature brachial artery and vein	1
Ligature axillary artery	1
COMPLICATIONS-
Purulent arthritis shoulder	2
Causalgia median	1
Ankylosis elbow (PW)	3
Ankylosis shoulder (PW)	1
Osteomyelitishumerus(PW)	1
MISSILES CAUSING-
Shell	109
Gunshot	43
Machine-gun	19
Bomb	1
Mortar	10
Mine	7
Grenade	3
Rifle	3
Other	7
DATE OF MEDICAL BOARDING-
PW	8
1941	5
1942	62
1943	27
1944	92
1945	23
? PW	3

Admissions to Hospital, 1941–45

Comp fract humerus	282
Simp fract humerus	18

Fractured Forearms Invalided from 2 NZEF

	Group A		Group B		Group C
	(BCs)		(BCs)		(AIs)
	Compound	Simple	Compound	Simple	Compound	Simple	Totals
Radius	61	2	26	2		11	102
Ulna	65	1	53	1		7	127
Radius and ulna	38	1	16	1	4	20	80
Involving elbow	18		5		2	3	28
Involving dislocation	1					1	2
	——		——		——		——
	187		104		48		339

	Group A
associated injuries—	(187 cases)
Involving wrist	18
Ulnar nerve	22
Median nerve	11
Musculo-spiral nerve	12
Post-interosseous nerve	9
Median and ulnar nerves	3
Ulnar and radial nerves	1
Radial artery	3
Ulnar artery	2
Brachial artery	1
complications—
Excision head radius	1
Osteomyelitis radius	1
Non-union ulna (PW)	3
Non-union radius (PW)	1
Osteomyelitis ulna (PW)	1
Bony ankylosis elbow (PW)	1
missiles causing—
Shell	72
Gunshot	31
Gunshot mult.	5page 300
Machine-gun	19
Mortar	16
Rifle	5
Bomb	4
Mine	4
Grenade	3
Other	3

date of medical boarding—
	Group A	Group C
PW	14
1941 (PW)	6
1942	39	10
1943	22	11
1944	63	21
1945	27	39
1946		2
? PW	8

Admissions to Hospital, 1941–45

Comp fracture radius and ulna	310
Simp fracture radius and ulna	17

Fractured Feet Invalided from 2 NZEF

	Group A (BCs) Compound	Simple	Group B (BCs) Compound	Simple
Tarsus	38	2	24
Tarsus and metatarsals	11
Metatarsus	63	1	11
Both tarsi	1	1
Os caicis	13	11	11
Os caicis double	3
Involving ankle	8
	——		——
	152		46

missiles causing—	Group A
Shell	47
Gunshot	23
Mine	29
Machine-gun	12
Bomb	13
Mortar	8
Grenade	3
Other	4
date of medical boarding—
1942	42
1943	35
1944	45
1945	11

Admissions to Hospital, 1941–45

	Compound	Simple
Fracture os caicis	61	21
Fracture tarsus	83	8
Fracture metatarsus	135	14

Fractured Jaws Invalided from 2 NZEF

	Group A (BCs)		Group C (BCs)		Group C (AIs)
	Compound	Simple	Compound	Simple	Compound	Simple
Mandible	35	1	19		8	5
Maxilla	12	1	8		5	1
	——		——		——
	49		27		19

page 301

missiles causing—	Group A
Shell	16
Gunshot	13
Mine	5
Mortar	5
Rifle	3
Other	5
date of medical boarding—
PW	4
1941	5
1942	8
1943	13
1944	11
1945	7

Admissions to Hospital, 1941–45

Fracture mandible	73
Fracture maxilla	46
Fracture malar	15