Skeletal Trauma: Basic Science,

Management, and Reconstruction,

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Browner
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 Sixth Edition

SKELETAL TRAUMA
BASIC SCIENCE,
MANAGEMENT, AND
RECONSTRUCTION
Bruce D. Browner, MD, MHCM, FACS, FAOA
Adjunct Professor
Departments of Orthopaedic Surgery
Duke University School of Medicine
Durham, North Carolina
and
Wake Forest University School of Medicine
Winston-Salem, North Carolina

Jesse B. Jupiter, MA, MD, FAOA

Professor
Orthopaedic Surgery
Massachusetts General Hospital
Boston, Massachusetts

Christian Krettek, MD, FRACS, FRCSEd

Professor and Director
Hannover Medical School (MHH)–Trauma Department
Hannover, Germany

Paul A. Anderson, MD, FAOA

Professor
Department of Orthopaedics and Rehabilitation
University of Wisconsin
Madison, Wisconsin
Elsevier
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SKELETAL TRAUMA: BASIC SCIENCES, MANAGEMENT, ISBN: 978-0-323-63924-8 (vol 1)

AND RECONSTRUCTION, SIXTH EDITION 978-0-323-63925-5 (vol 2)
Copyright © 2020 by Elsevier Inc. All rights reserved. 978-0-323-61114-5 (set)

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 The Editors Dedicate the Sixth Edition to their
Families and to Fallen and Wounded Warriors

To my wife, Barbara Thea Browner; to my children:

Jeremy Todd Browner, Esq, Nina Mikhellasvili Browner,
MD, Nicole Browner Samuel, and Marc Aaron Samuel,
Esq, and to my grandchildren: Benjamin Noah Browner,
Zachary Myer Samuel, Dylan Jethro Samuel, Sophia
Alexandra Browner, and Emily Jordyn Samuel
In memory of my parents, Mona and Eric Browner
In appreciation for encouragement from my mother-in-
law, Betty Appleman Jacowsky
Bruce D. Browner

To my wife, Beryl Stephanie Abrams Jupiter, to my

daughter, Stacy Deborah Jupiter
In memory of my son, Benjamin Scott Jupiter
In memory of my parents, Miriam and Samuel Jupiter
Jesse B. Jupiter

To my wife, Ulrike Krettek, MD, to my children: Felicitas

Krettek and Florian Krettek
In memory of my parents, Felizitas & Heinz Krettek
In appreciation of their continuous support and
encouragement
Christian Krettek

To my wife, Veronica for the all help and support she

provides and her assistance in editing all the
manuscripts
Paul Anderson

We dedicate this text also to the brave men and women

in the military who have sacrificed their lives or
sustained serious injuries while fighting to preserve the
freedom and security of our nations
Contributors

Yves P. Acklin, MD, DMedSc Paul A. Anderson, MD, FAOA

Assistant Professor Department of Orthopaedics and Rehabilitation
Kantonsspital Baselland University of Wisconsin
Bruderholz, Switzerland Madison, Wisconsin
46: Fractures of the Humeral Shaft 33: Thoracolumbar Trauma
35: Osteoporotic Spinal Fractures
Julie E. Adams, MD
Professor, Orthopaedic Surgery Ajay Antony, MD
Mayo Clinic Health System Department of Anesthesiology
Rochester, Minnesota University of Florida College of Medicine
44: Trauma to the Adult Elbow Gainesville, Florida
15: Chronic Pain Management
Samuel B. Adams, MD
Department of Orthopaedic Surgery Paul M. Arnold, MD
Duke University Medical Center Department of Neurosurgery
Durham, North Carolina University of Kansas Medical Center
66: Malleolar Fractures and Soft Tissue Injuries of the Ankle Kansas City, Kansas
29: Pathophysiology and Early Management of Spinal Cord
Sulaiman Alazzawi, MBChB, MSc, MRCS, FRCS Injury
Trauma and Orthopaedics
The Royal London Hospital Courtney E. Baker, MD
London, United Kingdom Resident Physician
73: Articular Cartilage Reconstruction Using Osteochondral Department of Orthopaedic Surgery
Allografts Mayo Clinic
Rochester, Minnesota
Volker Alt, MD 4: Vascularity and Stability: The Pillars of Fracture Healing
Department of Trauma Surgery
University Hospital Giessen–Marburg GmbH Tessa Balach, MD
Campus Giessen, Germany Associate Professor
25: Understanding and Treating Chronic Osteomyelitis Residency Program Director
Division of Orthopaedic Oncology
Anthony M. Alvarado Department of Orthopaedic Surgery
Department of Neurosurgery University of Chicago
University of Kansas Medical Center Chicago, Illinois
Kansas City, Kansas 21: Pathologic Fractures
29: Pathophysiology and Early Management of Spinal Cord
Injury Justin Barr, MD, PhD
Department of Surgery
Louis F. Amorosa, MD Duke University
Assistant Professor of Orthopaedic Surgery Durham, North Carolina
Columbia University Medical Center and New York 1: The History of Trauma Care
Presbyterian Hospitals
New York, New York Craig S. Bartlett III, MD
32: Subaxial Cervical Spine Trauma Medical Director of Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
Jonas Andermahr, MD The University of Vermont
Professor of University Clinic of Cologne Burlington, Vermont
Director Center of Orthopaedic and Traumasurgery 65: Fractures of the Tibial Pilon
Kreiskrankenhaus, Mechernich, Germany
48: Fractures and Dislocations of the Clavicle

iv
 Contributors v

Michael R. Baumgaertner, MD Randy R. Bindra, MCh, FRCS

Professor Professor of Orthopaedic Surgery
Department of Orthopaedics and Rehabilitation Griffith University and Gold Coast University Hospital
Chief of Orthopaedic Trauma and Reconstruction Gold Coast, Australia
Yale School of Medicine 40: Fractures and Dislocations of the Hand
New Haven, Connecticut
53: Medical Management of the Patient With Hip Fracture Robert E. Blease, MD
55: Intertrochanteric Hip Fractures Orthopaedic Trauma Surgeon
MAJ U.S. Army (Ret)
Joan Elizabeth Bechtold, PhD Missoula, Montana
Gustilo Professor of Orthopaedic Research 20: Gunshot Wounds and Blast Injuries
Vice Chair Research
Department of Orthopaedic Surgery André P. Boezaart, MD, PhD
University of Minnesota; Professor of Anesthesiology and Orthopaedic Surgery
Graduate Professor Department of Anesthesiology
Biomedical Engineering University of Florida College of Medicine
University of Minnesota; Gainesville, Florida
Investigator 14: The Management of Acute and Perioperative Pain
Hennepin County Medical Center Associated With Trauma and Surgery
Hennepin Healthcare Research Institute and Excelen 15: Chronic Pain Management
Center for Bone & Joint Research and Education
Minneapolis, Minnesota Donald S. Bohannon, MD
6: Biomechanics of Fractures Associate Professor of Anesthesiology
Department of Anesthesiology
Christopher P. Bednarz, MD University of Florida College of Medicine
Virginia Commonwealth University School of Medicine Gainesville, Florida
Richmond, Virginia 14: The Management of Acute and Perioperative Pain
22: Osteoporotic Fragility Fractures Associated With Trauma and Surgery

Carlo Bellabarba, MD Christopher T. Born, MD, FACS, FAAOS

Professor and Vice Chair, Department of Orthopaedics Intrepid Heroes Professor of Orthopaedic Surgery
and Sports Medicine The Alpert Medical School at Brown University
Joint Professor, Department of Neurological Surgery Emeritus Chief, Division of Orthopaedic Trauma;
University of Washington School of Medicine Director, Weiss Center for Orthopaedic Trauma Research
Seattle, Washington; Rhode Island Hospital
Chief of Orthopaedics Providence, Rhode Island
Harborview Medical Center 13: Disaster Management
Seattle, Washington
30: Craniocervical Injuries: Atlas Fractures, Atlanto-Occipital Michael J. Bosse, MD
Injuries, and Atlantoaxial Injuries Department of Orthopaedic Surgery
38: Pelvic Ring Injuries Carolinas Medical Center—Atrium Health
Charlotte, North Carolina
Emanuel Benninger, MD 28: Psychological, Social, and Functional Manifestations of
Department of Surgery Orthopaedic Trauma and Traumatic Brain Injury
Clinic of Orthopaedics and Traumatology
Kantonsspital, Winterthur, Switzerland Richard Jackson Bransford, MD
47: Proximal Humeral Fractures and Glenohumeral Professor and Spine Fellowship Director
Dislocations Department of Orthopaedics and Sports Medicine
University of Washington
Michael A. Benvenuti, MD Harborview Medical Center
Department of Orthopaedic Surgery Seattle, Washington
Vanderbilt University Medical Center 30: Craniocervical Injuries: Atlas Fractures, Atlanto-Occipital
Nashville, Tennessee Injuries, and Atlantoaxial Injuries
4: Vascularity and Stability: The Pillars of Fracture Healing 38: Pelvic Ring Injuries

Kavi Bhalla, PhD

Assistant Professor of Epidemiology and Global Health
Department of Public Health Sciences
The University of Chicago Biological Sciences
Chicago, Illinois
2: Global Burden of Musculoskeletal Injuries
vi Contributors

Mark R. Brinker, MD Neal Chen, MD

Director of Acute and Reconstructive Trauma Interim Chief, Hand and Upper Extremity Service
Texas Orthopaedic Hospital Massachusetts General Hospital
Fondren Orthopaedic Group, LLP Assistant Professor
Houston, Texas; Harvard Medical School
Clinical Professor of Orthopaedic Surgery Boston, Massachusetts
University of Texas Medical School—Houston 45: Fractures of the Distal Humerus
Houston, Texas;
Clinical Professor of Orthopaedic Surgery Christina W. Cheng, MD
Tulane University School of Medicine Orthopaedic Spine Fellow
New Orleans, Louisiana; Department of Orthopaedics and Sports Medicine
Clinical Professor of Orthopaedic Surgery Harborview Medical Center
Baylor College of Medicine University Washington
Houston, Texas Seattle, Washington
26: Nonunions: Evaluation and Treatment 30: Craniocervical Injuries: Atlas Fractures, Atlanto-Occipital
Injuries, and Atlantoaxial Injuries
Nico Bruns, MD
Resident Trauma Department Jan-Dierk Clausen, MD
Hannover Medical School (MHH) Resident Trauma Department
Hannover, Germany Hannover Medical School (MHH)
73: Articular Cartilage Reconstruction Using Osteochondral Hannover, Germany
Allografts 73: Articular Cartilage Reconstruction Using Osteochondral
Allografts
Constantinus F. Buckens, MD, PhD
Department of Radiology Mark S. Cohen, BS, MD
University Medical Center Hand and Upper Extremity Division
Utrecht, The Netherlands Department of Orthopaedic Surgery
34: Fractures in the Ankylosed Spine Rush University Medical Center
Chicago, Illinois
Ryan P. Calfee, MD, MSc 42: Fractures of the Distal Radius
Associate Professor
Department of Orthopaedic Surgery Peter A. Cole, MD
Washington University School of Medicine Professor, Department of Orthopaedic Surgery
St. Louis, Missouri University of Minnesota
13: Disaster Management Minneapolis, Minnesota;
Chair, Department of Orthopaedic Surgery
Jon Carlson, MD Regions Hospital
Department of Orthopaedic Surgery St. Paul, Minnesota
University of Louisville School of Medicine 49: Scapula Fractures
Louisville, Kentucky 50: Chest Wall Trauma: Rib and Sternum Fractures
24: Diagnosis and Treatment of Complications 62: Tibial Plateau Fractures

Charles Cassidy, MD Leo M. Cooney, Jr., MD

Henry H. Banks Professor and Chairman Humana Foundation Professor of Geriatric Medicine
Department of Orthopaedics Yale University School of Medicine
Tufts Medical Center New Haven, Connecticut
Boston, Massachusetts 53: Medical Management of the Patient With Hip Fracture
41: Fractures and Dislocations of the Carpus
R. Richard Coughlin, MD, MSC
Renan C. Castillo, PhD Professor Emeritus of Orthopaedic Surgery
Associate Professor University of California, San Francisco;
Department of Health Policy and Management Institute for Global Orthopaedics and Traumatology
Johns Hopkins Bloomberg School of Public Health Orthopaedic Trauma Institute
Baltimore, Maryland Department of Orthopaedic Surgery
2: Global Burden of Musculoskeletal Injuries University of California, San Francisco
San Francisco, California
3: The Challenges of Orthopaedic Trauma Care in the
Developing World
 Contributors vii

Aaron Creek, MD Austin T. Fragomen, MD

Clinical Instructor of Orthopaedic Surgery Fellowship Director
University of Louisville Department of Orthopaedic Associate Professor of Clinical Orthopaedic Surgery
Surgery Hospital for Special Surgery
Norton Leatherman Spine Center Weill Cornell Medical College
Louisville, Kentucky Cornell University
33: Thoracolumbar Trauma New York, New York
27: Motorized Intramedullary Lengthening Nail for Limb
Pim A. de Jong, MD, PhD Reconstruction
Department of Radiology
University Medical Center Brett A. Freedman, MD
Utrecht, The Netherlands Associate Professor of Orthopaedics
34: Fractures in the Ankylosed Spine Mayo Clinic
Rochester, Minnesota
Sebastian Decker, MD 17: Compartment Syndromes
Specialist Surgeon in Trauma Surgery
Trauma Department Eli C. Garrard, MD
Hannover Medical School (MHH) Assistant Professor
Hannover, Germany Emory University School of Medicine
31: Craniocervical Injuries: C2 Fractures Atlanta, Georgia
38: Pelvic Ring Injuries 33: Thoracolumbar Trauma

John R. Dimar, II, MD Joshua L. Gary, MD

Clinical Professor of Orthopaedic Surgery Associate Professor
University of Louisville Department of Orthopaedic McGovern Medical School at UTHealth Houston
Surgery Houston, Texas
Norton Leatherman Spine Center Staff 39: Surgical Treatment of Acetabular Fractures
Chief of Pediatric Orthopaedics
Norton Children’s Hospital Ralph Gaulke, MD, PhD
Louisville, Kentucky Professor
33: Thoracolumbar Trauma Deputy Head of the Trauma Department
Hannover Medical School (MHH)
Shah-Nawaz M. Dodwad, MD Hannover, Germany
Orthopaedic Spine Surgeon 43: Diaphyseal Fractures of the Forearm
Department of Orthopaedic Surgery
University of Texas Health Sciences Center at Houston Tad Gerlinger, MD, COL (ret)
Houston, Texas Director, Adult Reconstruction Fellowship
33: Thoracolumbar Trauma Assistant Professor, Rush University Medical Center
Associate Professor, USUHS
John C. Dunn, MD Midwest Orthopaedics at Rush
William Beaumont Army Medical Center Chicago, Illinois
El Paso, Texas 13: Disaster Management
19: Soft Tissue Reconstruction
George M. Ghobrial, MD
Elton R. Edwards, MB, BS, FRACS Department of Neurosurgery
Department of Orthopaedic Surgery Thomas Jefferson University
Alfred Hospital Philadelphia, Pennsylvania
Melbourne, Australia 36: Avoiding Complications in Spine Trauma Patients
57: Subtrochanteric Fractures of the Femur
Peter V. Giannoudis, MD, FACS, FRCS
Garth A. Elias, MD Professor and Chairman
Clinical Associate Professor of Surgery Academic Department of Trauma and Orthopaedic
University of Pittsburgh School of Medicine Surgery
Pittsburgh, Pennsylvania School of Medicine
10: Evaluation and Treatment of the Multi-Injured Trauma University of Leeds
Patient Leeds, United Kingdom
58: Femoral Shaft Fractures
James Ficke, MD, FACS 69: Periprosthetic Fractures of the Lower Extremity
Robert A. Robinson Professor and Chairman
Department of Orthopaedic Surgery
Johns Hopkins Medicine
Baltimore, Maryland
71: Limb Salvage and Reconstruction
viii Contributors

Peter Ginaitt, RN, EMT Daniel Guenther, MD

Senior Environmental Health and Safety Officer Consultant, Outside Lecturer
Emergency Manager Department of Orthopaedic Surgery, Trauma Surgery, and
Rhode Island Public Transit Authority Sports Medicine
Member, FEMA National Advisory Council Cologne Merheim Medical Center
Providence, Rhode Island Written/Herdecke University
13: Disaster Management Cologne, Germany
60: Patella Fractures and Extensor Mechanism Injuries
I. Leah Gitajn, MD 61: Dislocations and Soft Tissue Injuries of the Knee
Assistant Professor
Department of Orthopaedics George J. Haidukewych, MD
Dartmouth Geisel School of Medicine Department of Orthopaedic Surgery
Dartmouth Hitchcock Medical Center Orlando Medical Center
Lebanon, New Hampshire Orlando, Florida
67: Foot Injuries 56: Posttraumatic Reconstruction of the Hip Joint

Wade Gordon, MD Shannon Hann, MD

Southern Oregon Orthopaedics; Department of Neurosurgery
Rogue Regional Medical Center Thomas Jefferson University
Medford, Oregon Philadelphia, Pennsylvania
8: Principles and Complications of External Skeletal Fixation 36: Avoiding Complications in Spine Trauma Patients

Thomas Gösling, MD Sigvard T. Hansen, Jr., MD

Professor of Trauma and Orthopaedic Surgery Harborview Medical School
General Hospital Braunschweig Seattle, Washington
Braunschweig, Germany 68: Posttraumatic Reconstruction of the Foot and Ankle
58: Femoral Shaft Fractures
Mitchel B. Harris, MD
Richard A. Gosselin, MD, MPH, MSC, FRCS(C) Department of Orthopaedic Surgery
Associate Clinical Professor, Department of Orthopaedic Massachusetts General Hospital
Surgery Harvard Medical School
Co-Director, Institute for Global Orthopaedics and Boston, Massachusetts
Traumatology 11: Initial Evaluation of the Spine in Trauma Patients
University of California, San Francisco
San Francisco, California James S. Harrop, MD
3: The Challenges of Orthopaedic Trauma Care in the Department of Neurosurgery
Developing World Thomas Jefferson University
Philadelphia, Pennsylvania
James A. Goulet, MD 36: Avoiding Complications in Spine Trauma Patients
Professor and Chief of Orthopaedic Trauma
Department of Orthopaedic Surgery Brandi Hartley, MD
University of Michigan Department of Orthopaedic Surgery
Ann Arbor, Michigan University of Louisville School of Medicine
52: Hip Dislocations Louisville, Kentucky
24: Diagnosis and Treatment of Complications
Matt L. Graves, MD
Hansjörg Wyss AO Medical Foundation Chair of Nael Hawi, MD, MBA
Orthopaedic Trauma Consultant, Outside Lecturer
Professor and Residency Program Director Trauma Department
Department of Orthopaedic Surgery, Division of Trauma Hannover Medical School (MHH)
University of Mississippi Medical Center Hannover, Germany
Jackson, Mississippi 59: Fractures of the Distal Femur
8: Principles and Complications of External Skeletal Fixation
Roman Hayda, MD, COL (ret)
Stuart A. Green, MD Associate Professor Orthopaedic Surgery
Clinical Professor Brown University Warren Alpert School of Medicine
Orthopaedic Surgery Director Orthopaedic Trauma
University of California, Irvine Rhode Island Hospital
Irvine, California Providence, Rhode Island
8: Principles and Complications of External Skeletal Fixation 13: Disaster Management
 Contributors ix

Austin Heare, MD Joey P. Johnson, MD

Assistant Professor Orthopaedic Surgery Assistant Professor
University of Miami Miller School of Medicine Department of Orthopaedic Surgery
Department of Orthopaedics Loma Linda University
Miami, Florida Loma Linda, California
49: Scapula Fractures 2: Global Burden of Musculoskeletal Injuries

Matthew Herring, MD Clifford B. Jones, MD, FAOA, FACS

Orthopaedic Trauma Institute National Chief of Orthopaedic Trauma, Center for
Department of Orthopaedic Surgery Orthopaedic Research and Education (CORE
University of California, San Francisco Institute®)
Zuckerberg San Francisco General Hospital and Trauma Professor, Orthopaedic Surgery, University of Arizona
Center Medical School–Phoenix
San Francisco, California Center Chiefs for Orthopaedic Trauma, University Medical
50: Chest Wall Trauma: Rib and Sternum Fractures Center, Banner Orthopaedic & Spine Institute
Phoenix, Arizona
Jennifer Hoffman, MD 18: Open Fractures
Associate Professor
Department of Orthopaedics Bernhard Jost, MA, MD, FAOA
Tufts Medical Center Department of Orthopaedic Surgery and Traumatology
Boston, Massachusetts Kantonsspital, St. Gallen, Switzerland
41: Fractures and Dislocations of the Carpus 47: Proximal Humeral Fractures and Glenohumeral
Dislocations
Jacob Hoffmann, MD
Resident Jesse B. Jupiter, MD
Orthopaedics Director of Orthopaedic Hand Service
McGovern Medical School at The University of Texas Massachusetts General Hospital
Health Science Center at Houston Harvard Medical School
Houston, Texas Boston, Massachusetts
33: Thoracolumbar Trauma 48: Fractures and Dislocations of the Clavicle
51: Replantation
Langston T. Holly, MD
Professor and Vice Chair Warren Kadrmas, MD, COL (s)
Department of Neurosurgery and Orthopaedics Deceased
David Geffen School of Medicine at UCLA 13: Disaster Management
Los Angeles, California
37: Principles of Orthotic Management Steven P. Kalandiak, MD
Assistant Professor
Joseph R. Hsu, MD Orthopaedics
Orthopaedic Trauma Surgeon University of Miami
Professor, Department of Orthopaedic Surgery Miami, Florida
Carolinas Medical Center 20: Gunshot Wounds and Blast Injuries
Charlotte, North Carolina
71: Limb Salvage and Reconstruction Stephen L. Kates, MD
Professor and Chairman
Robert Jacobs, MD Department of Orthopaedic Surgery
University of Minnesota Virginia Commonwealth University
Minneapolis, Minnesota Richmond, Virginia
65: Fractures of the Tibial Pilon 22: Osteoporotic Fragility Fractures

Michael Jagodzinski, PhD Stuart D. Kinsella, MD

Department of Orthopaedic Trauma
Schaumburg Hospital
Obernkirchen, Germany
60: Patella Fractures and Extensor Mechanism Injuries
61: Dislocations and Soft Tissue Injuries of the Knee
Department of Orthopaedic Surgery
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts
11: Initial Evaluation of the Spine in Trauma Patients

Sameer Jain, MBChB, MSc, FRCS Melissa Klausmeyer, MD

Senior Arthroplasty Fellow Department of Surgery
Wrightington Hospital Kaiser Permanente
Wigan, United Kingdom West Los Angeles Medical Center
69: Periprosthetic Fractures of the Lower Extremity Los Angeles, California
51: Replantation
x Contributors

Brian S. Knipp, MD Richard F. Kyle, MD

Department of Surgical Services Professor of Orthopaedic Surgery
Naval Medical Center, Portsmouth University of Minnesota
Portsmouth, Virginia Faculty, Orthopaedic Department
16: Evaluation and Treatment of Vascular Injuries Hennepin Healthcare
38: Pelvic Ring Injuries Minneapolis, Minnesota
6: Biomechanics of Fractures
Dominic Konadu-Yeboah, MBChB, MPH, FGCS,
FWACS Paul M. Lafferty, MD
Adjunct Lecturer Director of Orthopaedic Trauma
Department of Surgery, Trauma and Orthopaedics Twin Cities Orthopaedics
Kwame Nkrumah University of Science and Technology, Golden Valley, Minnesota
Kumasi 62: Tibial Plateau Fractures
Part-Time Lecturer
Department of Surgery Loren Latta, PE, PhD
University of Health and Allied Sciences, Ho Professor Emeritus, Director of Biomechanics Research
Senior Specialist Orthopaedics
Komfo Anokye Teaching Hospital University of Miami, Miller School of Medicine
Kumasi, Ghana Miami, Florida
3: The Challenges of Orthopaedic Trauma Care in the 7: Closed Fracture Management
Developing World
William F. Lavelle, MD
Christian Krettek, PhD, FRACS, FRCSEd Department of Orthopaedic Surgery
University Professor SUNY Upstate Medical University
Director of the Trauma Department Syracuse, New York
Hannover Medical School (MHH) 33: Thoracolumbar Trauma
Hannover, Germany
31: Craniocervical Injuries: C2 Fractures Alexander Lerner, MD, PhD
59: Fractures of the Distal Femur Head of Department, Orthopaedic Surgery
63: Nonunions and Malunions about the Knee Ziv Medical Center
73: Articular Cartilage Reconstruction Using Osteochondral Professor, Faculty of Medicine in Galilee
Allografts Bar-Ilan University
Zefat, Israel
Ashesh Kumar, MD, MSc, FRCSC 71: Limb Salvage and Reconstruction
Orthopaedic Surgeon
St. Michael’s Hospital Michael P. Leslie, DO, FAOA
Toronto, Canada Department of Orthopaedics and Rehabilitation
7: Closed Fracture Management Yale School of Medicine
New Haven, Connecticut
Sanjeev Kumar, MD 55: Intertrochanteric Hip Fractures
Department of Anesthesiology
University of Florida College of Medicine Paul E. Levin, MD
Gainesville, Florida Professor of Orthopaedic Surgery and Vice-chairman
15: Chronic Pain Management Albert Einstein College of Medicine/Montefiore Medical
Center
Jonneke S. Kuperus, MD, PhD Bronx, New York
Department of Orthopaedic Surgery 28: Psychological, Social, and Functional Manifestations of
University Medical Center Orthopaedic Trauma and Traumatic Brain Injury
Utrecht, The Netherlands
34: Fractures in the Ankylosed Spine Geoffrey S.F. Ling, MD, PhD
COL (ret.), Medical Corps, U.S. Army
Swamy Kurra, MBBS Professor of Neurology, USUHS
Department of Orthopaedic Surgery The Johns Hopkins University
SUNY Upstate Medical University Baltimore, Maryland
Syracuse, New York 28: Psychological, Social, and Functional Manifestations of
33: Thoracolumbar Trauma Orthopaedic Trauma and Traumatic Brain Injury

John Y. Kwon, MD Travis Loidolt, DO

Chief, Orthopaedic Foot & Ankle Service The Orthopaedic Specialty Center of Northern California
Orthopaedic Surgery Roseville, California
Beth Israel Deaconess Medical Center 33: Thoracolumbar Trauma
Boston, Massachusetts
67: Foot Injuries
 Contributors xi

David W. Lowenberg, MD Gareth Medlock, FRCSGlasg

Clinical Professor Consultant, Trauma and Orthopaedics
Department of Orthopaedic Surgery Aberdeen University
Stanford University School of Medicine Aberdeen Royal Infirmary
Redwood City, California Aberdeen, Scotland, United Kingdom
25: Understanding and Treating Chronic Osteomyelitis 7: Closed Fracture Management

Thuan V. Ly, MD Umesh S. Metkar, MD

Associate Professor Department of Orthopaedic Surgery
Department of Orthopaedics Beth Israel Deaconess Medical Center
The Ohio State University Wexner Medical Center Boston, Massachusetts
Columbus, Ohio 33: Thoracolumbar Trauma
54: Intracapsular Hip Fractures
Phillip M. Mitchell, MD
Ellen J. MacKenzie, PhD Orthopaedic Surgery Resident
Bloomberg Distinguished Professor Department of Orthopaedic Surgery
Dean, Bloomberg School of Public Health Vanderbilt School of Medicine
The Johns Hopkins University Nashville, Tennessee
Baltimore, Maryland 4: Vascularity and Stability: The Pillars of Fracture Healing
28: Psychological, Social, and Functional Manifestations of
Orthopaedic Trauma and Traumatic Brain Injury Charles N. Mock, MD, PhD, FACS
Professor of Surgery
Christiaan N. Mamczak, DO, FAOAO University of Washington
Beacon Orthopaedics and Sports Specialists Seattle, Washington
Volunteer Clinical Faculty, Assistant Professor of 3: The Challenges of Orthopaedic Trauma Care in the
Orthopaedic Surgery Developing World
Indiana University School of Medicine–South Bend
South Bend, Indiana Philipp Mommsen, MD, PhD
12: Damage Control Orthopaedic Surgery: A Strategy for the Consultant, Outside Lecturer
Orthopaedic Care of the Critically Injured Patient Trauma Department
Hannover Medical School (MHH)
Meir T. Marmor, MD Hannover, Germany
University of California, San Francisco Orthopaedic 69: Periprosthetic Fractures of the Lower Extremity
Trauma Institute
Department of Orthopaedic Surgery Jensa C. Morris, MD, FACP
San Francisco General Hospital Assistant Clinical Professor of Medicine
San Francisco, California Yale University School of Medicine
64: Tibial Shaft Fractures Medical Director
Center for Musculoskeletal Care at Yale University School
Amir M. Matityahu, MD of Medicine and Yale New Haven Hospital
University of California, San Francisco Orthopaedic New Haven, Connecticut
Trauma Institute 53: Medical Management of the Patient With Hip Fracture
Department of Orthopaedic Surgery
San Francisco General Hospital Victor A. Morris, MD
San Francisco, California Assistant Professor of Medicine
64: Tibial Shaft Fractures Yale School of Medicine
New Haven, Connecticut
Tyler C. McDonald, MD 53: Medical Management of the Patient With Hip Fracture
House Officer
Department of Orthopaedic Surgery Yusef I. Mosley, MD
University of Mississippi Medical Center Marion Bloch Neuroscience Institute
Jackson, Mississippi Saint Luke’s Hospital
9: Principles of Internal Fixation Kansas City, Missouri
36: Avoiding Complications in Spine Trauma Patients
Tristan E. McMillan, MBChB, MRCS, PgC
Department of Orthopaedic Surgery Calin S. Moucha, MD
Aberdeen Royal Infirmary Associate Professor of Orthopaedic Surgery
Aberdeen, Scotland, United Kingdom Department of Orthopaedic Surgery
7: Closed Fracture Management Icahn School of Medicine at Mount Sinai
New York, New York
23: Surgical Site Infection Prevention
xii Contributors

Christian W. Müller, MD F. Cumhur Oner, MD, PhD

Trauma Department Department of Orthopaedic Surgery
Hannover Medical School (MHH) University Medical Center
Hannover, Germany; Utrecht, The Netherlands
Department for Orthopaedics and Trauma 34: Fractures of the Ankylosed Spine
Asklepios Klinik Wandsbek
Hamburg, Germany Brett D. Owens, MD
31: Craniocervical Injuries: C2 Fractures Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Alan D. Murdock, MD, FACS Warren Alpert Medical School, Brown University
Chief of Emergency Surgery Providence, Rhode Island
Division of Trauma 2: Global Burden of Musculoskeletal Injuries
Allegheny General Hospital
Pittsburgh, Pennsylvania Patrick W. Owens, MD
10: Evaluation and Treatment of the Multi-Injured Trauma Associate Professor
Patient Orthopaedic Surgery
University of Miami
George P. Nanos, III, MD Miami, Florida
Department of Surgery 20: Gunshot Wounds and Blast Injuries
Uniformed Services University
Department of Orthopaedics Eric Pagenkopf, MD
Walter Reed National Military Medical Center Envision Physician Services
Bethesda, Maryland Dallas, Texas
19: Soft Tissue Reconstruction 12: Damage Control Orthopaedic Surgery: A Strategy for the
72: Amputations in Trauma Orthopaedic Care of the Critically Injured Patient

Claudia Neunaber, MD Dror Paley, MD, FRCSC

Outside Lecturer Director
Head of the Experimental Trauma Research Laboratory Paley Orthopaedic and Spine Institute
Trauma Department West Palm Beach, Florida
Hannover Medical School 63: Malunions and Nonunions About the Knee
Hannover, Germany 70: Principles of Deformity Correction
73: Articular Cartilage Reconstruction Using Osteochondral
Allografts Hari K. Parvataneni, MD
Associate Professor of Orthopaedic Surgery
Olga C. Nin, MD Orthopaedics and Rehabilitation
Assistant Professor of Anesthesiology University of Florida College of Medicine
Department of Anesthesiology Gainesville, Florida
University of Florida College of Medicine 14: The Management of Acute and Perioperative Pain
Gainesville, Florida Associated With Trauma and Surgery
14: The Management of Acute and Perioperative Pain
Associated With Trauma and Surgery Alpesh A. Patel, MD, FACS
Department of Orthopaedic Surgery
Tianyi Niu, MD Department of Neurosurgery
Department of Neurosurgery Northwestern University
David Geffen UCLA School of Medicine Feinberg School of Medicine
Los Angeles, California Chicago, Illinois
37: Principles of Orthotic Management 33: Thoracolumbar Trauma

Sean E. Nork, MD Andrew B. Peitzman, MD, FACS

Department of Orthopaedic Surgery Distinguished Professor of Surgery
Harborview Medical Center Mark M. Ravitch Professor and Vice-Chairman,
Seattle, Washington Department of Surgery
57: Subtrochanteric Fractures of the Femur UPMC Vice-President for Trauma and Surgical Services
University of Pittsburgh School of Medicine
Daniel P. O’Connor, PhD Pittsburgh, Pennsylvania
Professor, Department of Health and Human 10: Evaluation and Treatment of the Multi-Injured Trauma
Performance Patient
University of Houston
Houston, Texas
26: Nonunions: Evaluation and Treatment
 Contributors xiii

Elizabeth M. Polfer, MD Craig S. Roberts, MD

Department of Orthopaedics Department of Orthopaedic Surgery
William Beaumont Army Medical Center University of Louisville School of Medicine
El Paso, Texas; Louisville, Kentucky
Department of Surgery 24: Diagnosis and Treatment of Complications
Uniformed Services University
Bethesda, Maryland Mellisa Roskosky, PhD
72: Amputations in Trauma Department of International Health
Johns Hopkins Bloomberg School of Public Health
Benjamin K. Potter, MD Baltimore, Maryland
Department of Surgery 17: Compartment Syndromes
Uniformed Services University
Department of Orthopaedics Milton Lee (Chip) Routt, Jr., MD
Walter Reed National Military Medical Center Professor
Bethesda, Maryland Andrew R. Burgess Endowed Chair
72: Amputations in Trauma McGovern Medical School at UTHealth Houston
Houston, Texas
Daniel E. Prince, MD 39: Surgical Treatment of Acetabular Fractures
Memorial Sloan Kettering Cancer Center
New York, New York Michael J. Roy, MD, MPH
63: Malunions and Nonunions About the Knee COL (ret), U.S. Army
Professor of Medicine
Rene Przkora, MD, PhD Uniformed Services University
Department of Anesthesiology Bethesda, Maryland
University of Florida College of Medicine 28: Psychological, Social, and Functional Manifestations of
Gainesville, Florida Orthopaedic Trauma and Traumatic Brain Injury
15: Chronic Pain Management
S. Robert Rozbruch, MD
Stefan Rammelt, MD, PhD Service Chief
University Hospital Carl Gustav Carus Professor of Clinical Orthopaedic Surgery
Dresden, Germany New York, New York
68: Posttraumatic Reconstruction of the Foot and Ankle 27: Motorized Intramedullary Lengthening Nail for Limb
Reconstruction
Mark C. Reilly, MD
Department of Orthopaedic Surgery David E. Ruchelsman, MD, FAAOS
Rutgers–The State University of New Jersey Chief, Hand and Upper Extremity Surgery
Newark, New Jersey Director, Hand Surgery Research & Education Foundation
57: Subtrochanteric Fractures of the Femur Clinical Associate Professor of Orthopaedic Surgery
Tufts University School of Medicine
Noam Reshef, MD Consultant, Massachusetts General Hospital/Harvard
Orthopaedic Surgeon Medical School
Orthopaedic Sports Services and Shoulder Surgery Newton, Massachusetts
Ziv Medical Center 40: Fractures and Dislocations of the Hand
Zefat, Israel
71: Limb Salvage and Reconstruction Markus Rupp, MD
Department of Trauma Surgery
Martinus Richter, MD, PhD University Hospital Giessen–Marburg GmbH
Department for Foot and Ankle Surgery Campus Giessen, Germany
Rummelsberg Hospital 25: Understanding and Treating Chronic Osteomyelitis
Schwarzenbruck, Germany
67: Foot Injuries Glenn S. Russo, MD, MS
Connecticut Orthopaedic Specialists
David Ring, MD, PhD Clinical Assistant Professor
Associate Dean for Comprehensive Care Department of Surgery
Department of Surgery and Perioperative Care Frank H. Netter School of Medicine at Quinnipiac
Dell Medical School—The University of Texas at Austin University
Austin, Texas Hamden, Connecticut
48: Fractures and Dislocations of the Clavicle 33: Thoracolumbar Trauma
xiv Contributors

Augusto Sarmiento, MD David W. Shearer, MD, MPH

Chairman Emeritus Chief Resident
Orthopaedics Department of Orthopaedic Surgery
University of Miami University of California San Francisco
Miami, Florida San Francisco, California
7: Closed Fracture Management 3: The Challenges of Orthopaedic Trauma Care in the
Developing World
Adam A. Sassoon, MD
Department of Orthopaedic Surgery Yushane Celestine Shih, MD
UCLA David Geffen School of Medicine Department of Orthopaedic Surgery
Los Angeles, California University of Minnesota
56: Posttraumatic Reconstruction of the Hip Joint Minneapolis, Minnesota
6: Biomechanics of Fractures
Jason W. Savage, MD
Center for Spine Health Michael S. Shuler, MD
Cleveland Clinic Hand and Upper Extremity
Cleveland, Ohio Athens Orthopaedic Clinic
35: Osteoporotic Spinal Fractures Athens, Georgia
17: Compartment Syndromes
Jonathan G. Schoenecker, MD, PhD
Associate Professor Cameron Smith, MD, PhD
Jeffrey W. Mast Chair in Orthopaedics, Trauma and Hip Assistant Professor of Anesthesiology
Surgery Department of Anesthesiology
Department of Orthopaedic, Pediatrics, Pathology and University of Florida College of Medicine
Pharmacology Gainesville, Florida
Vanderbilt University Medical Center 14: The Management of Acute and Perioperative Pain
Nashville, Tennessee Associated With Trauma and Surgery
4: Vascularity and Stability: The Pillars of Fracture Healing
Dale C. Smith, PhD
Patrick Schottel, MD Professor of Military Medicine and History
Assistant Professor Uniformed Services University of the Health Sciences
Orthopaedics and Rehabilitation Bethesda, Maryland
University of Vermont College of Medicine 1: The History of Trauma Care
Burlington, Vermont
65: Fractures of the Tibial Pilon Christoph Sommer, MD
Kantonsspital Graübunden
Lisa K. Schroder, BSME, MBA Graubünden, Switzerland
Director, Geriatric and Orthopaedic Trauma Academic 46: Fractures of the Humeral Shaft
Programs
Department of Orthopaedic Surgery David A. Spiegel, MD
University of Minnesota & Regions Hospital Pediatric Orthopaedic Surgeon
Minneapolis, Minnesota The Children’s Hospital of Philadelphia
49: Scapula Fractures Associate Professor of Orthopaedic Surgery
The University of Pennsylvania School of Medicine
Gregory D. Schroeder, MD Philadelphia, Pennsylvania;
Assistant Professor of Orthopaedic Surgery Consultant in Orthopaedics
Department of Orthopaedic Surgery Hospital and Rehabilitation Centre for Disabled Children
Rothman Institute at Thomas Jefferson University Banepa, Nepal
Philadelphia, Pennsylvania 3: The Challenges of Orthopaedic Trauma Care in the
33: Thoracolumbar Trauma Developing World

David Seligson, MD Andre R. Spiguel, MD

Department of Orthopaedic Surgery Assistant Professor, Division of Orthopaedic Oncology
University of Louisville School of Medicine Department of Orthopaedic Surgery
Louisville, Kentucky University of Florida
24: Diagnosis and Treatment of Complications Gainesville, Florida
21: Pathologic Fractures
 Contributors xv

Christian Spross, MD Daniel G. Tobert, MD

Department of Orthopaedic Surgery and Traumatology Department of Orthopaedic Surgery
Kantonsspital Massachusetts General Hospital
St. Gallen, Switzerland Harvard Medical School
47: Proximal Humeral Fractures and Glenohumeral Boston, Massachusetts
Dislocations 11: Initial Evaluation of the Spine in Trauma Patients

Ryan D. Stancil, MD Marko Tomov, MD

Department of Orthopaedics and Sports Medicine Orthopaedic Surgery
University of Washington Mayo Clinic
Seattle, Washington Rochester, Minnesota
56: Posttraumatic Reconstruction of the Hip Joint 17: Compartment Syndromes

Robert J. Steffner, MD Alexander R. Vaccaro, MD, PhD, MBA

Assistant Clinical Professor Richard H. Rothman Professor and Chairman,
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Stanford University Professor of Neurosurgery
Palo Alto, California Co-Director, Delaware Valley Spinal Cord Injury Center
21: Pathologic Fractures Co-Chief of Spine Surgery
Sidney Kimmel Medical Center at Thomas Jefferson
Scott P. Steinmann, MD University
Professor, Orthopaedic Surgery President, Rothman Institute
Mayo Clinic Health System Philadelphia, Pennsylvania
Rochester, Minnesota 32: Subaxial Cervical Spine Trauma
44: Trauma to the Adult Elbow
Jorrit-Jan Verlaan, MD, PhD
Iain M. Stevenson, MBChB, FRCS Department of Orthopaedic Surgery
Department of Orthopaedic and Trauma Surgery University Medical Center
Aberdeen Royal Infirmary Utrecht, The Netherlands
Aberdeen, Scotland, United Kingdom 34: Fractures in the Ankylosed Spine
7: Closed Fracture Management
James P. Waddell, CM, MD, FRCSC
Daniel Stinner, MD, FACS Professor, Division of Orthopaedic Surgery
Orthopaedic Trauma Surgeon University of Toronto
Assistant Professor Toronto, Ontario, Canada
Vanderbilt University Medical Center 7: Closed Fracture Management
Nashville, Tennessee
71: Limb Salvage and Reconstruction Richa Wardhan, MD
Associate Professor of Anesthesiology
Marc F. Swiontkowski, MD Department of Anesthesiology
Professor, Department of Orthopaedic Surgery University of Florida College of Medicine
University of Minnesota Medical School Gainesville, Florida
Minneapolis, Minnesota 14: The Management of Acute and Perioperative Pain
54: Intracapsular Hip Fractures Associated With Trauma and Surgery

David M. Tainter, MD Douglas Wardlaw, MBChB, ChM, FRCSEd

Department of Orthopaedic Surgery Professor
Duke University Medical Center Robert Gordon University
Durham, North Carolina Aberdeen, United Kingdom
66: Malleolar Fractures and Soft Tissue Injuries of the Ankle 7: Closed Fracture Management

Michel A. Taylor, MD, MSc, FRCSC Gregory A. Watson, MD, FACS

Department of Orthopaedic Surgery Assistant Professor of Surgery and Critical Care
Duke University Medical Center University of Pittsburgh School of Medicine
Durham, North Carolina Pittsburgh, Pennsylvania
66: Malleolar Fractures and Soft Tissue Injuries of the Ankle 10: Evaluation and Treatment of the Multi-Injured Trauma
Patient
Scott M. Tintle, MD
Associate Professor
Walter Reed National Military Medical Center
Bethesda, Maryland
19: Soft Tissue Reconstruction
xvi Contributors

J. Tracy Watson, MD Brad J. Yoo, MD, FACS

Professor of Orthopaedic Surgery
The CORE Institute
University of Arizona College of Medicine
Banner University Medical Center
Phoenix, Arizona
5: Biology and Enhancement of Skeletal Repair
Thomas Sanjay Weber-Spickschen, MD
Consultant
Trauma Department
Hannover Medical School (MHH)
Hannover, Germany
61: Dislocations and Soft Tissue Injuries of the Knee
Associate Professor
Department of Orthopaedics and Rehabilitation
Yale School of Medicine
New Haven, Connecticut
55: Intertrochanteric Hip Fractures
Yury Zasimovich, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
University of Florida College of Medicine
Gainesville, Florida
14: The Management of Acute and Perioperative Pain
Associated With Trauma and Surgery

Mitchell C. Weiser, MD, MEng Vilijam Zdravkovic, MD, MSc

Instructor of Orthopaedic Surgery Department of Orthopaedic Surgery and Traumatology
Department of Orthopaedic Surgery Kantonsspital
Montefiore Medical Center and Albert Einstein College of St. Gallen, Switzerland
Medicine 47: Proximal Humeral Fractures and Glenohumeral
Bronx, New York Dislocations
23: Surgical Site Infection Prevention
Lewis G. Zirkle, MD
Seth K. Williams, MD Founder and President
Associate Professor SIGN Fracture Care International
Spine and Trauma Divisions Clinical Professor
Department of Orthopaedics and Rehabilitation University of Washington
University of Wisconsin School of Medicine and Public Richland, Washington
Health 3: The Challenges of Orthopaedic Trauma Care in the
Madison, Wisconsin Developing World
33: Thoracolumbar Trauma
Hans Zwipp, MD
Marcel Winkelmann, MD Chairman (ret)
Specialist Surgeon in Trauma Surgery University Center of Orthopaedics and Trauma
Trauma Department University Hospital Carl Gustav Carus
Hannover Medical School (MHH) Dresden, Saxony, Germany
Hannover, Germany 68: Posttraumatic Reconstruction of the Foot and Ankle
38: Pelvic Ring Injuries
Gregory A. Zych, DO, FAOA
Jennifer Wozniczka, MD Christine E. Lynn Distinguished Chair in Orthopaedic
TRIA Orthopaedics Trauma
Minneapolis, Minnesota Professor, Orthopaedic Trauma
6: Biomechanics of Fractures Department of Orthopaedics
Miller School of Medicine
Robert Wysocki, MD University of Miami
Hand and Upper Extremity Division Miami, Florida
Department of Orthopaedic Surgery 20: Gunshot Wounds and Blast Injuries
Rush University Medical Center
Chicago, Illinois
42: Fractures of the Distal Radius

I am honored and humbled to have been asked to write the
foreword to the sixth edition of Skeletal Trauma. I have person-
ally relied on this formative text throughout my career, and
I look forward to placing this new edition on my bookshelf
alongside the many other volumes I frequent in the course
of my research.
The significance of asking a health services researcher,
not a surgeon, to write the foreword to this text is not lost
on me. It signals an appreciation of orthopaedic trauma as
a major public health problem—both here in the United
States and globally. So, allow me to bring a public health
perspective to some of the topics covered in this text and
on trauma orthopaedics more broadly.
It is appropriate that any comprehensive text on skeletal
trauma begin with a discussion of the global burden of
musculoskeletal injuries. As outlined in Chapter 2, injuries
remain a leading cause of death and disability in the United
States and around the world, claiming nearly 5 million lives
annually. For every injury death, there are an estimated 10 to
50 survivors who sustain temporary or permanent disabilities.
Although data on the long-term consequences of injury are
fragmented, it is generally acknowledged that much of this
disability is attributed to musculoskeletal trauma. Fractures
alone account for 40% of the health burden of nonfatal
injuries. Low- and middle-income countries (LMICs) suffer
a disproportionate share of the global injury burden. In
LMICs, injuries result in more than 220 million disability-
adjusted life years lost each year—more than heart disease,
cancer, tuberculosis, malaria, and HIV combined. Chapter
3 does a superb job of addressing the challenges in man-
aging this burden in LMICs with appropriate attention
paid to improving systemwide approaches to trauma care
within the context of the Global Alliance for Care of the
Injured.
I applaud the editors for continuing to leverage the col-
laborations between the military and civilian orthopaedic
communities. Throughout history, lessons learned from battle
have been fundamental to advancing injury care in civilian
life. Equally important, however, has been the need to further
develop and refine these advances in civilian practice during
peacetime so they are available during future conflicts. This
is particularly important today as US combat activity de-
escalates. Developing military–civilian partnerships and
establishing a national trauma system that can ensure the
delivery of optimal care from point of injury to hospitalization,
rehabilitation, and reintegration back into society were key
recommendations of a recent report from the National
Academies of Sciences, Engineering, and Medicine. The
commitment to these partnerships was embodied in the Major
Extremity Trauma Research Consortium (METRC), a network
of military and civilian trauma centers established to build
the evidence for best practices in orthopaedic trauma care.
Foreword
Now in its tenth year, and thanks to the generous support
of the Department of Defense, METRC has helped foster
collaborations in support of the research needed to address
the many unanswered questions raised throughout this
volume. Continued investment in collaborative research will
advance the care of injured service members in future conflicts
and contribute to the medical readiness of current forces
by optimizing recovery and return to duty following common
in-garrison musculoskeletal injuries.
I am particularly pleased to see increased attention paid in
this sixth edition to the management of both perioperative
pain and chronic pain. We know that postoperative pain is
a major determinant of long-term outcome and disability
following orthopaedic trauma. We also know that recent efforts
to address pain have led to an unprecedented increase in
opioid prescriptions and a monumental public health crisis.
Opioid overdose deaths now exceed the number of deaths
from car crashes, guns, HIV, and even the Vietnam War.
Today, more than 2 million Americans are afflicted with
opioid use disorder. Orthopaedic surgeons are the third-
highest prescribers of opioid pain medication, accounting
for nearly 8% of all prescriptions. In response to this growing
epidemic, new prescribing guidelines have taken shape,
and states have passed laws making it harder to prescribe
high doses to first-time patients. Opioid prescriptions have
declined by one-third since their peak; however, there have
been unintended consequences. Patients with uncontrolled
pain who are unable to obtain adequate relief are turning
to cheaper and more available street drugs as an alternative.
Today, the majority of opioid deaths are caused by heroin,
fentanyl, and other street drugs. Reducing opioid-related
deaths requires a comprehensive, community-based approach,
including broad access to medications such as methadone
and buprenorphine. Meanwhile, the orthopaedic community
must stay vigilant in following best practices in prescribing
opioids and continue to investigate new ways to manage
pain’s debilitating effects. Chapters 14 and 15 provide
a wide-ranging and forward-looking discussion on this
important topic.
I will end with a plea for paying more attention to the
psychosocial comorbidities that often accompany both military
and civilian musculoskeletal trauma. Depression and post-
traumatic stress are common. Even subclinical symptoms of
emotional distress and anxiety can affect recovery if not
addressed. Significant improvements in long-term patient
outcomes will not be possible without addressing the psy-
chological sequelae of the physical injury and traumatic event,
as Chapter 28 makes clear. The orthopaedic trauma care
team plays an important role in recognizing early signs of
psychological distress through effective screening mechanisms
and initiating strategies that can treat these symptoms within
a patient- and family-centered environment.
xvii
xviii Foreword

I congratulate the editors and the contributing authors Ellen J. MacKenzie, PhD
for pulling together the evidence and expert opinion we Bloomberg Distinguished Professor
have to date in such a comprehensive volume. It is a compel- Dean
ling testament to advances in care from both the individual Bloomberg School of Public Health
and public health perspectives. The Johns Hopkins University

It has been more than three decades since the conception
and writing of the first edition of Skeletal Trauma began. With
the sixth edition, the editors and publisher have maintained
their original commitment to presenting the best available
evidence-based information and expert opinion on the basic
science, diagnosis, and treatment of acute musculoskeletal
injuries and posttraumatic problems. The scope, which
expanded with the previous edition to cover war injuries in
depth, in addition to road traffic injuries, falls, and occupa-
tional injuries, has been continued. Military authors have
assumed lead authorship of additional chapters and continue
their collaborations with civilian authors in many other
chapters.
Market research into reader preferences, recognition of
new developments in the field, and a spirit of innovation
have also led the editors and publisher to add new chapters
and features, engage different authors, enhance the e-book,
and forge dramatic new partnerships.
Eight new chapters have been added, including “The
History of Trauma Care,” “Vascularity and Stability: The Pillars
of Fracture Healing” “The Management of Acute and Peri-
operative Pain Associated With Trauma and Surgery,” “Chronic
Pain Management,” “Understanding and Treating Chronic
Osteomyelitis,” “Motorized Intramedullary Lengthening Nail
for Limb Reconstruction,” “Chest Wall Trauma: Rib and
Sternum Fractures” and “Articular Cartilage Reconstruction
Using Osteochondral Allografts.”
In response to reader requests for authors to highlight key
points, technical tips, pitfalls, and avoidable complications,
many chapters include a new feature, Key Points boxes, to
enable quick access to such information. Classifications,
charts, and surgical procedures are set off with enhanced
color illustrations. Further, authors have included an
increased number of illustrative case studies with serial
radiographs.
Our research also found that to help provide the best
outcomes and treatment for patients, surgeons want a source
of constantly updated information in addition to periodic
advances noted in our textbooks. As a result, Elsevier and
the editors of Skeletal Trauma, Sixth Edition and Green’s Skeletal
Trauma in Children, Sixth Edition have established a partnership
with OrthoEvidence to provide our print readers with a 1-year
complimentary subscription to OrthoEvidence. Founded
and led by Mohit Bhandari, MD, PhD, a world-renowned
orthopaedic trauma surgeon and clinical epidemiologist,
OrthoEvidence is a global online resource that provides high-
quality, peer-reviewed orthopaedic evidence-based summaries,
exclusive author interviews and data analyses of the latest and
most relevant literature. Our print customers will be able to
access OrthoEvidence through a pin code within the front
matter of our books. On signing in, you’ll have automatic
access to Trauma Advanced Clinical Evidence (ACE) reports
Preface
with the option to add reports in any other areas according
to your interests.
Market research has also taught us that readers want more
just-in-time access to videos demonstrating surgical techniques
to supplement text and illustrations in Skeletal Trauma. Videos
contributed by chapter authors are available in-text on Expert
Consult and have also been added to the outstanding col-
lection of videos acquired from the Trauma Department in
Hannover, Germany, leading to a total of 135 videos included
with the text. Although this is responsive to readers’ desires,
the editors felt that even greater video linkage was needed.
To meet this goal, a relationship has been developed with
VuMedi to allow readers of Skeletal Trauma and Green’s Skeletal
Trauma in Children to link directly with segments of the VuMedi
video collection by specific subject categories covered in the
texts. We are grateful to Jamie Rowan, VuMedi Education
Manager for Orthopaedics, for obtaining approval from
VuMedi’s CEO Roman Giverts to provide Elsevier and the
editors of the adult and pediatric Skeletal Trauma texts with
a limited, nonsublicensable and nonexclusive right to create
text hyperlinks to VuMedi for noncommercial or commercial
purposes. The ability to view the videos through these
hyperlinks will be enabled for readers after they register with
VuMedi.
We also know that injury is now recognized to be a major
global public health problem. Each year more than 5 million
people die from road traffic accidents, violence, and other
mechanisms of injury. The Global Burden of Disease studies
have noted that the worldwide increases in economic develop-
ment, life expectancy, and motorization have been associated
with an epidemiologic transition from a historical preponder-
ance of communicable diseases to a new prominence of
noncommunicable diseases and injury. There is now less
premature death from infectious diseases and far more life
lived with disability caused by injuries and chronic conditions.
To provide a global overview on these issues, we are delighted
and honored that Ellen MacKenzie, PhD, Dean of the
Bloomberg School of Public Health at Johns Hopkins Uni-
versity, has agreed to write the foreword for the sixth edition.
She is well known to the editors and many of our authors
from her career-long focus on the epidemiology, impact,
and significance of trauma and her outstanding leadership
of major multicenter studies, including LEAP, METALS, and
METRIC. Through her position as Dean, she has developed
additional perspective.
We are also pleased that Elsevier will continue a tradition
started with the first edition. Unsold texts for the previous
edition of Skeletal Trauma remaining in the warehouse after
the new edition publishes have been sent to centers in the
developing world, at the publisher’s expense, through the
personal efforts of a succession of acquisitions editors.
The donation sites for the first through third editions were
xix
xx Preface
designated by Orthopaedics Overseas and for the fourth
edition by SIGN Fracture Care International. SIGN has centers
in developing areas, including Africa, Southeast Asia, Central
America, and Eastern Europe. They will designate copies of
the fifth edition to their most active centers that include
training. This donation has always been a humanitarian action
that the editors feel reflects well on the publisher and
broadens the impact of the text.
Finally, the growing epidemic of road traffic injuries,
especially in the developing world, and the persistence of
armed conflicts and insurgencies in many parts of the world
will continue to produce many musculoskeletal injures that
require acute and reconstructive care to ensure optimal
function and mobility and avoid disabling complications.
We believe the material assembled for the sixth edition by
the dedicated authors, editors, publisher’s team, and the
partnerships formed with OrthoEvidence and VuMedi will
assist caregivers worldwide with this continuing challenge.
Bruce D. Browner, MD, MHCM, FACS, FAOA
Jesse B. Jupiter, MA, MD, FAOA
Christian Krettek, MD, FRACS, FRCSEd
Paul A. Anderson, MD, FAOA

On this edition, we had the privilege of working with a talented
and committed group of professionals from Elsevier who
carried on the tradition of excellence established in previous
editions. We would particularly like to acknowledge Kristine
Jones, Senior Content Strategist, the driving force behind
the project. We are indebted to Kathryn DeFrancesco, Senior
Content Development Manager. She tirelessly communicated
with authors and editors to collect the pieces and keep the
work on track. Tracey Schriefer, Senior Project Manager,
led the production phase that converted our content to a
printed text and an e-book. Their contributions combined
with those of our authors helped produce a product of which
we are all very proud.
No staff were hired by the editors for the development of
the text. Again, we relied upon the hard work and dedication
of our own personal staff and institutional resources. We
recognize that their help was critical in helping us reach the
level of excellence to which we aspired.
Paul Anderson would like to thank Veronica McCann
Anderson for her timely and expert review and editing of
the manuscripts.
Christian Krettek would like to express his strong apprecia-
tion to Dr. Marcus Örgel, senior resident at the Orthopaedic
Trauma Department of Hannover Medical School (MHH)
for his tireless efforts and pivotal role in completing this
edition by performing numerous tasks, including proofread-
ing manuscripts and page proofs, and communicating with
the authors. Dr. Örgel high academic work ethic, endless
energy, unparalleled precision, and clear focus were absolutely
outstanding.
Acknowledgments
He also would like to recognize the assistance of Mrs.
Sandra Dragicevic and Ümit Demirörs, his personal admin-
istrative assistants in the head office, who assisted him with
communicating with the authors, editors, and publisher
during multiple phases of the development and editorial
process of the sixth edition.
He would like to thank the staff of the audio-visual support
team, namely Mrs. Kosmalski and Mrs. Siefke, who were
responsible for the high quality of digital images and videos
in the OR, outpatient department, biomechanics lab, and
other occasions.
Strong appreciation is also given to Kurt Singelmann who
spent enormous time and effort to produce videos and agreed
to share their expertise and video material with the readers
of Skeletal Trauma.
And last but not least, Dr. Krettek would like to acknowledge
the enormous continuous academic, clinical, and administra-
tive support as well as the daily inspiration of the entire staff
of the Trauma Department at the Hannover Medical School,
apl. Professor Dr. med. R. Gaulke, apl. Professor Dr. med.
R. Meller, apl. Professor Dr. med. E. Liodakis, Dr. med. M.
Panzica, Privatdozent Dr. med. C. Müller, Privatdozent Dr.
med. Mommsen, Privatdozent Dr. med. Stübig, Privatdozent
Dr. med. Omar, Privatdozent Dr. med. N. Hawi, Dr. med. M.
Winkelmann, Dr. med. S. Decker, J.D. Clausen, Dr. med. C.
Macke., Dr. med. S. Weber-Spickschen, Dr. med. H.H. Aschoff,
Dr. med. M. Örgel and Dr. med. L. Herold.
xxi
Video Contents

7 Closed Fracture Management 26 Nonunions: Evaluation and Treatment

Video 7.1 Scaphoid cast. Video 26.1 Plate osteosynthesis.
Video 7.2 Distal radius cast.
27 Motorized Intramedullary Lengthening Nail for
Video 7.3 Sugar-tong splint. Limb Reconstruction
Video 7.4 Sugar-tong cast. Video 27.1 Femur lengthening with an antegrade piriformis
Video 7.5 Application of the fracture brace. entry precice nail.

Video 7.6 Stirrup splint. Video 27.2 Femur lengthening with a retrograde entry precice
nail.
Video 7.7 Below-knee cast.
Video 27.3 Tibia lengthening with a remote-controlled
Video 7.8 Tibial bracing. magnetic intramedullary precice nail.
Video 27.4 Management of bone defects with the precice
8 Principles and Complications of External Skeletal lengthening-compression IM nail.
Fixation
Video 8.1 The modular technique of applying external fixation.
40 Fractures and Dislocations of the Hand
Video 40.1 Thumb metacarpal base.
Video 8.2 Taylor Spatial Frame.
Video 40.2 Metacarpal shaft placing.
9 Principles of Internal Fixation Video 40.3 Complex metacarpophalangeal joint dislocation.
Video 9.1 Reduction technique—surgical strategy.
41 Fractures and Dislocations of the Carpus
Video 9.2 Intraoperative 3-dimensional imaging (ISO-C).
Video 41.1 Volar approach to the scaphoid.
16 Evaluation and Treatment of Vascular Injuries Video 41.2 Dorsal approach to the scaphoid.
Video 16.1 Femoral artery exposure. Video 41.3 Acute scapholunate dissociation.
Video 16.2 Potts loop and Rummel tourniquet technique. Video 41.4 Four-corner fusion of the wrist.
Video 16.3 Dissection of common femoral artery and major Video 41.5 Wrist joint arthrodesis.
branches.
Video 41.6 Operative technique of dorsopalmar plate
Video 16.4 Primary lateral arteriography. osteosynthesis.
Video 16.5 Temporary vascular shunt placement. Video 41.7 Surgical treatment of scaphoid nonunion.
Video 16.6 Retroperitoneal exposure of the iIiac artery and Video 41.8 Operative technique of palmar plate
vein. osteosynthesis.
Video 16.7 Exposure of the axillary artery. Video 41.9 Operative technique of the radioscapholunate
fusion.
17 Compartment Syndromes Video 41.10 Antegrade and retrograde screw osteosynthesis
of the scaphoid.
Video 17.1 Intracompartmental pressure measurements.
Video 41.11 Indications and techniques of arthroscopy of the
Video 17.2 Stryker Stic device assembly.
wrist.
Video 17.3 Pressure measurement with Stryker.
Video 41.12 Corrections of deformities in rheumatoid arthritis.
Video 17.4 Compartment syndrome: diagnosis and operative
Video 41.13 Indications for surgery, approaches.
therapy.
Video 41.14 Operative technique of dorsal plate
18 Open Fractures osteosynthesis.

Video 18.1 Vacuum techniques for acute traumatic wound Video 41.15 MRI of lesions of the wrist.
management. Video 41.16 Carpal instability and carpal fractures.

19 Soft Tissue Reconstruction 42 Fractures of the Distal Radius

Video 19.1 Soleus flap. Video 42.1 Distal radius fracture: bridging external fixation.

xxvi

Video 42.2 Distal radius fractures: nonbridging and
transarticular external fixation.
Video 42.3 Extensor indicis transfer for rupture of the extensor
pollicis longus tendon.
Video 42.4 Corrective osteotomy for malunion of the distal radius.
Video 42.5 Fractures of the styloid process: indications for
surgery, techniques.
43 Diaphyseal Fractures of the Forearm
Video 43.1 Compensation of restricted forearm rotation.
Video 43.2 Vascular examination.
Video 43.3 Neurologic examination.
Video 43.4 Examination of the elbow.
Video 43.5 Examination of the forearm.
Video 43.6 Examination of the wrist.
Video 43.7 Operative technique Monteggia fracture type II
(type 22-B1.3).
Video 43.8 Operative technique complex radius and simple
ulna fracture (AO/OTA-type 22-C2.1).
Video 43.9 Operative technique of peri-implant fracture of the
radius.
46 Fractures of the Humeral Shaft
Video 46.1 Complex humerus shaft fracture.
48 Fractures and Dislocations of the Clavicle
Video 48.1 Midshaft fracture of the clavicle: intramedullary
nailing of the clavicle.
Video 48.2 Lateral clavicle fracture: anatomic angle stable
plate plus suture anchor.
49 Scapula Fractures
Video 49.1 Scapular malunion: shoulder kinematics before
and after surgical reconstruction.
Video 49.2 Posterior scapular approach: identification and
marking of bony landmarks.
Video 49.3 Posterior scapular approach: Judet skin incision.
Video 49.4 Posterior scapular approach: deltoid-sparing
exposure for lateral border and posterior glenoid
fracture patterns.
Video 49.5 Posterior scapular approach: vertebral border
exposure for transverse fracture patterns.
Video 49.6 Posterior scapular approach: straight lateral
border exposure.
Video 49.7 Posterior scapular approach: extensile Judet
exposure for complex scapular fracture patterns
and reconstruction.
Video 49.8 Posterior scapular approach: minimally invasive
surgical technique.
Video 49.9 Anterior approach: extended exposure and
fixation techniques for distal and acromial tip
fracture patterns.
Video 49.10 Anterior approach: extended exposure for
coracoid fractures.
Video 49.11 Plate contouring for scapular vertebral border
and acromial spine fixation.
Video Contents xxvii
54 Intracapsular Hip Fractures
Video 54.1 Pipkin fractures—anterior approach.
Video 54.2 Surgical hip dislocation in the treatment of Pipkin
fractures.
55 Intertrochanteric Hip Fractures
Video 55.1 Treatment of a failed, infected osteosynthesis of a
pertrochanteric fracture.
58 Femoral Shaft Fractures
Video 58.1 Antegrade nailing with conventional entry point.
Video 58.2 C-arm based navigated femoral nailing.
Video 58.3 Comparison of femoral nailing in the supine
position with manual reduction versus lateral
decubitus position using a fracture table.
Video 58.4 Lateral decubitus position for antegrade femoral
nailing.
Video 58.5 Plating the osteoporotic femur—number and
placement of screws.
Video 58.6 Periprosthetic femur fractures: locking plate.
Video 58.7 Retrograde rodding of femoral fractures.
59 Fractures of the Distal Femur
Video 59.1 Three-dimensional (3-D) scan of an intact distal
femur demonstrating muscle and underlying
bone.
Video 59.2 Sagittal views through the distal femur
demonstrating the eccentric position of the
femoral shaft aligned with the anterior half of the
condyles.
Video 59.3 Distal femur (cadaver bone).
Video 59.4 Transmission of energy.
Video 59.5 Three-dimensional (3-D) reconstruction of
a complex distal femur fracture (floating
knee).
Video 59.6 The principle of the Dynamic Locking Screw
(Synthes) is demonstrated.
Video 59.7 Minimally invasive percutaneous plate
osteosynthesis (MIPPO) approach.
Video 59.8 Surgical procedure of a distal femoral
replacement in a case of a 76-year-old
woman with a comminuted AO type C2 fracture
with osteoporosis and pre-existing arthrosis of
the knee joint (MUTARS, KRI, Implantcast,
Germany).
Video 59.9 Torsional range of motion with hip extended.
Video 59.10 Torsional range of motion with hip flexed.
Video 59.11 Changes of the shape of the lesser trochanter
with femoral rotation.
Video 59.12 Length measurement of the contralateral side.
Video 59.13 Cable technique for frontal plane analysis.
Video 59.14 Computer navigated placement of locking
compression plate for the distal femur (LCP-DF).
Video 59.15 MIPPO approach for application of a locking
plate (LISS).
Video 59.16 MIPPO approach for application of a DCS.
xxviii Video Contents
Video 59.17 Step-by-step demonstration of how the Poller
screw corrects malalignment (varus) and stiffens
the bone-implant complex.
Video 59.18 3-dimensional reconstruction of a malpositioned
LISS plate with obvious condylar screw
overlength. Be aware of the 3-dimensional
trapezoidal shape of the distal femur.
Video 59.19 Large bone defect in the lateral femoral condyle
in a Charcot type knee after minor trauma,
treated with primary knee arthroplasty.
Video 59.20 Rotationplasty after open type O3C distal
femoral fracture with complicated treatment
course.
Video 59.21 ROM, alignment, and walking pattern at 10
years after injury.
Video 59.22 Tips and tricks for fixation in osteoporotic bone
(off-label use of implants).
Video 59.23 Minimally invasive implant removal.
Video 59.24 Posttraumatic “pseudo-instability” from
recurvatum deformity after a distal intraarticular
fracture (AO type 33C2) of the right femur,
before and after corrective osteotomy.
60 Patella Fractures and Extensor Mechanism
Injuries
Video 60.1 Augmentation of the medial patellofemoral
ligament by a free gracilis tendon graft.
61 Dislocations and Soft Tissue Injuries of the Knee
Video 61.1 Knee dislocation Schenck type IIIM JaK D3 (APM).
Video 61.2 Knee dislocation Schenck type IIIL–JaK I3 (APL).
Video 61.3 Knee dislocation Schenck type I–JaK I2 (PL).
Video 61.4 Clinical management of knee dislocation Schenck
type V–JaK III (APM) 41B3.2.
Video 61.5 Salvage knee arthrodesis using an arthrodesis
intramedullary (IM) rod for failed total knee
replacement.
64 Tibial Shaft Fractures
Video 64.1 Tibial rodding using the MHH Distraction Frame.
65 Fractures of the Tibial Pilon
Video 65.1 Surgical technique—plate osteosynthesis for tibial
pilon fractures.
Video 65.2 Surgical technique—unilateral hybrid fixator for
tibial pilon fractures.
Video 65.3 Surgical technique—Ilizarov fixator for tibial pilon
fractures.
Video 65.4 Surgical technique—interlocking nailing for the
treatment of tibial pilon fractures.
66 Malleolar Fractures and Soft Tissue Injuries of
the Ankle
Video 66.1 Compartment syndrome of the leg and foot.
68 Posttraumatic Reconstruction of the Foot and
Ankle
Video 68.1 Surgical technique—ankle arthrodesis with a
retrograde nail.
Video 68.2 Surgical technique—ankle arthrodesis by external
fixation.
Video 68.3 Surgical technique for dislocation fractures of the
Chopart and Lisfranc joints.
Video 68.4 Operative techniques for ankle arthrodesis,
including techniques with severe bone loss.
Video 68.5 Correction of poorly healed tarsal fractures.
Video 68.6 Open repair of Achilles tendon (mini-open).
69 Periprosthetic Fractures of the Lower Extremity
Video 69.1 Retrograde locked rodding for periprosthetic
fractures of the distal femur after total knee
replacement.
71 Limb Salvage and Reconstruction
Video 71.1 Leg lengthening with monorail technique.
Video 71.2 Leg lengthening with intramedullary device.
Video 71.3 The role of nerve decompression for acute and
gradual deformity correction.
Video 71.4 The hexapod fixator.
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 1 The History of Trauma Care
Justin Barr | Dale C. Smith
INTRODUCTION
Trauma derives from the Greek word τραῦµα, literally
meaning “wound.” The history of trauma is thus the history
of wounds and their management over time. Wounds provide
an unusually pellucid window into the science, society, and
culture of the past. Unlike medical diseases, they are imme-
diately identifiable and recognized as pathologic. Although
societies managed them differently across both geography
and time, they all applied their highest levels of science and
knowledge in an effort to treat patients. Wounds hurt and
kill humans in three obvious ways: (1) loss of function, (2)
bleeding, and (3) infection. Medical efforts to treat wounds
thus focused on managing these three insults. Relevant to
this textbook, trauma care knowledge predominantly focused
on the extremities until quite recently, given the high mortality
rates of wounds to the head, chest, and abdomen despite
surgeons’ efforts to intervene.
THE ANCIENT WORLD
Trauma dates to the earliest records of mankind. Archaeologic
evidence identifies wounds in A. africanus, dating from over
5 million years ago. Cave art depicts men struck by arrows.1
Some of the earliest documented healed fractures derive
from the “Iceman,” a mummified corpse found in an Austrian
glacier. Dating back over 5000 years, it presents clear radio-
graphic evidence of completely healed fractures in ribs 5
through 9 on the left side, although with unknown etiology
or therapeutic intervention.2 Skeletons of early H. sapiens
demonstrate arrows lodged in bones, particularly the lumbar
vertebrae. The location of these projectiles raises questions
about the presence of shields that might have protected
more superior structures, thus demonstrating the earliest
treatment for trauma: prevention.1 Societies have engaged
in a multitude of preventive practices over the millennia,
from the shields of Neanderthals to automatic braking on
new cars; for reasons of space, this chapter will not address
preventive medicine.
The views expressed are those of the author and do not reflect the
official position of the Uniformed Services University, the Department
of Defense, or the United States Government.
2
ANCIENT EGYPT
As one of the world’s earliest civilizations, ancient Egypt
produced some of the first medical texts describing systematic
approaches to trauma. The Egyptian medical system combined
religion, sorcery, and science in an effort to explain and
treat disease, though efforts to manage trauma were decidedly
more naturalistic.3 Healers, called swnw, cared for patients
using a variety of spells, medications, and manual interven-
tions. For snake and scorpion bites, they would suction out
blood and then apply a tourniquet; they treated burns by
applying honey and butter oils.4 Bleeding vessels were cauter-
ized or, possibly, ligated5 (Fig. 1.1).
The Edwin Smith Papyrus provides the best description
of trauma management for the era. Written around 1500
BCE and likely reflecting practice from centuries earlier, it
presents 48 wounds categorized anatomically and describes
their diagnosis, treatment, and prognosis.6 The papyrus as
it exists today starts with head injuries and moves down the
body systematically, abruptly breaking off below the shoulder.
By its nature it is almost surely a compiled teaching or refer-
ence text for young practitioners. It provided examples of
what signs to anticipate, describing a cervical dislocation that
presents with quadriplegia, including priapism and inconti-
nence (case 31).7 Although the Papyrus acknowledged the
grim outcome in that patient, for others it offered a variety
of therapeutic interventions. It recommended meat to staunch
bleeding (case 1), a stratagem used by Harvey Cushing and
others before his development, with William T. Bovie, of
electrocautery. Case 25 clearly instructs the reader on reducing
mandibular fractures, and to treat clavicle fractures the Edwin
Smith Papyrus specifies reduction, realignment, and immo-
bilization (case 35). Staffs splinted long bone fractures (case
36). Multiple preserved skeletons from the era reveal well-
healed fractures of various bones, indicating some success—
perchance or per design—in treating them.
Artwork portrays some of these medical interventions, with
paintings suggesting a healer treating the eye injury of a
workman and another setting what appears to be a broken
shoulder.4 Ancient Greeks certainly knew of and greatly
respected ancient Egyptian medicine, and some scholars have
suggested that it influenced the development of their medical
system several centuries later.8
ANCIENT GREECE
Ancient Greece provided the theoretical foundations for
medicine for the next two millennia.9 In the epic poem The
Iliad, Homer wrote of 213 casualties, with a 90% mortality
 CHAPTER 1 — The History of Trauma Care 3

Fig. 1.1 Medicine in ancient Egypt. This 20th-century rendition of ancient Egyptian medicine portrays a temple-based healer providing
succor to a patient likely suffering from lockjaw (tetanus). Note the combination of medical intervention and prayer. Like all modern reproductions,
the image suffers from 20th-century prejudices, such as the lily-white bandages that were uncommon until Florence Nightingale’s reforms in
the 1800s. (Image accessed at https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101651528-img. Reproduced courtesy of Pfizer.)

rate.10 Long-range weapons such as spears caused more injuries
but were less lethal than swords. Most warriors who died did
so before receiving any medical attention, but some lived.
Homer describes how Machaon, son of Asclepius, treated
Menelaus, husband of Helen, who had been shot with an
arrow, detailing the mechanism of injury, the anatomy
afflicted, and the treatment rendered.11 Multiple Greek vase
paintings depict similar scenes (Fig. 1.2).
Centuries after Homer, the Hippocratic Corpus came to
represent Greek medicine, constructing a system based on
the harmonization of four humors and defining disease by
an imbalance of these humors in an individual. Medical
interventions worked by maintaining or restoring harmony.
This theoretical system did little for trauma. However, with
injuries from war and daily living common, the Corpus did
address surgery as a therapy, recommending multiple means
of reducing dislocated joints and concocting various salves
to stem bleeding and soothe burns. Numerous texts provided
instruction on the splinting of broken limbs, such as Hip-
pocrates’ book Fractures, and described elaborate contraptions
to reduce fractured bones12 (Fig. 1.3).
ANCIENT ROME
The medical therapies practiced by Roman physicians and
the physiologic theory on which they are based differed little
from those of the Greeks, and much of what we think of as
Greek medicine is in fact the systematic review and consolida-
tion by a Greek-speaking practitioner in Rome named Galen.
Galen described the work of his predecessors as articulating
three broad sources of pathology: the naturals, or the normal
physiology gone awry; the nonnaturals, or environmental
factors such as climate and diet that were not inherently
good or bad but must be managed; and the contranaturals,
or forces that harm the body, such as traumatic injuries.
Although most ancient writings focused on the contranaturals
as opportunities for effective intervention, Galen and others
recognized the importance of total care of the patient for
recovery to health.9
The innovative Roman military medical system emblemized
this dedication to preventive, trauma, and convalescent care
through a remarkable organizational effort to maintain the
health of their soldiers.13 All recruits underwent screening
physicals to minimize disease at the outset. The praefectus
castorum staffed legions as the second in command and was
charged with medical care of the troops. Medici served with
the legion and provided medical care to soldiers, though
with no certification or other educational requirements before
joining. Forts—particularly larger, established facilities—
contained valetudinaria, or hospitals for the sick and wounded,
marking one of the first examples of dedicated spaces for
medical practice. Actual medical care delivered remains poorly
described and likely reflected the variegated traditions from
which the medici came. No notion of triage appears in any
text. Although archaeological expeditions have unearthed
contemporary surgical instruments, few written descriptions
of operations exist.14,15
Recent scholarship has challenged prior accounts of a
uniform system of Roman military medicine, but evidence
clearly indicates a concerted, if varied, effort by Rome to
4 Section ONE — General Principles
Fig. 1.2 Aeneas having arrowhead removed from thigh. This
first-century fresco from the walls of Pompeii provides one of the few
contemporary portrayals of ancient surgery. Here, a Greek healer uses
long-necked forceps to extract an arrow from the thigh of Aeneas,
the mythologic Trojan hero. Although stylized (few patients would
tolerate the operation standing upright), it accurately depicts the role
of the ancient surgeon, some of his tools, and the types of wounds
he treated. (Courtesy of Museo Nazionale, Naples.)
care for the legionnaires.16 Self-interest motivated the empire
more than altruism—they realized the cost of recruiting and
training a new soldier exceeded that of maintaining those
who already served—but the system they created and imple-
mented nonetheless stands apart as a state-organized, centrally
run effort for taking care of the sick and traumatically injured.
THE MIDDLE AGES
Medicine in the Middle Ages followed the humoralism
propagated by the Hippocratic Corpus and Galen.17 Gener-
alizations across centuries and countries are subject to specific
exceptions, but scholars agree on some broad similarities.
Notably, medieval medicine argued that even traumatic
injuries resulted in humoral imbalance, requiring treatment
not only for the external wound but also for the internal
pathology.18 Surgeons, who had existed informally since
antiquity, emerged in the literature for the first time as a
distinct, educated group of medical providers in the Middle
Ages.19 They held responsibility for managing wounds and
diseases affecting the exterior of the body (predominantly
contranaturals), whereas physicians focused on internal
maladies (naturals).20 Education for surgeons developed from
the apprenticeship model that characterized the previous
two millennia into a text-based curriculum steeped in both
theory and practical application.21 As universities became
Fig. 1.3 Reduction of dislocations. Illustrations from 11th-century
Hippocratic treatise On Joints demonstrating the reduction of hip and
other dislocations. Although the image heralds from some 15 centuries
after the initial publication of the book, the machinery and techniques
remained essentially unchanged. Their persistence into the 1400s
demonstrates the lasting influence of the Hippocratic Corpus on the
practice of Western medicine and surgery. (From Hippocrates, On
Joints.)
the premier sites of medical education,22 the best surgical
education slowly moved into these formal curricula.23
Despite these radical changes in the structure and education
of surgery in the Middle Ages, methods for treating wounds
largely paralleled interventions from the ancient world.24
Surgeons would wash wounds, often with wine, and dress
them. The types of dressings and salves applied varied
enormously from one practitioner to another, each convinced
his concoction superior. Texts describe various instruments
to help remove foreign bodies from the wound, as well as
instructions on which wounds to sew closed and how, as
surgeons dedicated large portions of their writing to the
management of traumatic injuries.25 Recognition of the
importance of longitudinal care emerged in the 10th century
with debates on the virtues of what we now call healing by
primary and secondary intention, with most surgeons prefer-
ring to allow the wound to granulate in over time (Fig. 1.4).
The rarity of elective invasive procedures ensured surgical
texts focused on wounds. Documents provide illuminating
evidence on ideas in trauma management but simultane-
ously problematize our understanding of actual practice. For
example, one novel methodology involved using a crossbow
to remove stuck arrows from patients.26 Crossbows became
increasingly common weapons after the 11th century, and
the arrows fired from them and traditional bows could lodge
in the body with such force that manual removal proved
impossible.27 Surgeons could tie the stuck arrow to the
bowstring of the crossbow, fire the weapon, and use the
force to extract the offending missile (Fig. 1.5). Although
efficacy remains unclear (particularly for barbed arrows),
multiple surgical texts from around Europe and over
several centuries explicate the technique and reference
its common usage. But almost no one describes employ-
ing the technique in practice, leaving actual application
undetermined.
The importance and prevalence of wounds in the Middle
Ages become obvious through their depiction in literature
at the time. Injury and death occur frequently to King Arthur’s
knights, for example, with the chest and head the most
common locations for fatal trauma.28 Although no doctor
or surgeon accompanied the knights on their quests, the

Fig. 1.4 Operating on the upper arm. This 13th-century image from
Theodoric Borgognoni’s text Chirurgia portrays a surgeon cleaning a
traumatic wound to the arm in preparation for dressing it. Theodoric
stressed the importance of approximating the wound edges to ensure
proper healing. The long robe worn by the surgeon connotes formal
training and membership in a guild/society. (From Chirurgia, by Theodoric
of Cervia, 13th century.)
Fig. 1.5 Arrow extraction by crossbow. This 13th-century illustration
shows a healer using a crossbow to extract an arrow from a wounded
soldier’s thigh. The arrow is tied to the bowstring of the weapon,
which, when fired, will vellicate the foreign body from the wound.
Although texts often described and illustrated the technique, actual
utilization is unclear; it promised poor results for barbed arrows. (From
Patijn M. The medical crossbow from Jan Yperman to Isaac Koedijck.
In: Kirkham A, Warr C, eds. Wounds in the Middle Ages. Burlington, VT:
Ashgate; 2014:197–211. Image from Guy de Chauliac, Ars Chirurgica,
Venice, 1546 [manuscript in Leiden University Library, #647 A 24, page
27v].)
CHAPTER 1 — The History of Trauma Care 5
wounded could receive care at monasteries. Other paeans
praised knights’ ability not only to endure wounds but also
to treat and heal themselves, highlighting the heroism inher-
ent in their suffering.29 This trope parlayed with the broader
meme of the wounded Christ. Christianity interwove with
most aspects of medieval society, including the practice of
medicine.30 Although some tensions between clergy and
medical practitioners existed,31 the two professions largely
cooperated, with each healer treating the wounded with their
respective, but symbiotic, therapies.32 Given the urban
concentration of formally trained healers, priests likely
performed basic wound care on a rural population subject
to agricultural trauma of falls, horse kicks, and so on. Although
these injuries and their treatment do not appear in texts,
paleopathology documents a significant number of healed
fractures from this era.33 Simple fractures were splinted and
generally required bed rest to heal; displaced fractures typically
led to extremity shortening.
Some of the best-studied medieval wounds occurred in
those who fought for the Christian church in the crusades.34
Crusaders brought physicians and surgeons along with them
from Europe, ensuring continuity of care. Of the nobility
who ventured to the Middle East, around 15% to 20% died
from disease, and another 15% to 20% died from combat
wounds; data for foot soldiers remain unavailable. Archaeologi-
cal evidence of skeletons demonstrates the devastating effect
of battlefield trauma and how commonly it afflicted the
crusaders. Spears and lances proved the most fatal instruments,
followed by arrows, which were the most common. Wounds
to the skull, forearm, and lower legs—likely the least armored
areas—were the most frequent. For head wounds without
obvious fractures, surgeons would pour black ink on the
skull to try to detect occult injuries, explore the break, remove
bone shards, and dress the wound. Of note, surgeons who
made gross errors in setting bones were punished with the
amputation of their right thumb.
THE EARLY MODERN ERA
(CA. 1450–CA. 1800)
Medicine in the Early Modern era reflected a time of change
as the humoral system of Hippocrates and Galen slowly faded
from relevance and alternative explanations of disease came
to the fore.35 Andreas Vesalius’ monumental 1543 text De
Humani Corporis Fabrica Libri Septem helped reinvigorate the
study of anatomy and demonstrated the need to rely on
personal investigation over textual authority.36 After publish-
ing, Vesalius became a military surgeon for Emperor Charles
V and subsequently his son, Phillip II, King of Spain, where
he was called to consult on the case of King Henry II of
France, who had been struck in the head with a lance during
a jousting tournament celebrating the marriage of his son.
The case brought in medical authorities from around Europe
who debated whether the brain could sustain injuries without
a skull fracture. Vesalius argued that it could and prognos-
ticated death. On autopsy, Vesalius identified cerebral
compression, a contracoup injury, and a subdural hemorrhage,
clearly proving the possibility of neurologic injury sans
fracture.37 A practically experienced military surgeon consult-
ing bedside who had agreed with Vesalius was the famous
Frenchman Ambroise Paré.
6 Section ONE — General Principles
Fig. 1.6 Amputation of leg, 16th century. This image from Hans
von Gersdorff’s Feldbuch der Wundartzney shows a leg amputation
in 1517. The patient is apparently passed out from pain with a cloth
over his eyes to keep him from witnessing the event. An assistant
holds the leg stable while the surgeon saws through the bone; the
knife for skin incision rests on a pedestal in the foreground. Unlike
Fig. 1.4, this surgeon does not wear a long robe, connoting his likely
status as a barber-surgeon similar to Paré. Although not Paré himself,
the scene accurately captures surgery in his era. Note the arterial
hemorrhage—until Petit’s tourniquet, surgeons controlled bleeding
after the amputation with cautery or (following Paré) ligation. The
standing figure sports a waterproof animal bladder over the stump
of his amputated left arm; the Greek letter tau indicates that he suf-
fered from St. Anthony’s Fire. (From Hans von Gersdorff’s Feldbuch
der Wundartzney; copyright held by SmithKline Beckman Corporation
Fund, Philadelphia Museum of Art.)
Ambroise Paré was born sometime between 1510 and 1517
just outside of Laval, France. Although never receiving formal,
university-based education in surgery, he gained extensive
experience apprenticing to barber-surgeons and working in
the massive French public hospital Hotel Dieu.38 He is perhaps
best remembered for his advocacy of ligating blood vessels
after limb amputation instead of applying the standard
contemporary therapy: cautery.39 He invented a new instru-
ment, the bec de corbin, as the first vascular clamp to grasp
vessels in preparation for their ligation.40 However, until Jean
Petit’s invention of the screw-tourniquet in 1718 to control
hemorrhage, ligation remained rare (Figs. 1.6 and 1.7).
Fig. 1.7 Amputation of leg, early 19th century. Comparing this
preanesthesia 19th-century image by surgeon Charles Bell (of Bell’s
palsy) of leg amputation against the previous figure highlights several
developments of surgical practice. Most notably, a Petit-style screw
tourniquet controls bleeding until the conclusion of the operation. The
color images portray the circular technique of amputation, which gained
popularity in the Napoleonic Wars but was largely replaced by the
flap method in the late 19th century. The line drawing in the lower
corner demonstrates concern for postoperative functionality and
possible prosthetics. (Image accessed at https://commons.wikimedia
.org/wiki/File:Plate_IX,_illustration_of_leg_amputation,_Sir_Charles_Bell
_Wellcome_L0072192.jpg.)
More important than ligation was Paré’s treatment of
gunshot wounds. Firearms were not new weapons in the 16th
century, having entered Europe by the 1320s, but they had
received little attention in medical or surgical texts until
after the development of printing.41 Gunshot wounds were
particularly challenging when fracturing bones. The Hip-
pocratic bench and bed rest were generally ineffective, and
surgical intervention to align bones suffered from inadequate
anatomic knowledge and nearly omnipresent infection.
Military surgeons often resorted to amputation, but even
this procedure had high mortality rates.42 French surgeon
Jean de Vigo discussed their management in his 1514 book
Practica in Arte Chirurgica Copiosa, which, translated into most
European languages, was the standard surgical text of the
era used by Paré and most other practitioners. Firearms clearly
caused devastating wounds, with posttraumatic sequelae
resembling the effects of animal poison bites; Vigo assumed
that some of the pathology resulted from a poisonous effect
of the gunpowder. As such, he recommended pouring boiling
oil into gunshot wounds to neutralize the poison and facilitate
healing. With this instruction at hand, Paré set off on his
first military campaign in 1537, when the French sought to
wrest Turin, Italy, from the Holy Roman Empire. At that
time, Paré had never even seen a patient with a gunshot
wound.43 In 1537 at the siege of Turin, the number of casual-
ties exhausted his supply of oil.
At last my oil lacked and I was constrained to apply in its place
a digestive made of yolk of eggs, oil of roses and turpentine. That
night I could not sleep at my ease, fearing by lack of cauterization
that I should find the wounded on whom I had failed to put the
said oil dead or empoisoned, which made me rise very early to

visit them, where beyond my hope, I found those upon whom I
had put the digestive medicament feeling little pain, and their
wounds without inflammation or swells having rested fairly well
throughout the night; the others to whom I had applied the said
boiling oil, I found feverish, with great pain and swelling about
their wounds. Then I resolved with myself never more to burn
thus cruelly poor men wounded with gunshot.44
Paré’s new treatment of gunshot wounds—avoiding the
application of boiling oil—rapidly spread through contem-
porary surgical practice and brought him lasting fame. It
also contributed to the general trend in early modern
medicine of reporting and relying on personal, empirical
observation to shape treatment instead of the dogmatic textual
adherence that characterized the tomes of earlier eras.
The early modern era was also significant for the estab-
lishment and organization of formal military medicine. In
this era, political states emerged, and these states required
professional armies to expand their territory and guard against
invasion.45 States created and funded a medical system to
support these armies, evidenced by the contemporaneous
founding of European surgical societies that went on to
establish common standards of training and practice.46
Neither needing nor wishing to compensate university-
educated, socially elite practitioners, military medicine
often featured apprentice-trained surgeons who were
required to manage a diverse array of medical and surgical
conditions.47
Economic changes prompted urbanization in the 18th
century, which led to greater opportunities for medical
investigation as patients more often interacted with a formal
healthcare system that increasingly received state funding.
Although this new social condition would support many
changes in medical thinking, probably the most important
in the history of trauma was the introduction of the word
shock by John Sparrow in his 1740 translation of LeDran’s
Observations in Surgery. Many 18th-century surgeons com-
mented on the decline suffered by patients after wounding,
whether by trauma or by the surgeon. John Hunter opined
that the body sympathized with the wounded part48; his student
Astley Cooper defined it as a constitutional irritation; and
George James Guthrie, who bridged the 18th and 19th
centuries, described a constitutional alarm. The French
surgeon Henri LeDran had said the body suffered a jar
(secousse), which Sparrow translated as shock.49 The term was
uncommon until the later part of the 19th century, probably
related to Guthrie’s adoption of it after the Crimean War.
Regardless of the term, the physiologic changes were real
and surgeons would increasingly work to combat them in
their trauma patients.
TRAUMA MANAGEMENT IN THE
19TH CENTURY
NAPOLEONIC WARS
The Napoleonic Wars (1793–1815) dominated the early
decades of the 19th century politically, militarily, and medi-
cally. Losses exceeded three million Europeans; like all
previous conflicts, deaths from disease far outnumbered
combat fatalities, but traumatic wounds still numbered in
CHAPTER 1 — The History of Trauma Care 7
the hundreds of thousands, caused predominantly by small
arms fire.50 Few new therapies emerged, but the impact of
the systemization of surgery in the 18th century is obvious
from discussions of postsurgical care. The debility that fol-
lowed wounding, whether called shock or something else,
was clearly articulated and surgeons discussed how to prevent
and treat it. Clinically, debates centered on the timing and
technique of amputation: whether to amputate immediately
after injury or wait several days for the unhealthy tissue to
demarcate. Supporters of the circular and flap techniques
each maintained the supremacy of their method. Although
the wars ended without substantial agreement of proper
technique, almost all surgeons insisted that early amputation—
within 4 hours of injury—improved patient survival. The
prodigious number of amputations led surgeons to acquire
tremendous experience and skill, with French surgeon
Dominique-Jean Larrey allegedly completing 200 amputations
in 24 hours after the Battle of Borodino in Russia.51
Other interventions remained limited. Surgeons occasion-
ally trephined skull wounds and inserted chest tubes to drain
secretions after thoracic trauma. Anecdotal reports attest to
their sporadic success, but these therapies did not see
widespread use, and by the end of the wars, many leading
surgeons discouraged them.50 Soft tissue injuries were drained
and bandaged; practitioners rarely sutured wounds closed
as healing by secondary intention remained safer. A great
deal of trauma practice (especially outside the military)
involved waiting for nature to heal the wound. Given available
remedies, the gunshot wound, particularly when compounded
by long bone fracture, received the most attention from
surgeons both in written texts and on the wards.
Developments in military medical organization exceeded
clinical advances. The French had a well-established, well-
organized military medical system for much of the 18th
century, but the turmoil of the French Revolution disrupted
the medical profession both in and out of uniform.52,53 After
military medical disasters in 1792–1793, the French strove
to create a more effective system.54 They insisted on educa-
tional standards, instituted warrant rank for at least some
uniformed doctors, and created hospitals both to care for
the injured and to train the next generation of clinicians.
Several French physicians and surgeons played important
roles in this reform (and the establishment of the Paris School
of Medicine postbellum), but none rose to the enduring
international fame of Dominique-Jean Larrey55 (Fig. 1.8).
From treating revolutionaries struck down storming the
Bastille in 1789 to his capture at Waterloo in 1815, Larrey
served throughout the Napoleonic Wars in nearly every
theater.56 He made many contributions to the organization
of medical services, diagnosis of disease, and care of the
injured; he remains best known for his “flying ambulances,”
designed to carry surgeons forward and then spirit wounded
soldiers off the battlefield to the nearest medical facility for
recovery. Larrey recognized that amputation could be avoided
in many cases if the limb was immobilized soon after fracture,
and he and others experimented with stiffening materials,
usually starch in one form or another, during and after the
wars. When necessary, forward surgical amputations made
possible by the flying ambulance surgeons likely contributed
to safe convalescence, though any confirmatory data are
lacking. The vehicles certainly made transportation of the
patient more convenient and reduced the pain of transit in
8 Section ONE — General Principles

Fig. 1.8 Larrey and his flying ambulances. Larrey is dramatically

handed a scalpel as he prepared to operate on the wounded soldier
to his right. The background soldiers firing accurately portray Larrey’s
proximity to the fighting. A flying ambulance on the left of the painting Fig. 1.9 Industrial surgery. In this 1895 painting titled “A Wounded
stands ready to whisk the wounded rearward. (Image accessed at Workman,” artist Erik Henningsen depicts an industrial laborer, injured
http://aqwedc.free.fr/spip2112/spip.php?article183. Courtesy Académie on the job, receiving care from the company surgeon. Note both the
Nationale de Médicine, Paris, France.) proximity of the “clinic” to the worksite and the limited resources
present. The cross in the foreground marks the grave of an unlucky
coworker who apparently succumbed to his injuries. (Courtesy Statens
Museum for Kunst. Image accessed at https://useum.org/artwork/A
an era of minimal analgesics. As a result of his experiences, -Wounded-Workman-Erik-Henningsen-1895.)
his personal association with Napoleon, and his prodigious
postwar writings, Larrey emerged as the prototypical surgeon
of the era, although in Britain Charles Bell and James Guthrie
remained best known.57

MID 19TH CENTURY

The years after the Napoleonic Wars also marked the coming
of the Industrial Revolution. In this period, the same machines,
railroads, and factories that came to dominate sectors of the
economy also produced a rash of traumatic injuries. Injuries
and disease among the working poor led to voluntary (phil-
anthropic) hospitals in the Anglo-American world of the
18th and 19th centuries. Other countries had more organized
church and then government sponsorship.58 London’s Charing
Cross hospital, for example, treated over 66,000 traumatic
injuries between 1834 and 1850; other facilities published
similar statistics.59 Workers were injured on the job and rushed
by their mates to the nearest hospital where a volunteer
surgeon was summoned to provide care. As the century Fig. 1.10 The introduction of ether anesthesia. First public dem-
progressed and such injuries increased in number, surgeons onstration of ether anesthesia, Massachusetts General Hospital, 1846,
staffed the casualty services on a more routine basis. An as John Collins Warren removes a vascular tumor from a patient’s
entire specialty of Railway Surgery emerged to care for the neck while the dentist William Morton administers ether anesthesia.
proliferation of trauma from both building and riding the (Image accessed at http://www.massgeneral.org/pathology/training/
rails.60 Industrial injuries that reached a hospital typically mgh_case_records_history.aspx.)
afflicted the extremities, providing surgeons a greater
opportunity to intervene than abdominal or thoracic wounds.
The practice of industrial medicine grew substantially in the such as Stromeyer commonly used sand—either burying a
19th century to care for these patients61 (Fig. 1.9). Through limb or surrounding it with sandbags—to immobilize it.
the 1840s, many of these clinicians had served in the Napo- The other factor that led to a decreased rush to amputate
leonic Wars and brought their wartime experience to the was the introduction of inhalation (ether) anesthesia in 1846
bedside.62 Their surgical expertise proved particularly useful (chloroform followed in 1847)65 (Fig. 1.10). The focus of
in managing the orthopaedic trauma and crush injuries that anesthesia has largely been on pain control, but ether also
afflicted workers. As the generations changed and war experi- gave surgeons the gift of time and a still patient on whom
ence became less common in shaping practice, surgeons to operate. The nature and role of pain in the body was not
began adopting more conservative principles, such as those well understood, and some physicians feared interrupting
of the Hanoverian surgeon Georg Louis Stromeyer.63,64 normal healing processes. Guthrie, working with John Snow,
Stromeyer argued that even in compound comminuted led speculation on the role of anesthesia in shock by his
fractures the bone would heal if the suppuration could be follow-up on patients reported from the Crimean War.66 As
avoided, and the rush to amputation slowed. Practitioners ether and chloroform came into increasingly common use,

the pace of operations slowed, but the postoperative mortality
rate did not, raising questions about the propriety of elective
operations.67
Simultaneously, the late 19th century experienced renewed
attention to anatomy and surgical education. An ongoing
effort since the Renaissance, anatomic studies proved socially
distasteful in western Europe, largely due to the grave robbing
(and even murder) involved in acquiring bodies.68 Through
the course of the 19th century, society enacted laws permitting
dissection, allowing surgeons to study anatomy freely.69,70 This
improved knowledge continued a trend toward more conserva-
tive operations and, later, resection therapy as the hallmark
of surgical care. In orthopaedic trauma, this conservatism
was assisted by the introduction and rapid spread of plaster
of Paris casting. Antonius Mathijsen (1805–1878) was born
in the Netherlands and spent his working life as a medical
officer in the Dutch Army. Building on suggestions in military
campaigns of the Napoleonic era to stiffen bandages, he
introduced plaster of Paris bandaging in 1851. Nikolai Iva-
novich Pirogov (1810–1881), a Russian army doctor and
professor of surgery, heard of Mathijsen’s work and applied
it in the Crimean War, where it attracted significant attention
and improved the care of closed fractures; open wounds
remained deadly.
AMERICAN CIVIL WAR
In the 1860s the American Civil War again created hundreds
of thousands of trauma patients for surgeons to manage.
Anesthesia spread rapidly such that in the Civil War, only
254 of the documented 80,000 operations on Union sol-
diers proceeded without anesthesia.71 (Most Confederate
medical records burned in Richmond in 1865, limiting
analysis of their side.72) Anesthesia undoubtedly benefited
patients by providing them pain-free surgery, but it did not
notably increase either the number or variety of operations.
Intracranial, intrathoracic, and intra-abdominal operations
remained exquisitely rare—and rarely successful. Approxi-
mately 62% of patients with penetrating chest wounds and
89% of patients with abdominal wounds in the Civil War
died.73 Therapy again focused on mangled extremities
(Fig. 1.11).
Trauma caused by the new minie bullets resulted in devastat-
ing injuries. Claude Etienne Minié (1804–1879) introduced
the new muzzle-loading spin-stabilized rifle, increasing
projectile velocity and tissue destruction significantly. In
wounds limited to soft tissue, surgeons tried to remove the
bullet and other foreign bodies. Those affecting the bone
chiefly resulted in amputation, of which there were approxi-
mately 30,000 by Union surgeons, who preferred the flap
technique over circular methods. Again, early amputation
proved superior to delayed operations. Overall, about 26%
of amputees died from their wounds, although the rate
differed dramatically by anatomic location, with hip disarticula-
tions having a nearly 100% fatality rate.71 They also pioneered
more conservative operations that removed segments of
damaged bone and soft tissue while preserving the limb.
Much death resulted from hospital gangrene and erysipelas.
Although Civil War doctors did not yet recognize the germ
theory of disease, they did come to realize the infectious
nature of these septic (meaning putrid or rotten) conditions
and experimented with various therapies to prevent and treat
CHAPTER 1 — The History of Trauma Care 9
Fig. 1.11 Civil War surgery. Hospital scene at Battle of Antietam
(1862) with surgeons operating outdoors, a common practice to make
best use of available light. The bucket in front of the operating table
was a likely receptacle for amputated limbs. Note the line of Letterman’s
ambulance wagons in the background. (From Bollet AJ. Civil War
Medicine: Challenges and Triumphs. Tucson, AZ: Galen Press, Ltd;
2002:100. Original source in Harper’s Weekly and in public domain.)
them, including application of antiseptic solutions such as
bromine.74
Like Larrey’s contributions before, some of the most
important developments in trauma care in the Civil War
resulted from infrastructure improvements, most famously
the evacuation system designed and championed by Jonathan
Letterman.75 Providing integrated ambulance units and
organization of field hospitals, it established the model for
military medical evacuation chains for American and Euro-
pean armies through the First World War.
Critically, after the war, the US Army published the heralded
Medical and Surgical History of the War of Rebellion.76 This docu-
ment built on the nascent science of medical statistics,
pioneered in the early 19th-century public health move-
ments.77 Whereas information from conflicts predating the
Napoleonic Wars usually represented haphazard collections
from individual officers, starting in the 1800s militaries made
a concerted effort to track medical data. This practice,
epitomized by the Medical and Surgical History, not only enabled
armies to improve the health of their soldiers but also allowed
others to study, appreciate, and learn the lessons of trauma
care.78 Its six volumes compiled the most substantial accumula-
tion of medical data ever before seen. Because literally
thousands of American practitioners contributed to the Medical
and Surgical History, it remained widely popular for a genera-
tion and was vigorously mined by European surgeons.79
LATE 19TH CENTURY
Doctors who fought in the Civil War returned home to apply
their knowledge to civilian patients. The US Army had only
114 medical officers in 1861; by the end of the war, over
12,000 physicians served Union forces—a substantial portion
of America’s clinicians.73 They brought back anatomic
knowledge, skills in surgery, and experience caring for injured
patients; as a result of their service, they elevated the field
in respectability and importance.80 Recognizing the benefit
of hospitals, they helped establish these institutions as
mainstays of medical and surgical care. Their exposure to
10 Section ONE — General Principles

Fig. 1.12 Listerism. In a reenactment of his first published case, Joseph Lister cares for the compound leg fracture of a young boy by dressing
the injury with carbolic acid–soaked guaze to prevent infection, an intervention that saved both life and limb. Once proven effective for compound
fractures, Listerism expanded to traumatic and elective surgery. (Courtesy Pfizer; image available from National Library of Medicine at https://
collections.nlm.nih.gov/catalog/nlm:nlmuid-101651506-img.)

contagious diseases in camps and military hospitals along

with the novel efforts to control suppuration primed the
profession to accept the germ theory of disease in the coming
decades.74
Just 2 years after the US Civil War ended, Joseph Lister,
working on the casualty ward of the Glasgow Royal Infirmary
with compound fracture cases from street accidents, published
his now classic article describing antiseptic surgery, where
he applied carbolic acid to sterilize the wound and prevent
infection.81 Lister’s discovery was part of a gradual acceptance
of the germ theory of disease.82 Although it took decades
for antiseptic (and later aseptic) surgery to become standard
of care,83 this development eventually expanded the number Fig. 1.13 Founding of the Deutsche Gesellschaft für Chirurgie,
and repertoire of operations surgeons could perform84 (Fig. 1872. This painting serves as a synechdoche not only for the formation
of various surgical organizations but also for the importance of military
1.12). By 1876, when Lister visited America and began to
surgery to the civilian profession at the time. From left to right: Richard
convert leading US surgeons to his ideas,85 there were new von Volkmann (secretary), Johann Friedrich August von Esmarch,
hospitals in hundreds of American cities and towns to care Heinrich Adolf Bardeleben, Bernhard Rudolf Conrad von Langenbeck
for the injuries associated with the rapidly growing Industrial (chairman), Theodor Billroth, Victor von Bruns, Gustav Simon, and
Revolution.86 From the burns of the steel mills to the crush Ernst Julius Gurlt. (Image accessed at https://upload.wikimedia.org/
injuries of the rail yards to the thousands of mangled arms wikipedia/commons/3/39/Gr%C3%BCnder_Dt._Ges._Chirurgie.jpg. Public
and legs from open gears, trauma was common in the late domain.)
19th-century city and industrial town. The prevalence of
trauma prompted ongoing discussions in new professional
organizations such as the American Surgical Association thermometer and sphygmomanometer as well as new notions
(founded in 1880) and the Deutsche Gesellschaft für Chirurgie of pathophysiology to bear. The care of trauma patients was
(1872) that fostered shared knowledge and experience87,88 now studied with the same rigor and basic sciences as the
(Fig. 1.13). Together now, surgeons and physicians built on rest of medicine, spurring progress and innovation through
the foundation of scientific investigation to explain disease. the 19th and 20th centuries.
The same germs that caused infectious diseases contaminated One late 19th-century invention further shaped 20th-
wounds as well, bringing novel technologies such as the century medicine: radiographs. Like anesthesia and antisepsis

before it, this new technology took time to become standard
of care.89 William Roentgen’s discovery of radiographs in
1895 and their deployment to war from 1896 (Italian-Abyssian
War) onward greatly improved the ability of military surgeons
to localize foreign bodies, identify injuries, and treat the
injured.90 The US military deployed them to Cuba in the
1898 Spanish-American War, but limitations in technology
and interpretive ability rendered them more a curiosity than
a valuable adjunct to care.91
Other innovations made a significant difference in the
Spanish-American War.92 Antiseptic bandages and attempts
at aseptic surgery graced the battlefield, reducing infection
rates. Amputations made up approximately 40% of all opera-
tions, compared with nearly 75% in the Civil War, as more
conservative interventions on extremities and surgery on the
abdomen and chest became increasingly common. Although
routine wound débridement, fluid resuscitation, and standard
operative fixation of fractures would not arrive until the 20th
century, trauma care improved considerably by the turn of
the century.
TRAUMA MANAGEMENT IN THE
20TH CENTURY
As operations increasingly expanded into the chest and
abdomen in the 20th century, surgeons experienced, and
investigated, a broader array of complications. Physiologic
questions about pressure gradients across the chest wall, or
why bowels stopped moving after laparotomy, filled the lit-
erature. Most disconcertingly, surgeons wondered why a
technically excellent operation still ended with the patient
dying of “shock.” Different surgeons proposed various etiolo-
gies, including blood pressure, blood loss, anesthetics, or
sympathetic nervous responses, but no single explanation
sufficed. Microbiology provided some clues. Paul Friedrich’s
studies of the late 19th century showed that it took roughly
6 hours for germs in a wound to enter the bloodstream and
cause systemic detriment93; this finding contributed to the
adoption of débridement in the First World War. In 1897
Carl Flügge demonstrated the potential importance of droplet
transmission of germs and almost immediately Jan Mikulicz-
Radecki began using and advocating a gauze mask in the
operating room.94 The steady progress in aseptic technique
slowly improved outcomes, but much remained empirical
(and idiosyncratic) in trauma care.
WORLD WAR I
As the first major, international European war since Napoleon
lost at Waterloo (1815), World War I (WW I) ravaged the
continent and its inhabitants. Like medicine, war had changed
substantially in the intervening century. Machine guns, barbed
wire, and rapid-fire artillery created stagnant, deadly trench
warfare, further complicated by the deployment of poison
gases. Submarines stalked the oceans and airplanes swarmed
the skies.95 New military technology created casualties in
heretofore unseen numbers and magnitude, severely taxing
the successful management of trauma.
Combatant forces responded by expanding and redesigning
military medical systems. They recruited tens of thousands of
civilian physicians who helped provide care, charging these
CHAPTER 1 — The History of Trauma Care 11
unevenly trained practitioners to treat massive numbers
of horribly wounded patients, with predictably discrepant
outcomes.96 Building on the lessons of Larrey and Letter-
man, countries created evacuation chains that emphasized
early and forward surgery. Disorganized in 1914, by 1915
an effective system was in place. For British and American
(after 1917) forces, the Casualty Clearing Station (CCS) and
Mobile Hospital (US) served as the primary locus for forward
care. Functioning sometimes within enemy artillery range,
CCSs expanded to hundreds of beds, triaging incoming
wounded, operating on the injured, and determining who
could return to duty and who required evacuation for further
management97 (Fig. 1.14).
Surgeons at the CCS confronted two major problems:
resuscitation and wound infection. Despite efforts at early
evacuation, the enormous numbers of casualties (over 60,000
on the first day of the Battle of the Somme) resulted in
patients taking hours or days to reach definitive medical
care, often cold, wet, malnourished, and exhausted.98 Those
who survived evacuation and triage commonly arrived in
shock, a condition still poorly understood at the time.
Contemporary explanations varied from George Crile’s theory
of vasomotor malfunction causing venous dilation to Walter
B. Cannon’s idea that acidosis resulted in blood pooling in
the abdomen.49 In 1917 an Anglo-American conference
featuring the world leaders in pathology convened to discuss
the subject but left it unresolved.99 Surgeons on the front
line noted that “although physiologists have for years past
been trying to define shock for us, we clinicians are fairly
well agreed upon the matter,” diagnosing patients based on
tachycardia, hypotension, tachypnea, and altered mental
status.100 Treatments varied but centered on keeping the
patient warm and dry. Many doctors attempted fluid resuscita-
tion through saline enemas, subcutaneous injections, and
intravenous boluses of both crystalloid and colloid solutions,
though in volumes (typically less than 1 liter) that in retrospect
explained their relative inefficacy. Toward the end of the
war, blood transfusions became more common with the
establishment of embryonic blood banks (Fig. 1.15).101
Fig. 1.14 World War I military surgery. This busy diorama captures
the chaos of a World War I battlefield. In the foreground a team of
surgeons operate in a bunker marked atop by a pitifully drooping red
cross. The white clothing and dressings nod to attempts at sterility,
as does the primitive autoclave on the table. Notice, however, that
no members of the team don masks, gloves, or headcoverings. In the
background, shellfire continues as an ambulance either receives or
unloads casualties carried by teams of stretcherbearers over the uneven
ground cut by barbed wire and scarred by high explosives. (Courtesy
Science Museum, London. From the Wellcome Collection; available at
https://wellcomecollection.org/works/x7ds6fru?query=great+war+forwa
rd+treatment.)
12 Section ONE — General Principles

Fig. 1.15 Blood transfusion kit. This British blood transfusion kit from circa 1917, designed by Geoffrey Keynes, exposes the challenges of
frontline transfusion in the First World War where physicians lacked access to blood banks. Transfusions were minor surgical procedures,
obtaining blood from a willing donor and directly infusing it into the patient. This kit includes special equipment to regulate the rate of flow.
Keynes went on to found London’s blood transfusion service in 1921. (Courtesy Science Museum, London. From the Wellcome Collection; available
at https://wellcomecollection.org/works/gmz8tngz?query=transfusion+kit+keynes.)

Patients who survived the initial trauma and shock of their
wounds risked dying from infection. Manure-fertilized fields in
France combined with unsanitary conditions of the trenches
where, according to one military medical manual, “the earth
teemed with micro-organisms” to contaminate wounds.102
Despite the acceptance of the germ theory of disease, infection
felled thousands of wounded soldiers, with gas gangrene
and tetanus afflicting over 12% of British cases in 1915, with
nearly a 60% mortality rate.103 In the first year of the war, an
estimated 70% of France’s 70,000 amputations resulted from
efforts to control infection.104 Before antibiotics, surgeons
depended on a combination of débridement and antiseptics.
Hearkening back to Listerian principles, antiseptics included
topical (British and American) or intravenous (German)
solutions that killed cells on contact and included formulas
ranging from hyperosmolar saline to bleach.105 The best-
known system, the Carrel-Dakin method, included a series
of integrated drainage catheters and remained in use for
civilian trauma through World War II (WW II), when penicillin
largely replaced it.106 Base hospitals across France had wards
filled with Balkan frames to provide traction for fractured
limbs (presumably originating from the Balkan Wars of 1911
and 1912) and Carrel-Dakin apparatuses for the prolonged
process of treating compound fractures.
These antiseptics buttressed but did not replace effective
surgical débridement. Wounds in the Boer and Russo-
Japanese Wars seldom suppurated, supporting conservative
management.107,108 The heavily contaminated fields of
western Europe, and often prolonged evacuation times,
vitiated this doctrine and led surgeons to operate on almost
every penetrating wound, removing dead tissue and foreign
bodies in an effort to prevent infection.109 Whereas wound
débridement was rare in 1914, by spring 1917 it had become
expected in all armies and has remained a core principle of
trauma surgery.103 This strategy of débridement extended to
abdominal wounds, as the trauma laparotomy emerged as
standard of care by 1916.110 A rare example of the military
adopting a civilian-initiated therapy, laparotomy dramatically
improved outcomes for penetrating abdominal trauma
from mortality rates exceeding 80% in 1914 to under 40%
by 1918.
Later in the war, CCSs began to specialize. Harvey Cushing
famously pioneered modern neurosurgical interventions for
head trauma, although his work had greater historical than
clinical significance.111 The advent of gas warfare presented
an entirely new type of injury to surgeons who invented ad
hoc prophylactic and treatment regimens that came to include
masks, inhaled oxygen, various emollients for the skin, and
venesection.112 Surgeons also confronted nonphysical trauma
in large numbers, with the label of “shell-shock” applied to
those suffering neuropsychiatric injuries.113 Despite the
emergence of various exotic therapies, standard management
had surgeons rest patients close to the front lines, allowing
most to return to duty. In orthopaedics, the introduction of
the Thomas splint in 1916 reduced mortality rates from femur
fractures from 80% to nearly 15%114 (Fig. 1.16). Operative
repair of fractures remained rare, but orthopaedic surgeons
parlayed their success in the Great War into increased

Fig. 1.16 Thomas splint. One of the original Thomas splints to treat femur fractures that dramatically lowered the mortality rate from the
injury. (Courtesy Science Museum, London. From the Wellcome Collection; available at https://wellcomecollection.org/works/mgu6qt9x?query=
thomas+splint.)
professional stature.115 The high volume of maimed men
catalyzed the growing field of rehabilitation medicine.116
INTERWAR YEARS
The period between World Wars I and II was notable for
several significant clinical developments. Germans discovered
the first antibiotics in the form of sulfa drugs, which spread
throughout the globe in a continued effort to manage infec-
tion. Through most of WW II, surgeons sprinkled sulfa powder
onto open wounds, trying to limit the bacteria load.117 Building
on the success in battle, call-in blood donor programs and
then civilian blood banks emerged in the 1930s, first in the
Soviet Union and later in the United States and Western
Europe.118 In the Spanish Civil War, Joseph Trueta published
on the closed treatment of fractures and other wounds,
advocating for radical exposure and débridement, followed
by prolonged casting.119 For trauma, among the most impor-
tant contributions was the demonstration by Alfred Blalock
that fluid loss (chiefly blood) was the primary etiology in
shock, and that fluid replacement, in significant volume, was
the first key to immediate therapy.120
These years are also notable for the first glimmers of
organized trauma care. In 1922 the American College of
Surgeons created the Committee on Trauma (originally the
Committee on Fractures), which began to focus on systemic
interventions to improve outcomes for patients with traumatic
injuries both before reaching a hospital and after. The
founding of the American Association for the Surgery of
Trauma (AAST) in 1939 marked an important organizational
moment for the field. The stimulus for the organization
came from a 1937 meeting of the Western Surgical Association,
which had only one trauma surgery paper (on hip fractures)
featured on its program. A group of surgeons recognized
the general, national paucity of trauma presentations and
CHAPTER 1 — The History of Trauma Care 13
banded together to form a society dedicated to the cross-
disciplinary study and management of trauma.121 Composed
chiefly of general and orthopaedic surgeons, it met annually
and eventually published its own journal to disseminate both
science and practice.122 This foundation provided a crucial
forum for trauma research, albeit mostly still anecdotal.
Previously a topic of discussion during wars and frequently
ignored in peace, with the AAST and Committee on Trauma,
trauma surgery was starting to emerge as a defined field of
study and practice. But before the society could firmly take
root, WW II broke out.
WORLD WAR II
Optimal clinical surgery did not change substantially between
World Wars I and II. The operative plan of controlling
hemorrhage and wide débridement remained in place.123
Although the CCS that formed the mainstay of operations
in WW I did not adapt well to mobile warfare, the general
philosophical and logistical commitment to forward surgery
continued in this conflict through field hospitals and the
US Army Auxiliary Surgery Teams.124 The tanks and trucks
associated with mobile warfare dramatically increased the
number of burn injuries in combat.125 They also combined
with airplanes to shorten the time between wounding and
definitive surgery. Although aeronautical evacuation did not
extricate men from the front lines, it did transport them to
base hospitals and surgical specialists with an ease and rapidity
heretofore never seen.126 It proved particularly valuable for
extremity trauma, where prolonged vehicular rides over
rugged roads caused not only suffering but also worsening
damage to bone and soft tissue (Fig. 1.17).
Building on studies of shock in WW I and the interwar
period, military physicians worked to diagnose the pathology
quickly and initially treated it with large-volume administration
14 Section ONE — General Principles

Fig. 1.17 Loading wounded into a C-46 plane for evacuation. Like blood transfusions, some early attempts at evacuating wounded via
airplane occurred in World War I, but the technology (and military situation) limited its applicability. With the production of more powerful airframes,
aeroevacuation became more common, first in the Spanish Civil War and especially in World War II. The powerful C-54 enabled transoceanic
carriage, bringing injured US service members to specialists in the United States mere weeks after being wounded. By the end of the war,
almost 1.2 million wounded American soldiers benefited from aeroevacuation. (From Otis Historical Collection of the National Museum of Health
and Medicine. Public domain.)

of blood plasma, which, unlike red blood cells, had a long
shelf life that facilitated logistics. However, experience in
North Africa quickly demonstrated the insufficiency of
albumin and other colloids.127 First the British, then after
some delay the Americans recognized the superiority of whole
blood transfusions, prompting a doctrinal shift to prioritize
the use of blood and a major logistical effort to obtain it
from donors near and far128 (Fig. 1.18).
Perhaps most significantly, the United States developed
penicillin—at a cost equal to that of the Manhattan Project.129
Widely available to the military by mid-1944, the new “miracle
drug” dramatically reduced the incidence of wound infections.
Rapidly replacing the elaborate Carrel-Dakin method, the
medication also permitted more limited débridement of
wounds, enabling conservative surgery to preserve limbs and
tissue. Penicillin epitomized the stimulatory effects of war
on trauma care, marshaling the economic and industrial
resources of a country to address a clear clinical need with
evidence of efficacy demonstrated by controlled hospital trials
and broad field experience.
MID-CENTURY DEVELOPMENTS
The war introduced trauma problems that remained for
further research to explain, such as renal failure and burns.
The London Blitz brought the problem of crush syndrome,
and its accompanying kidney injury, to the fore.130 Known
in Japan and Germany before the war, crush syndrome
remained unrecognized in the West until Bywater’s classic
description of British civilians suffering from prolonged blunt
trauma after bombings.131 Attention to burns also increased
in the 1940s as a result of military and civilian events. Texts
described attempts at caring for burns since the Egyptian
Ebers Papyrus.132 For centuries clinicians had recognized
that burn patients died from causes other than the thermal
trauma, often attributing deaths to poisons released by the
heat. Frank Underhill’s pioneering work in 1920s New Haven
demonstrated the critical importance of fluid loss in patient
mortality, prompting a therapeutic turn toward intravenous
rehydration. Later investigators developed specific formulae
to replenish fluid appropriately, accounting for patient weight
and burn size, with E. I. Evans publishing the first in 1952.
Multiple variants followed, including the famous Parkland
Formula in the 1960s.133 Occlusive dressings, promoted by
Harvey Allen in 1942, soon covered burns, although skin
grafting, popularized by John Staige’s pinch grafts in 1914,
grew more common in the 1940s after the invention of
dermatomes. The disastrous Coconut Grove Fire of 1942
that killed nearly 500 patrons illuminated the importance
of these investigations.134 Victims were transported to both
the Massachusetts General Hospital (MGH) and Boston City
Hospital. Although both facilities provided modern, efficient
care, the MGH focused on fluid replacement from the new
hospital blood bank, as well as pioneering efforts using
penicillin mold.135 Whereas about 30% of patients treated
at Boston City Hospital perished, none did at MGH. This
catastrophe demonstrated the importance of fluid resuscita-
tion and the possibility of antibiotics. It also prompted the
 CHAPTER 1 — The History of Trauma Care 15

Fig. 1.18 Blood banking in World War II. World War II marked a transition to whole blood transfusion for casualty resuscitation. When
demand for blood outstripped local supply, the military and Red Cross coordinated an international logistical effort to ship American blood
overseas. Here, blood collected in the United States makes it way to the front lines of Belgium in 1944 in specialized refrigerated trucks. (From
Otis Historical Collection of the National Museum of Health and Medicine. Public domain.)

US Army to create a burn center to study the pathology and
led a young surgeon, Francis Moore, to research metabolic
variables in trauma patients.
By the middle of the 20th century, nations had established
markedly different healthcare systems in terms of specializa-
tion, healthcare access, openness to innovation, and so on.
They also experienced different amounts and proportions
(e.g., blunt vs. penetrating) of trauma. Although trauma
pathology is universal, its management in different healthcare
systems varies across the globe. The remainder of this chapter
will concentrate on the United States of America because of
its widespread influence and the import of innovations that
occurred within.
FROM THE KOREAN WAR THROUGH THE WAR
IN VIETNAM
Five years after WW II ended, the United States found itself at
war again, this time on the Korean Peninsula. The antibiotic
armamentarium had expanded to included broad-spectrum
drugs in the streptomycin family,136 and the military quickly
established a trans-Pacific supply chain transporting fresh blood
from the United States to Asia.137 Hemodialysis machines,
deployed to war for the first time, treated trauma patients in
acute renal failure, markedly improving survival.138 By 1953
most combatants wore body armor, increasing survivability
and redirecting trauma from the trunk to the extremities.139
Famously, Mobile Army Surgical Hospital (MASH) units
provided frontline surgery and supportive care140 (Fig. 1.19).
Although novel in organization, their conceptual underpin-
nings date to the work of Larrey and Letterman. The static
nature of the war led to MASH units functioning as de facto
evacuation hospitals; they quickly captured popular attention,
appearing in movies and articles of the day and ultimately
featuring prominently in the television series M*A*S*H.141
At the MASH, wounded service members encountered
surgeons trained far more extensively than in previous
conflicts. World Wars I and II had conclusively demonstrated
the benefit of specialized medicine, but militaries lacked
adequate numbers of trained surgeons. In the United States,
residencies in all surgical specialties remained rare before
WW II, educating an elite group of surgeons but leaving
general practitioners to care for the majority of patients.
After WW II, residency positions expanded exponentially.142
With the expansion of residencies, specialists (or at least
partially trained residents) deployed to MASH units and other
forward hospitals in Korea, providing expert care. Their
difference manifested in vascular surgery. Whereas in previous
conflicts surgeons ligated essentially all damaged arteries, in
Korea they began to repair them with suture and grafts.
These efforts dramatically reduced the amputation rate among
the wounded and helped catalyze the spread of the technique
in civilian surgery.143
Building on experience in the wars, Francis Moore at
Harvard conducted a series of investigations that used radio
nucleotides to establish needed composition of “fluid replace-
ment.”144 His studies on the volume of water, nitrogen,
potassium, sodium, blood, and other bodily components and
how they changed before, during, and after surgery resulted
in his classic text Metabolic Care of the Surgical Patient, relied
on by a generation of clinicians managing trauma patients.145
Other surgeon-scientists continued Moore’s work on burn
physiology. With infection now killing the majority of burn
patients, research focused on antimicrobial strategies,
16 Section ONE — General Principles
Fig. 1.19 Mobile Army Surgical Hospital (MASH) unit, Korea. Surgeons work side-by-side in this undated photo of a MASH unit in Korea.
The infrastructure (hung lights, solid structure with windows) dates it to 1952 or later. Note the glass bottles of blood hanging from intravenous
poles; plastic bags of blood arrived in-country at the end of the war. (From Otis Historical Collection of the National Museum of Health and Medicine.
Public domain.)
including topical agents such as sulfamylon popularized in
the 1950s to parental, broad-spectrum agents.146 The introduc-
tion of antibiotics subsequently altered wound pathology.
Whereas initially gram-positive bacteria killed patients, after
penicillin, gram-negative rods, and especially pseudomonas,
claimed the greatest number of lives. More recently, fungi
have emerged as the deadliest pathogen.147 The persistence
of infectious material despite chemotherapy prompted
explorations of effective débridement techniques from baths
to surgery, although interventions on metabolically deranged
severely burned patients carried significant risks.148
The characteristics of the Vietnam War distinguished it
from other 20th-century conflicts militarily and medically
while forecasting future engagements. Bullets and booby
traps replaced artillery as the primary cause of wounds, with
polytrauma becoming the norm.149 Small-unit engagements
replaced large-scale battles that had previously swamped
military hospitals with thousands of simultaneous casualties,
facilitating evacuation and enabling surgeons in Vietnam to
devote more attention to individual wounded. Helicopter
evacuation, pioneered in WW II and expanded in the Korean
War, became the primary route of evacuation over uncon-
trolled, geographically forbidding territory.150 Almost 1 million
sick and injured service members rode a helicopter to a
hospital, decreasing the time from being wounded to seeing
a physician to around 90 minutes151 (Fig. 1.20). This repre-
sented a dramatic reduction from prior conflicts, when
wounded often lingered for hours on the field. This speed
of evacuation saved lives as the official killed in action numbers
dropped from 21% in Korea to 17% in Vietnam, but it also
brought patients to hospitals who never would have survived
to reach medical care in previous conflicts.152 Accordingly,
the died-of-wounds rate, a metric that roughly assesses the
quality of trauma care, rose slightly for the first time in over
a hundred years (Table 1.1).153
Trauma surgery continued with débridement and delayed
primary closure, although whereas in prior wars surgeons
closed wounds in-theater, by Vietnam, with developments in
strategic aeromedical evacuation, they had started evacuating
them to base hospitals in the Pacific rim and even the United
States for definitive treatment. Improved antibiotic arma-
mentarium made destructive exploration for every foreign
body less critical, a trend particularly observed in head
wounds.154,155 Mortality rates for chest and abdominal wounds
did not change significantly between Korea and Vietnam,
with advances in trauma care offset by the severity of patients’
conditions.156,157
Partly due to the nature of warfare and partly from the
body armor worn by soldiers and Marines, extremity injuries
were common. Whereas orthopaedic surgeons previously
treated most femur fractures with splinting or casting, external
fixation became standard of care in Vietnam. They also
developed a cast-brace, enabling patients to ambulate and
begin rehabilitation sooner.158 Amputations—and especially
multiple amputations—increased dramatically in frequency,
with the percentage of amputees losing multiple limbs rising
from 5% in WW II to 19% in Vietnam.159 With 75% of
amputations traumatic, these number again reflect both the
 CHAPTER 1 — The History of Trauma Care 17

Fig. 1.20 Helicopter evacuation in Vietnam. Men rush a wounded American off a UH-1 “Huey” medevac helicopter, which had just extracted
him from a jungle battlefield in Vietnam. Although the US Army used helicopters in World War II and Korea, the Vietnam War made them an
iconic feature of military medicine and demonstrated their potential for use in civilian trauma systems in the United States. (Image accessed at
http://ausar-web01.inetu.net/publications/ausanews/archives/2016/01/Pages/AUSAsupportsmedalforVietnamWarDustOffmedicalcrews.aspx.)

Table 1.1 Died-of-Wounds Rate by War

War: Crimean War World War I World War II Korean War Vietnam War

Died-of-Wounds Rate: 20% 6.1% 4.5% 2.5% 2.6%

From Garfield RM, Neugut AI. Epidemiologic analysis of warfare: a historical review. J Am Med Assoc. 1991;266(5):688–692.

severity of injuries the patients received and the ability to
keep the severely wounded alive long enough to reach defini-
tive trauma care.160
POST-VIETNAM TRAUMA CARE IN THE UNITED
STATES AND THE CREATION OF AN AMERICAN
TRAUMA SYSTEM
Between the 1960s and 1980s, a new standard of trauma care
developed in the United States. Preceding this era, trauma
care consisted mostly of episodic advances in various wars
that, in the best cases, were brought home and applied to
civilians. Often, lessons learned had to be relearned (and
re-relearned) with each new war. Although the AAST and
American College of Surgeons (ACS) Committee on Trauma
had started to institutionalize the subject, in the early 1960s
there was still no field of trauma or substantial infrastructure
dedicated to it; by the late 1980s, this had changed. No single
source documents this evolution, and to do so appropriately
would require more space than this format allows, but some
broad outlines and specific examples help convey the mag-
nitude of the change.161 Progress occurred on three broad
fronts: (1) the recognition of a major problem that required
systemic change in the management of trauma, (2) clinicians
who increasingly focused their efforts on the management
of trauma, and (3) the scientific study of the pathophysiology
and treatment of trauma. The value of the modern American
trauma care system is evident when viewing homicide rates,
which are approaching a half-century nadir despite aggravated
assaults, particularly with firearms, more than tripling in that
period.162,163
Post–WW II America witnessed a dramatic rise in the
incidence of trauma. This increase partly resulted from
worsening urban violence, as assaults, both with and
without deadly weapons, grew markedly as drug wars,
mass shootings, and easily available weapons proliferated.
Motor vehicle accidents proved far more epidemiologically
significant. Courtesy of government loans and the GI Bill,
America suburbanized after WW II, prompting a dramatic
increase in car ownership and miles driven.164 A “car culture”
emerged in the 1950s, with new models applying WW II
engineering to create more power, higher speeds, and faster
acceleration.165 President Dwight D. Eisenhower designed
the interstate system, carrying passengers—and many future
trauma patients—around the country.166 Consumer activists
such as Ralph Nader warned of the danger in publications
such as Unsafe at Any Speed.167 The American medical profes-
sion worked with the automobile industry and government
18 Section ONE — General Principles
regulators to improve the safety profile of cars, leading to
changes such as headrests to prevent cervical injuries and
guardrails on perilous roads; other efforts, such as seatbelts
and drunk-driving legislation, took decades to implement
broadly.168,169
As trauma spread through America, so too did its study
expand from a few research and military hospitals to a broader
array of facilities. Burn therapy and investigation, for example,
spread nationwide as Shriners Hospitals opened in the 1960s
in cities across the country. The first International Congress
dedicated to burns took place in 1960, and the American
Burn Association was founded in 1968.170 These professional
movements created an infrastructure that enabled and
enhanced the development of burn care.171 The localization
of trauma care also resulted from the influence of the “doctor
draft,” wherein physicians learned trauma management in
the military and then applied those lessons back at their
civilian institutions.172 Curtis Artz, for example, an Army
researcher in San Antonio and the Korean War, brought his
investigations to the University of Texas at Galveston as the
Shrine Professor, then the Medical College of South Carolina
as chairman. John Howard, who directed the Army Research
Team in Korea, subsequently chaired departments at Emory
Hahnemann and Toledo. These men and others like them
fulfilled a crucial role in moving physiologic research to
trauma units across the nation.
In 1966 the National Academy of Science published its
landmark report, Accidental Death and Disability: The Neglected
Disease of American Society.173 It noted that in 1965 alone, 52
million accidental injuries killed 107,000 Americans, disabled
10 million, and cost the economy roughly $18 billion—an
extraordinary burden to society. Moreover, American society
was both unaware of and ill-equipped to manage trauma.
The report noted with bitter irony that American GIs wounded
in the middle of a jungle in Vietnam often received better
care than Americans injured in a major metropolis and urged
both political and medical interventions to address this dispar-
ity. This difference inspired a 1970 trial, Military Assistance
to Safety and Traffic, in which civilian medical authorities
in five American cities used military helicopters equipped
with uniformed corpsmen to speed automobile accident
victims to a hospital. The project clearly demonstrated the
feasibility of civilian helicopter evacuation, although the
medical impact was difficult to measure as the quality of
trauma care, pre– and post–emergency department, was still
evolving.174 The program continued through the mid-1970s,
largely at the behest of the Army’s leading advocate of
helicopter evacuation, Spurgeon Neel, who convinced
American leaders in medicine and politics that aerial transport
would particularly improve rural medical care.175,176
The creation of effective ambulance systems represented
a significant medical and organizational effort. Despite
the attention to early medical evacuation in wars, in 1966
morticians transported over 50% of injured Americans in
hearses—because those were the only vehicles communities
owned capable of carrying a stretcher.177 Accidental Death and
Disability catalyzed the US Congress to pass the Highway Safety
Act in 1966, which, along with the National Academy of
Science, provided funding and direction for nascent trauma
efforts. Ambulances themselves changed form, evolving from
hearses to the van and box shapes that allowed paramedics
to provide care en route. R. Adams Cowley extended this
concept to air-based ambulances. Building on the use of
military helicopters, in 1969 he established a state-supported
helicopter evacuation system to cover the entire state of
Maryland that enabled the most severely injured to access
the most advanced healthcare facilities rapidly.178 This concept
eventually spread to cover the United States.179
Formally trained paramedics began staffing these ambu-
lances. Before the 1960s, the majority of first responders had
little or no training in treating injured patients. The American
Society of Orthopaedic Surgeons took the lead in trying to
solve this issue, sponsoring a course for paramedics starting
in 1964 and publishing the definitive training textbook in
1971. That same year saw the first certifications, based on
uniformed standards guided by a national registry of Emer-
gency Medical Technicians.180
Although the federal government helped guide and fund
trauma systems, ultimately states held responsibility for imple-
mentation. Illinois represented the vanguard of trauma care,
with Cook County Hospital as its headquarters.181 Under the
direction of David Boyd, it pioneered a systems approach to
trauma care that coordinated prevention, prehospital care,
and specialized regional trauma centers.182 Importantly, it
also capitalized on intensive care units (ICUs)—relatively
new additions to American hospitals—and demonstrated the
value of having dedicated space for trauma patients. The 1973
Emergency Medical Services Systems Act reinforced this model
and catalyzed its spread around the country.161 Education for
paramedics continued to expand throughout the 20th and 21st
centuries. A similar training regimen developed for physicians
through the Advanced Trauma Life Support (ATLS) course.183
Created when a plane crash transformed orthopaedic surgeon
James Styner and his family into patients deeply dissatisfied
with the care they received at a rural hospital in 1976, by
the 1980s ATLS evolved into an international course run by
the ACS to ensure that providers encountering trauma are
well versed in its initial management.
The creation of injury scores helped categorize trauma
patients and facilitated research by enabling interfacility
comparisons. Burn surgeons classified patients based on total
body surface area afflicted. Other surgeons expanded this
idea to polytrauma. Susan Baker and colleagues at Johns
Hopkins assessed automobile accident victims initially using
the American Medical Association’s Abbreviated Injury Scale,
a metric designed to help car manufacturers develop safety
data. On this foundation, they built the Injury Severity Score
(1974) to define objectively and translationally the gravity
of trauma.184 Shortly thereafter, the Glasgow Coma Scale
emerged, which proved particularly valuable in an era before
rapid, widely available cross-sectional imaging of the head.185
A 1978 multicenter trial confirmed its prognostic accuracy,
interhospital applicability, and broad utility.185a Despite these
advances, trauma care remained heavily based on personal
experience through the 1970s and early 1980s, epitomized
by the ongoing debate that decade over the utility of Military
Anti-Shock Trousers (MAST)186,187; a Cochrane review eventu-
ally demonstrated no benefit to their use.188
MODERN TRAUMA PHYSIOLOGY AND DAMAGE
CONTROL SURGERY
Through the 1980s, trauma doctrine, heavily influenced by
the penetrating trauma and blood loss of the Vietnam War,
focused on prompt anatomic repair and blood pressure

restoration. Hepatic trauma simultaneously demonstrated
progress since WW II—with the case fatality rate among the
best surgeons dropping from 27% to 20%—as well as ongoing
challenges.189,190 Before WW II, surgeons managed hepatic
trauma almost exclusively with conservative packing, but
leaders of the postwar generation had developed new methods
to control hemorrhage and débride devitalized tissue in an
effort to reduce death rates.191 Despite some success with
cauterization technologies and diverse techniques such as
arterial ligation, blood loss continued to determine, and
often doom, outcomes.192 Between 1968 and 1973 Charles
Lucas in Detroit conducted a prospective trial to evaluate
the results of the various approaches and found that packing
and later surgery had some practical benefits.193 The trauma
team at Houston’s Ben Taub Trauma Center further focused
attention on packing to control hemorrhage and operating
to make definitive repairs later.194
Meanwhile, efforts to understand the pathophysiology of
trauma continued. Laboratory investigations documented
coagulation problems specific to the trauma patient.195,196
Kenneth Mattox and collaborators in Houston focused
increasingly on the fact that maintaining blood pressure at
normal levels led to further bleeding and increased coagula-
tion complications, and they proposed a doctrine eventually
dubbed permissive hypotension. Simultaneously, physicians
recognized other problems associated with massive transfusion,
including significant drops of core temperature despite novel
technologies such as blood warmers.197 Recalling the known
association of shock and cold patients, surgeons began
exploring this variable among the traumatically injured.198,199
Prospective studies soon documented both the frequency
and high morbidity of hypothermia in this population.200,201
Resulting from this research, investigations of penetrating
liver trauma introduced a waiting approach using abdominal
packing for patients “in whom coagulopathies, hypothermia,
and acidosis make further surgical efforts likely to increase
hemorrhage.”194 Studies such as these identified a so-called
lethal triad: how coagulopathy, hypothermia, and acidosis
additively lead to death.202
The 1980s witnessed a dramatic increase in penetrating
trauma, especially for urban hospitals.203,204 The proliferation
of gunshot wounds emphasized the importance of exploratory
surgery despite cross-sectional imaging. But the proliferation
of laparotomies reidentified the challenge of hemorrhage
control in coagulopathic trauma patients. Harlan Stone at
Emory, perhaps best known for his burn studies, presented
a series of cases that demonstrated survival benefit of abbrevi-
ated initial surgery to tamponade bleeding followed by
resuscitation and subsequent reparative operations.205 Other
teams soon replicated this experience.206,207 The Western
Association sponsored a multicenter trial and confirmed that
the staged approach was safer for patients with liver trauma.208
This stratagem then expanded to encompass nonhepatic
injuries as well.209,210 Success across broad presentations of
trauma accelerated a widespread return to staged surgery,211
soon given the military-derived name of damage control surgery
by the team at the University of Pennsylvania.212 Surgeons
sought to lower mortality rates by returning to a multistep
approach: exploration and temporary hemostasis followed
by resuscitation in the ICU, with subsequent definitive opera-
tions when clinically appropriate. Infections remained an
important consideration, particularly with spread of antibiotic
CHAPTER 1 — The History of Trauma Care 19
resistance in hospitals and communities. By 2000 damage
control surgery had become standard of care, although recent
studies have since questioned its overuse.213
EDUCATION AND SYSTEMS
Applying these advances proved challenging, and for most
of the 20th century hospitals varied enormously in their ability
and willingness to care for trauma. Patient outcomes ranged
accordingly. Emergency medicine as a field evolved in this
same era and took over management of minor injuries.214
But significant trauma required expedient, multidisciplinary
engagement. It also demanded competent, trained surgeons.
Surgeons who encountered trauma in the 1960s, 1970s, and
1980s were mainly generalists who spent most of their clinical
time engaged in other, more structured and planned surgical
interventions. Outside a few centers, specialized trauma
surgeons did not exist, and patients suffered. Many Cold
War–era surgeons at least had some exposure to military
medicine and thus trauma indoctrination through the physi-
cian draft, but this ceased in 1972. Surveys from the early
1990s clearly showed broad disenchantment with trauma
care among residents.215 For various medical, social, and
economic factors, trauma fellowships started in the 1970s
and have expanded and regularized, particularly since the
1990s; they frequently incorporate critical care components.216
Most major hospitals today benefit from specialized, fellowship-
trained trauma surgeons. As penetrating trauma has decreased
in prevalence since the 1990s217,218 and management of blunt
trauma has become progressively nonoperative,219 trauma
surgeons have increasingly assumed acute care surgery roles
in the past two decades.220
Effective trauma care also requires expensive, advanced
technology such as computed tomography scanners, ventila-
tors, and ICUs. Recognizing both the complexity and
importance of effective hospital trauma care, the ACS Com-
mittee on Trauma established a trauma center verification
review process in 1987.221 Establishing and enforcing standards,
it classified hospitals into the now-familiar level I, II, or III
trauma centers. The recently developed injury severity score
demonstrated the survival benefits of patients receiving care
at a trauma center compared with another hospital and helped
drive the expansion of centers222; the benefits remain apparent
today.223 Since 2008 participation in the Committee’s National
Trauma Database (founded 1989) has been mandatory for
designated trauma centers. Much like the Medical and Surgical
History of the War of Rebellion, this database crucially avails
researchers of data that enable the evaluation and improve-
ment of trauma care.224 When the US military deployed to
Iraq and Afghanistan, it built on concepts such as Medical
and Surgical History, Norman Rich’s Vietnam Vascular Registry,
and the National Trauma Database to create a similar infra-
structure to track, manage, and improve the care wounded
service members received.225
WAR ON TERROR
Since 2001 the United States and its allies have engaged in
an ongoing war with terrorists around the globe, resulting in
a new flood of casualties and concomitant changes in trauma
management.226 Organization changed as Forward Surgical
Teams and Combat Support Hospitals (CSHs) replaced MASH
20 Section ONE — General Principles
Fig. 1.21 Global War on Terror. This image of the lower extremities depicts the devastating effects of improvised explosive devices on
service members serving in the Global War on Terror, as well as the importance of tourniquets (here, the bilaterally placed Combat Application
Tourniquet) in preventing exsanguination. (From Nessen SC et al. War Surgery in Afghanistan and Iraq. Washington, DC: Borden Institute; 2008:288.
Public domain.)
units.162 Explosions, usually in the form of improvised explosive
devices, now caused the vast majority (72%) of casualties,
with gunshot wounds causing 18%.227 These statistics do not
include traumatic brain injuries, a pathology brought to the
fore by the War on Terror.228 They further fail to account for
the psychiatric trauma that, although also not immediately
apparent, has resulted in significant morbidity and mortality.
Explosions are also more likely to cause polytrauma and blast
injuries, which, combined with the improved body armor and
rapid helicopter evacuation, has been delivering heretofore
unsurvivable injuries to surgeons.226
Many of the civilian advances of the 1970s to 1990s proved
irrelevant or sometimes even counterproductive in wartime.
The 1993 Battle for Mogadishu demonstrated some challenges
physicians faced integrating military and civilian trauma
systems. In particular, the ATLS protocol seemed less appli-
cable to combat scenarios prompting the military, led primarily
by Frank Butler, to develop a new paradigm called Tactical
Combat Casualty Care (TCCC).229 Implemented in Special
Operations units in the 1990s and then throughout the US
forces by the mid-2000s, TCCC prioritized hemorrhage control
to minimize preventable death. Among other interventions,
TCCC advocated for tourniquet use. Tourniquets, described
since antiquity, have waxed and waned in popularity over
the centuries, fading from use in trauma almost entirely by
the end of the 20th century.230 Accepted doctrine taught that
applying tourniquets intrinsically sacrificed the limb; even
obtaining effective devices proved difficult. But in Afghanistan
and later Iraq, they quickly proved effective at controlling
hemorrhage, saving lives without costing a limb.231 By 2005
the US Army Surgeon General recommended that every
deploying soldier carry one; they have since become common
in ambulances and emergency departments in the United
States232 (Fig. 1.21).
While tourniquets and new hemostatic dressings helped
control bleeding, surgeons in hospitals worked on new
methods to replace that which was lost. In the 1960s large-
volume crystalloid resuscitation supplemented—and in some
cases supplanted—whole blood in trauma cases.233 In Iraq,
studies showed that 1:1:1 volume replacement with blood,
fresh-frozen plasma, and platelets (mimicking whole blood)
led to higher survival rates in trauma patients.234 Moreover,
instead of emphasizing arbitrary blood pressure goals, with
concomitant high volumes of fluids, surgeons increasingly
practice permissive hypotension. This strategy emphasizes
physiologic goals of critical organ perfusion. Both permissive
hypotension and 1:1:1 volume replacement have since spread
throughout military and civilian practice in the care of trauma
patients.
CONCLUSION
Traumatic wounds have afflicted humans since the emergence
of our species, but human efforts to prevent, control, and
treat such pathology have nearly as long a history. Dating
from the first medical treatises written nearly 3500 years ago
to ongoing efforts in military and civilian hospitals today,
healers have identified, classified, researched, and managed
traumatic injuries. Initially centered on military conflicts,
trauma care in the past half-century has seen a more sustained,
scientific, and broader effort than ever previously marshaled,
with correspondingly improved patient outcomes. Throughout
these millennia, advances in trauma have depended on
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 “Here you are, sir. Follow me!” This from one of the men, who had
brought a wooden, rope-handled bucket of steaming water.
Ingomar was conducted to the half-deck, and, when he emerged, but for
his romantic dress of skins, no one would have known him.
The skin, even of his hands, was now as white as a lady’s, and his
complexion perfect.
And his every action, movement, and sentence were those of a well-bred
man of the world.
He looked about ten years younger than he did when he stepped on
board.
“By the way, Captain—eh——”
“Mayne Brace,” said Charlie.
“Captain Mayne Brace, I have been dreaming for weeks in my tent, far
away over the hills yonder, that I was sailing southwards in a British
barque. The fact is, sir, though life in these regions may have a spice of
romance about it, one gets tired after a time of the winter’s darkness; and a
diet of dried fish, seal-mutton, and whale-blubber becomes irksome at last,
even if a bear-steak is now and then added to the menu.
“Do you know, sir,” he added, interrupting himself, “that if your tailor
could make me a serge suit of some sort, and if I had my hair cut, I’d really
have the audacity to ask you to grant me a passage back to temperate
regions with you?”
“We will be delighted, Ingomar,” from the captain.
“Oh, that isn’t my name, but the name of the play in which I last took
part in a Chicago theatre. But I should be glad to tell you who and what I
am after I have munched a ship biscuit.”
As they went below to dinner, Captain Brace leaving orders for the man
in the sledge and the dogs also, to be fed, Charlie found time to seize
Ingomar’s hand again and pull himself up, while he whispered—
“Don’t have your hair cut, and don’t wear a serge suit. You look ever so
much better in skins.”
* * * * *
After dinner Ingomar consented to sit in an easy-chair, but well away
from the fire.
 He lit his cigar.
“I’m very happy, Captain Brace,” he said.
“So pleased!” said Brace.
“You promised to tell us your story,” said Charlie.
“Well, yes,” returned the stranger, “and for your sake I’m sorry it must
be brief. But, Captain Brace, may I first go and give Humpty Dumpty his
orders, if I am to sleep on board all night?”
“Humpty Dumpty, as you call him, is perhaps, like yourself, an
Englishman?”
“Oh, pardon me, captain, but neither Humpty nor I have the honour to be
English. I am an American, sir, born and bred, and so is my mate. I don’t
drawl, and I don’t ‘guess’ and ‘calculate,’ and I don’t use my nose much to
talk with. Humpty does a little. But Humpty Dumpty was only a man before
the mast when we became first acquainted. I’ll run up and speak to him
over the side.”
“No, no,” cried the captain. “We’ll have Humpty down here for a
minute.”
“What a strange name!” said Walt.
“Well, yes, but it fits him. It fits his shape and build. His real name is a
deal too—a—aristocratic, don’t you call it, for him. Hampden is his
surname, so I call him Humpty Dumpty for short.”
“Hullo, here he is!”
Humpty stood in the doorway, cap in hand.
He was about five feet or less in height, and in his Eskimo dress, with his
tremendous breadth of shoulder, shaped somewhat like the capital letter V.
“You called me, sir?”
“Um, yes, Humpty. You are to drive back to our tribe, and tell them they
must get away over the horizon again and camp there, but to return to-
morrow before sunrise, because I believe these young gentlemen would like
to ride in a dogsledge, and see the village of which I am king.”
“Oh!” from both boys.
“Right, sir; I’m off straight’s an arrow.”
“One minute, Mr. Hampden. You’ll have a glass of wine?”
 “Excuse me, capen, but I’ve tasted it before, I reckon. Yes, sirree, once I
took a thimbleful too much, and next day, sez I to myse’f, ‘No more liquor
for Dumpty.’ ”
In a minute or two after this Dumpty was dashing over the snow to the
spot where his tribe had been left.
The doctor entered now.
The steward had kept his dinner hot.
“The Teelies have gone back, sir, and peace is restored.”
He bowed and smiled to Ingomar, then sat down to dinner; but while he
ate, only ordinary subjects were talked about.
Then Wright joined the circle round the fire, and, having cleared away,
the steward considered himself privileged to stand in the doorway for a
short time to listen.
For on board Arctic ships faithful servants are allowed quite a deal of
freedom, which, by the way, I have never known them abuse.
“Well, my friends,” said Ingomar, “you must excuse my shortcomings as
a story-teller. I suppose I’m not old enough to tell fibs, so my yarn, if short
and stupid, has at least truthfulness in its favour.”
“Heave round, sir,” said Captain Mayne Brace.
And Ingomar, smiling, obeyed.

CHAPTER III

“MY PRIDE WARRED AGAINST MY BETTER FEELINGS”

“Well, gentlemen, Ingomar being merely my stage name because I played

in that piece more than in any other, I ought at the very offset to tell you my
baptismal one. That was Hans, and my father being an Armstrong, I very
naturally adopted his surname. Hans Armstrong, then; and here you have
me clad in skins, of which rig-out I am beginning to be slightly ashamed.”
“Pardon me,” said Captain Brace, “you tell us that you belonged to
Chicago. Do you happen to have any personal acquaintance with the Dutch-
American millionaire Armstrong?”
 “I have known that gentleman, sir, since I was eighteen inches long. He
wasn’t much of a millionaire then. I do myself the honour of believing that
it was I who brought all the good luck to that well-known family; and
although when I was a child Mrs. A. occasionally showed her extreme
affection by spanking me, I loved and love her very much. If alive, young
gentlemen, she is my mother; if dead, she is a saint in heaven. They have
just one other child, a girl, my dear sister Marie, years younger than myself,
and she will fall heir some day, I suppose, to all my father’s millions.”
“But you yourself, Hans?”
“Well, sir, I—I suppose I am a fool, sir, or, more probably, a born idiot. I
am likewise the prodigal son. For the last six months and over I have not
certainly been eating husks with the swine. It would be wrong and cowardly
in me to allude to my friends the Yak-Yaks as swine; but I have been living,
as I have already told you, in a somewhat unrefined way.
“The Armstrongs, I think I have heard my father say, first went to Britain
and settled there, then across the sea to America, and fought against you
during the War of Independence. But that has nothing whatever to do with
me. My parents have been very, very good to me, and my education has
been quite up to the Boston standard. Only when I reached the advanced
age of seventeen—I am now two and twenty—I began to grow reckless.
Civilization was not good enough for me. It was too much in the same
groove. I determined therefore to shake the dust of Chicago off my shoes—
there is a good deal of dust in Chicago—and find my way into regions
remote, where, if the people were not rich, they were at least honest. My
sister’s wild entreaties, my mother’s tears, prevailed not against my
headstrong self.
“My adventures among the Rocky Mountains and forests of the Far West
would fill a book. I thought seriously of living in the wilds for life, and
marrying the daughter of a chief.
“He was ugly enough to have stopped a clock, but a splendid warrior,
and his braves were all that braves should be. Cheena, the daughter, was but
a child of twelve. But she interested and amused me, and perhaps captivated
me with her beauty and her innocent ways. One of these innocent ways was
to play with snakes. She even taught me to boldly touch and handle the
rattler.
 “No wild beast would harm Cheena, and she went fearlessly into the
dens of even grizzly bears, and played with their puppies as if they had been
dolls.
“I lived in the wilds with this wandering tribe for nearly three happy
years. Cheena knew English, and I taught her more. Shakespeare was my
constant companion. Better perhaps had it been my Bible. But Cheena and I
played many a scene together in glades of the beautiful forest.
“I must hurry over all this, though.
“Well, one day, with three men and two tame wolves, I went away on a
big shoot. When we returned, I found that a warlike tribe had attacked the
chief’s camp, and that he and his braves had been defeated and scattered.
“I never saw him again, nor poor Cheena, though I wandered about in
search of them for three long, dreary months.
“Then one day I returned to my father’s house. It was late at night, but I
climbed up into my own old bedroom, just as I used to do when a lad.
“Nothing was changed. Everything had been kept sacred as a temple.
“I went quietly to bed, and when next morning I coolly rang for water
and old Roberts entered, he shook with fear so that he would have fallen
had I not supported him.
“ ‘Is—it—you, Master Hans?’ he quavered, ‘and not a dead—go—go—
ghost?’
“ ‘Is that like the hand of a dead go—go—ghost, Roberts?’ I said,
grasping his arm with my forest-hardened fingers.
“ ‘Oh—no—no,’ he almost shrieked. ‘Lor, sir, how you’ve growed! Your
mother and Sissie will be skeered, I guess, when they sees you.’
“ ‘And they are all well?’
“ ‘That’s so, Master Hans; and the old man too.’
“ ‘Well, some hot water, Roberts. I’ll wash and come downstairs to
breakfast.’
“I was down before anybody, and sitting quietly in a rocker, smoking
one of dad’s best Havanas, when Sissie and mother entered.
“You may judge what followed, boys.”
“But,” pleaded Charlie, “you’re not making the story half long enough.”
“I settled down now, sir, to the hardest work ever I had in my life.”
 “And that was?”
“Doing nothing. But I couldn’t keep it up. It was ruining my fine
constitution.
“I was always fond of the stage, and took Marie to see Ingomar one
evening.
“She was delighted. I was not. Ingomar was not written by Shakespeare,
I believe, but it was a pet play of mine, and I knew I could act the part
better.
“But somehow I went back several nights running. Then, as my good or
my bad fortune would have it, one evening the excited manager rushed
before the screen to announce that, to his grief and chagrin, the principal
actor had been taken suddenly ill, and that the play could not be put on. Yes,
of course, he added, the gate-money would be refunded.
“After this, some impulse seized me. I stood boldly up in the box, and
shouted with arm extended—
“ ‘Stay, I know the part, and if the manager will but give me a chance, I
will try my best.’
“Every eye was turned towards my box, while Sissie shrank behind the
curtain. I am told, sir, that I am not bad looking, and my figure is fairly
good.
“There was a wild ‘Hooray!’ now, at all events, and that evening found
me before the footlights.
“I played with heart and soul. I had the people with me, and felt I had;
and when at the end of the first act I was called before the curtain, I
received an ovation that would have satisfied a far better actor than I.
“Hardly thinking about the disgrace my people would imagine I was
bringing on them, I accepted the manager’s terms to play for three weeks.
“I told them that night what I had done. Mother was silent, Sissie looked
frightened; and when next morning we all met at breakfast, I could see that
both had been crying.
“Scarcely a word was said, but that forenoon my father asked me into his
sanctum.
“ ‘Boy, boy,’ he began, ‘why this madness? Do you wish to bring my
grey hairs down with sorrow to the grave?’
 “I sat quietly down that our eyes might be more on a level, for I am very
tall.
“ ‘Dear father,’ I said, ‘I am foolish enough to think that I shall be an
honour to you as an actor.’
“ ‘Honour! Actor!’ he cried.
“ ‘It is a noble profession,’ I said quietly; ‘and when you come to listen
to my interpretation of Hamlet, you will believe that God has gifted your
son with genius. There will be no sorrow then, dear daddy.
“ ‘Besides,’ I added mischievously, ‘you haven’t got a single solitary
grey hair in head or whiskers.’
“Some people are hard to convince. My father is one of them.
“ ‘I will cut you off with a dollar,’ he thundered, ‘if you do not give up
this disgraceful fad. If you do I will take you into partnership.’
“Then I told him grandiosely that the resolution I had taken was fixed,
immutable; but that rather than bring disgrace upon him, I would change
my name as soon as this engagement was over, and go into a far country to
act where no one would know me.
“ ‘I began life,’ he said, as he sunk back in his chair, ‘with fourpence in
my pocket.’
“ ‘And I, daddy,’ I replied, ‘am beginning life without a penny, but
possessed of one of the dearest old fathers that ever a young man was gifted
with.’
“He was softened.
“ ‘Boy,’ he said, after a pause, ‘I am wealthy, but your sister must be my
heir. If you must go—then go. I will place a trifle at your disposal in my
bank at New York. You will have that to fall back upon, when your fad and
folly leave you. Good-bye. I may never see you more.’
“He started from his chair and marched straight out of the room.
“Here, boys, ends the second act of the prodigal son.
“Just two months after this I found that my father’s words were coming
true. I had attempted Hamlet, but was playing to very poor houses.
“When I came home one evening and found a very humble dinner
waiting for me, I became very sad indeed.
 “But worse was to follow, for in a week’s time my engagement at the
theatre was over, and I was politely told I was not good business, and could
not be retained.
“I went quietly and, I thought, calmly away; but happening to enter a
club that evening where my presence had always been welcome before, I
found only coldness. When a rival actor taunted me as to my success, I
completely lost control of myself. I flew at the fellow, picked him up,
armchair and all, and threw him to the other side of the room.
“I heard no more of the matter, but in a week’s time I found myself alone
in my dingy lodgings without a copper in my pocket.
“I was alone with my pride. I might beg, but never again, I told myself,
would I darken my father’s door.
“It was two days after this when, while strolling along near to the docks,
I was met by a French seafaring man. He looked at me and I at him.
“ ‘Do you want work?’ he asked.
“ ‘That I do. I’ll do anything.’
“ ‘Well, you look a likely sportsman. I’m off in a day or two on a curious
kind of cruise to the very far north.’
“ ‘I’ll go with you,’ I answered, ‘if the wages are not starvation.’
“ ‘Come with me now,’ he said. ‘We will soon settle matters.’
“He had a boat, and we were both rowed off to a strange-looking but
strong and sturdy brig.
“Every man on board except this same Humpty Dumpty was French.
What cared I? Surely I could hold my own in a fight against a score of little
sailors.
“ ‘You are not a sailor,’ said my new friend, when we were together in
his little cabin.
“ ‘No,’ I said; ‘but I can shoot, and wield an axe, and I can fish.’
“ ‘You’re my man. But I must explain. We are engaged by a celebrated
firm of chemists to go to Greenland waters and fish for sharks. The oil of
the livers is not only finer and richer but more abundant than that of the
cod, and it is considered an infallible cure for consumption.
“ ‘You’ll have to rough it,’ he added. “ ‘Thank God to have the chance.’
“And the bargain was speedily made, and the articles signed.
 “I was to join in two days’ time.
“That night it suddenly occurred to me to visit my father’s bank here. I
still had his letter, and by its aid could identify myself.
“I must confess that I went to that bank in bitterness of spirit against my
poor daddy. But I felt sure that the trifle he had deposited to my credit,
would be but the traditional dollar with which prodigal sons are often cut
off. I meant to bore a hole in it, and wear it round my neck.
“I had no sooner made myself known than the manager, to my great
surprise, shook me by the hand.
“ ‘Come into my room,’ he said. ‘Your father has sent me your
photograph, so that there is no need for identification. And the cheque is a
handsome one.’
“ ‘I hope, sir,’ I said, ‘you will not tantalize me. I expect nothing from
my father except one dollar.’
“ ‘The cash standing to your credit,’ he said, ‘is two millions sterling.’
“I answered scarcely a word. I was too dazed to speak. This, then, was
the dollar with which my father had cut me off.
“I arose from my chair, and, hardly taking time to shake hands with this
business-like banker, I walked straight out, and away home to my dingy,
dismal lodgings.
“I wanted to think, and to be alone.
“ ‘My poor father!’ These were the first words I said to myself. And at
this moment I would have given a good deal to be sitting once more in our
old-fashioned parlour, with mother and sister near me, and my father
studying the markets as he sat in his chair.
“But evil thoughts began to take the place of good, and my pride warred
against my better feelings.
“These two millions were a million times more than I deserved, though it
would leave him but little poorer. This was true, but nevertheless I felt that I
was cut off.
“ ‘Here is thy portion, boy,’ he seemed to have said. ‘Get thee away into
a far country, and come not near us again.’
“I was banished. I would keep to my engagement with the French shark-
hunter strictly and to the letter. My millions might lie there. I would not
draw a cheque even for a dollar. I was proud, and my pride bred bitterness
of heart.
“I wrote at least half a dozen letters to Sissie and mother, read them over,
and tore them up as soon as penned. For somehow that bitterness of heart
breathed all through each one of them.
“Then, when calmer, I wrote one simple, loving letter, bidding all good-
bye. And it ended thus: ‘When I am worthy to be my good old father’s son I
will return.’ ”
* * * * *
“Ah, gentlemen,” he continued, after a pause of silence that no one cared
to break, “my long banishment to this dreary country, though self-inflicted,
has done me good and changed my mind. Before, I could see men but as
trees walking, now I can read all my father’s motives. Like all our forbears,
he is proud, but he is true, and—well, I must confess I love him. There!
“My adventures since I left home are too numerous to tell you. Our ship
was wrecked, and Dumpty and I alone were saved. Then I joined a band of
wandering Eskimos—the Yak-Yaks. I did not care what became of me. I felt
I was running away from myself, from my evil, prideful nature, and so here
I am, a changed and, I trust, a better man.
“One thing, however, I have determined upon. I will not return to my
father’s house, until I have done something which shall show him that I
possess some of the sand and grit in me, which has descended to us from
the old fighting Armstrongs.
“But, I say,” he added comically, “you will get me that serge suit, won’t
you? And you will let me and Humpty Dumpty join your ship, and let me
have my hair cut, and—well, and just share your adventures, won’t you?”
“By all means,” replied Captain Mayne Brace.
“One minute before you finally decide,” said Ingomar. “For all you
know, I may be a mere adventurer or a madman. But see, I have some
business-like method in my madness.”
He pulled from an inside pouch a bundle of papers.
“I have kept these, Captain Brace. I place them before you, and, unless
you promise me you will glance over them, I shall return to-morrow to my
igloo among the Yak-Yaks, and trouble you no more.”
 “I will take them to my cabin, young sir, though I think there is no need
to. I can read honesty in your eyes.”
Ingomar’s manner changed now at once. He was brimful of happiness
apparently, and addressed himself more to the boys than the others.
“I say, lads,” he cried, “won’t we have a day of it to-morrow, if your
good captain will permit you to cross the mountains with me?”
“Oh, we shall enjoy it!” cried Charlie.
“Won’t we just,” said Walt.
“I’ve never driven dogs, but I think I could if I tried.”
“Hurrah!”
And the evening passed very happily away.

CHAPTER IV

THE AGREEMENT DRAWN UP AND SIGNED

Like all men who are ever likely to do any good in this world, and leave
footsteps in the sands of time, Captain Mayne Brace was an early riser.
The stars were still glowing like diamonds in the sky, then, and the
merry dancers—the aurora—were still at their revels when he turned out to
have his bath. A quarter of an hour after this found him on deck.
Here, to his surprise, he met young Ingomar. He stood on the poop, his
face skywards and to the north.
“Is it not a grand sight, sir?” he said. “How near and how brightly these
stars and planets burn! It seems as if one could touch them with one’s rifle
or fishing-rod. And the aurora-gleams—the positive magnetism that comes
from the far-off Southern Pole—how beautiful their transparency of
colours! Those ribbons of light seem to me like living things. And in the
stillness of this early morning do you not hear them talking? Shsh—shs—
shs—shs! Oh, sir, is it not God Himself who is speaking there—the God of
power, the God we know so little of, the God whom in our pride of
knowledge we sometimes venture to impugn, to correct, to criticize!
Forgive me, sir, for speaking thus before an older man than myself. But oh,
sir, there is a glamour about that sky, about these northern solitary wilds,
which gets around the heart and soul, and makes one feel one is really face
to face with the Creator—Maker not alone of this puny earth, but of yonder
universe—of infinity itself!”
He scarcely gave Captain Brace time to reply.
“Down in one’s bunk,” he continued, “one belongs to this world. Up
here among the stars and aurora one is with God. But down below last
night, sir, I was thinking of my father, my mother, and sister. To say that I
was not longing a little for home would be to insinuate that I was more than
a young man. Yet my resolution has not been one whit shaken. When I can
do something that no one else has ever yet done, or at least made an attempt
to do this something, the prodigal son will return to his father’s house; not
till then. My father is a very Napoleon of finance. In that line I may never,
can never, hope to equal him, nor do I desire to do so. Yet I may become a
great explorer, and help to add to the world’s fund of knowledge for the
world’s benefit.
“I had made up my mind never to finger a frank of those two millions,
but I shall, and will gladly, spend one million, if need be, for the furtherance
of a plan I have in view, and have well thought out. It is an ambitious one,
sir. I feel I ought to blush even to mention it.”
“You need not, young sir, if it be honourable,” said Brace.
Ingomar, as we may continue to call him, had been walking up and down
the deck so rapidly, that it was difficult to keep pace with his gigantic
strides.
But he hove to now suddenly, and confronted the captain.
“Listen,” he said. “The Americans have done as much as any other
nation save Britain to solve the mystery that hangs around the Pole yonder.
The veil will soon be raised. I would go farther; I would venture to aid in
the attempts that are now about to be made by you Britishers and by the
Germans, to wrench its secrets from the Great Unknown, from the Antarctic
itself, to force it to tell what it knows of the story of the earth.”
“The ambition,” said the captain, “is a noble one, certainly, and even I
have had thoughts of bringing the knowledge I have gained in regions
round our own North Pole to bear upon the South. Indeed, I was almost
thinking of joining the expedition when I got home.”
“But I,” said Ingomar, “would not join any expedition. No, no, sir, and a
thousand ‘No’s.’ I should fit out my own. And if I were to die in the
attempt, why, I should die in a worthy cause; and to youth death does not
seem so very dreadful if surrounded by a halo of noble adventure.
“And would you believe it,” he went on, “while in my lonesome igloo
over the hills yonder, I have for months been forming all my plans for
future operation. I would rather lay these before older and more skilled and
scientific men than myself, and all I should do, all the honour I might
obtain, would be that of finding the money for the expedition.
“Well, now, it may seem an abrupt question to ask, but I think that as
long as a fellow keeps a clear brain and a good look-out ahead, abruptness
is no great sin. Can you, then, or will you, sell me your ship?”
“This barque is not my own, alas! or, after having been so singularly
unfortunate in ‘making a voyage,’[B] and presuming that you are sincere, I
would gladly do so on the understanding that my services as master mariner
of the Walrus should be retained. But come down below. The fire is well
alight, and we can talk uninterruptedly for a good hour yet before the others
turn out.”
Although the acquaintance with each other of these two men was so very
recent, there was a something—call it by any scientific name you please—
that seemed to draw them together.
Captain Mayne Brace was very favourably impressed by the prodigal
son, as he would insist upon calling himself. The coincidence that had
brought them together was certainly strange, but Fate moves in a
mysterious way, and Brace determined to take advantage of the meeting
between Ingomar and himself.
He candidly opened his mind to the young millionaire.
“I am bound,” he said, “to do all I can to secure a good voyage during
the spring fishery. Nothing could prevent me from attempting this for the
benefit of my owners; and if I must return ‘a clean ship,’ then I shall have to
steel my nerves to encounter my owners. The ship is well—too well—
insured, and it was hinted to me that if I failed in making a paying voyage,
no questions would be asked if I cast her away. There would be little chance
of that, for even after a rough-and-tumble life at sea for so many years, I
have a little honour left me, a clean heart, and a clear conscience.
“But, Mr. Armstrong——”
“Call me not Armstrong yet, sir—just Ingomar, and hang the ‘Mr.’ ”
 “Well, Ingomar, I have no doubt my owners would be willing to sell the
Walrus, and therefore, if you choose now to sign articles, I shall rate you as
harpooner, and shall be perfectly willing to ship for you, before we leave
these regions, the Yak-Yaks, the dogs, and young bears you say would be
necessary to make our expedition a success.
“We are a sturdy ship and good sailer, and we have plenty of room, if we
do not make a voyage, for you and your pets.”
“You have made me very happy, sir. Let us make the agreement at once.”
“Just one moment, young sir. You have told me that the Walrus will be
the auxiliary vessel carrying extra stores, the dogs, the Yak-Yak hunters,
sledges, etc., and that you would build or buy and fit out a special ship for
the actual scientific exploration. Now, I am a plain man—under what flag
should we sail?”
“The Stars and Stripes?” said Ingomar.
This was more like a question than an answer, and Brace replied sturdily
—
“No, sir. I will sail under no flag except the British.

‘The flag that braved a thousand years

The battle and the breeze.’

But,” he added, half regretfully, “if you succeed in purchasing this good
barque—and a better never sailed to the Sea of Ice—she will belong to you,
and you can hoist your Stars and Stripes; only——”
“I understand,” said Ingomar, “and honour your sentiment. Well, you
must be captain of the Walrus, that is clear. But everything else must be
made clear, and I am certain we will not quarrel about the flag displayed.”
He considered a moment.
“Let us have the two in one,” he said. “Not one beneath the other, else
we should quarrel worse than ever.”
He laughed at his own quaint notion, as he added—
“Why not have the two flags tacked together, so that their united ensign
should show from one side the Bird of Freedom—the eagle, and on the
other your British batch of Lions?”
It was Captain Brace’s turn to laugh now, and he did so right heartily.
 “ ‘Pon my soul,” he said, “the conceit is a good one. I see that you and I,
sir, are united, anyhow—just as the British and the Americans should ever
be.”
Then the agreement was drawn up and signed by both, and so this
memorable interview came to a close.
“I feel so happy now, captain,” said young Ingomar, “that—that I could
cry.”
“Rather an original method of showing happiness, isn’t it?”
“Rather effeminate, anyhow. But now I feel at home here; and within the
last four and twenty hours my prospects in life have brightened, and my sky
is clear; the star of hope is shining as brightly as the Pole star yonder. I’m
young, you see, sir, and—— Well, I can’t help that, can I, Captain Brace?
But I don’t mean to fail, anyhow.”
“No; and you have nothing to be ashamed of, Ingomar. As to failure—

‘In the lexicon of youth which fate reserves

For a bright manhood, there is no such word
As Fail.’ ”

* * * * *
True to time—in fact, a little before it—the Yak-Yaks were seen
returning to the barque, yelling and whooping, the dogs stretched out, and
apparently hugging the snow as they sped onwards like a hairy hurricane
across the level stretch of bay.
It was arranged that Nick and Nora both should accompany this tour
inland, but as they could not be expected to keep pace with these trained
Arctic dogs, one was taken up into Captain Brace’s sledge, and the other
with the boys themselves in Ingomar’s.
Food was not forgotten, you may be well sure, nor tobacco and
knickknacks for the natives.
The journey was a long one, and many a halt had to be made on hill-
tops, and even in the valleys beneath.
No one who has not travelled in a real Eskimo well-appointed dog-sleigh
can have the faintest notion of the speed obtained on good snow.
To-day it seemed as if the drivers were bent upon making a record, and it
was one that I would defy any motor-car to make over the same track. The
dogs needed to rest now and then, to lie down and pant a little, and refresh
themselves by gulping down mouthfuls of the pure snow that was within
easy reach.
Then they were fit again once more.
Though it was but little past one o’clock p.m., the sun was already going
down when the halt for luncheon was called; and it need hardly be said that
under so bracing a sky our travellers made each a hearty meal.
They were high up on a rounded hill, and the view all around from the
rugged mountains of the west to the east, where lay the rough and rugged
sea of ice, was indescribably beautiful.
Even the Yak-Yaks themselves seemed impressed with the transcendent
loveliness of this marvellous Arctic sunset, and those moments of such
stillness and silence that one might have heard a snowflake fall.
It was night and starlight before they reached the Eskimo village.
A moon by this time had risen solemnly over the hills, and flooded all
the country with its strange, mysterious light—- a light the like of which I
have seen in no land save the Arctic, a light that seems mystic and
positively holy.
All the inhabitants turned out to welcome our heroes, and a wild, strange
welcome it was.
This was a wandering tribe, and consequently a more brave and fearless
people than the inhabitants of the igloo villages around the coast.
But they were safe; and they looked upon Ingomar as their sun-king, as
in their musical, labial language they expressed it.
This tribe might have numbered altogether some six or seven hundred
souls, and I may as well tell the truth about them—they never fished for
blubber themselves, but levied blackmail on their humbler and more
industrious neighbours who lived along the shores of gulfs and bays.
They had very large stores of frozen blubber, however, thousands of
skins, and plenty of stored fish, and flesh of every sort, from seagulls’ to
whales’.
Stimulants in the shape of rum or brandy I do not believe they ever
tasted, but they seemed all the more happy in consequence.
Ingomar strode round among them, and even the children ran towards
him to kiss his hand. Nay, more, the very dogs danced about him, but
“down-charged” whenever he lifted his hand.
It was a queer sight to see the splendid jet-black Newfoundland standing
close by his Nora’s side and defying the whole howling pack, turning his
head sideways now and then to give Nora a lick, as much as to say, “Don’t
be afraid, my dear; they’re only ignorant savages. I could fight them six at a
time.”
The night was to be one of hard frost; but these nomads, much to our
heroes’ astonishment, lit a great fire of ancient pine wood, which they had
excavated from a hillside not far off, and so John Frost was defied for once.
The arrival of real “Eengleeshmen” at their winter camp was an event
that no one would ever forget.
Though, in a manner of speaking, warlike in comparison to the ordinary
Eskimos, these Yak-Yaks seemed very gentle and tractable, and did all in
their power to entertain their guests. They sang queer little musical ditties,
and the men and women joined in every chorus, clapping knees and brows
with their palms in quite a funny way.
Then some of the head hunters gave a kind of dramatic performance,
spear-armed; and even Charlie and Walter could see that this represented
every phase of a great bear-hunt, even to the slaying of Bruin, and the death
of one of the hunters.
Then Ingomar himself took the snowy stage, and if he had been listened
to with the same rapt attention in New York that he was to-night by these
semi-savages, the probability is that he never would have left his own
country.
Ingomar’s igloo was a very large one, and in it burned two huge lamps,
giving plenty of heat and light. There was no smoke, because that which
arose from the oil was carried right up through, and though all the whites
slept here in their bear and seal-skins, there was not a particle of discomfort
felt.
And all slumbered well till eight o’clock next morning.
The fire was now replenished, and smoked fish made a right dainty
addition to the breakfast. The menu was certainly not so extensive as that of
a Glasgow or London hotel, but our heroes sat down to it with hearty
appetites, and that is more than most people can boast of in gloomy London
town.
 A surprise was awaiting them this morning, of which Ingomar had given
the visitors no previous hint.

CHAPTER V

THE SHIP’S BEARS: GRUFF, AND GROWLEY, AND GRUMPEY, AND MEG

The surprise was this: no fewer than four young Greenland bears[C] were
led forth, and attached or harnessed to a hugely large sledge, and seemed so
perfectly quiet and well broken, that neither Charlie nor Walt hesitated for a
moment to take their seats.
This sleigh could accommodate as many as ten men.
But these bears, although they moved not with half the rapidity of a team
of dogs, never varied their pace, and never needed rest until they had
covered a distance of not less than twelve miles.
Both the Newfoundlands had been shut up in an igloo. This was a
precautionary measure, for although the bears never attempted to molest the
Yak-dogs, they might not have objected to a mouthful or two of fine, fresh
Newfoundland.
And the end of it all was that Captain Mayne Brace considered himself
quite justified in purchasing these noble animals, for if anything came of the
proposed Antarctic expedition, there was no reason why they should not be
taken south with the force.
The days grew longer and longer now, fresh snow fell, softer winds
began to blow, and at long last, with noises that are indescribable, the ice all
around began to crack and break with the force of great waves that rolled in
beneath them from the Eastern ocean.
Previous to this, however, peace had been established between the Yak-
Yaks and the Teelies. The former had encamped close to the bay, and plenty
of provisions and necessaries having been landed, Humpty Dumpty himself
was left in charge of the whole—a kind of white king, in fact, who
considered himself of no small importance. He had orders to keep the peace
until the Walrus should return after the spring fishing.
The sun was now shining nineteen hours out of the twenty-four, and
soon it would rise not to set again for months; and so one glorious morning
sail was set, and the Walrus, scorning the lesser baybergs, went ploughing
her way slowly seawards, and in good time reached the whaling grounds.
If Captain Mayne Brace had come to these northern seas merely for
sport and pleasure, he might have had plenty of both. There were seals
enough, though rather scattered; there were bears in abundance, strolling
defiantly on their native ice, or buffeting the billows in search of pastures
new; there were bladder-noses, sharks in scores—oh, in shoals sometimes
—walruses on the ice and in the water, lonely unicorns, and those
marvellous narwhals that go plunging about, and always seem to be going
somewhere on particular business, but never getting there. Yet glorious
times of it the beasts have for all that when they reach shoal water, and can
spear with their wonderful weapons the flat fish and skates that there do
dwell. For my own part I should rather like to be a narwhal for a month or
two in summer. Hammer-headed sharks, too, there were, those hideous
zygænas, and birds in millions; but, alas, for Brace’s pretty barque and her
greedy owners, hardly ever was a true Greenland whale seen or tackled.
And so when the season was waxing to a close, and these monster
whales had babies of their own with which they departed southward to
warmer seas, for their children’s sake, Captain Brace determined one
morning that it was time to bear up once more for Britain’s shores.
Of course the men were down-hearted, because many of them had
families to provide for, and did not want to return with empty pockets. But
“better luck next” is the motto of your Arctic sailor; and when Brace, their
well-beloved skipper, told them that there was considerable probability that
many of them—if they chose to volunteer—would be engaged for an
expedition to the Southern Pole, they regained heart, and made the welkin
ring with their lusty cheers.
When the Walrus arrived at last at Incognita Bay, and the anchor was let
go in a cosy corner, as near to the shore as they could venture with safety,
preparations were immediately commenced, first, for the shipment of huge
blocks of fresh-water ice, and afterwards, for the embarkation of the dogs
and Yak-Yaks they were to take southwards with them.
The bears were going to be the great difficulty. They were splendidly
trained, it is true. But then they were but young; and who could say that
they might not, when at sea, kick over the traces, eat their Yak-Yak keepers,
and become frantically unmanageable?
 The whole of the fo’cas’le was turned into a huge bear-den for their
accommodation, and seal-meat in abundance was lowered into an ice-tank,
that, during their long voyage, they might not starve.
It was a happy thought of Slap-dash, a brave Innuit and chief keeper of
the bears, to have trained three of the Yak-dogs to sleep with his monster
pets. The bears had become very fond of these, and growled a good deal at
each other over them at night, but never actually fought.
But for these honest dogs the shipment of the Bruins would have
presented far greater difficulties.
I must describe how this shipment was actually effected. To have roped
the poor beasts would have rendered them savage, and this would have been
rather indiscreet, to say the least. So a large raft was constructed, as well as
a sort of inclined plane of wood, similar to a horse’s ladder. This last was
made fast to the fo’cas’le bulwark above, while the other end was held in its
place, on the sea below, by means of floats and beams from the ship’s
water-line.
The three pet dogs, the bears’ favourites, were easily got on to the raft,
and the Bruins followed. The Innuit himself kept feeding them as they were
being towed all the way to the ship, and while the raft was made fast to the
inclined plane. Then up sprang Slap-dash, and called the dogs to follow.
“Oh,” said the biggest bear, whose name was Gruff, “if that’s your game,
here’s for after.”
And up he went.
In less time than it takes me to write these lines all the lot were
comfortably caged.
They were not quite satisfied with their lot to begin with, however.
They had never been to sea or on board ship before in their lives, though
they had been permitted to swim about the bay many times and oft, and
even to stalk seals for themselves. But to be placed in a den with strong iron
stanchions before it, was a trifle more than they had bargained for.
Slap-dash was a very good master to them, however, and tried to comfort
them in every way that he could. And so did the dogs.
Before I go any further let me mention that bears are almost, if not quite,
as sagacious, in their own way, as cats. Yet the ways of bears are a little
peculiar, and as pets—well, they are not altogether satisfactory. The reason