The last step is wound closure. In OTL as of 2000, we generally worked with primary closure of almost all wounds if there was enough tissue left to cover the wound, and the wound did not involve an animal bite. Under austere conditions, this is often not the best choice of treatment. Areas with an extremely good blood supply (generally the head, face and neck) will do well with primary closure under most circumstances, thus limiting scarring in cosmetically-sensitive locations. Other areas of the body are best treated with delayed primary closure, where the wound is either packed with a non-stick material (gauze impregnated with petrolatum jelly in the NTL) or the deep spaces are closed loosely with the skin and subcutaneous tissues left open, and the whole wound covered with a bulky, sterile, absorbent dressing. The dressing and wound is then left alone for at least forty-eight hours to allow healing to start.
This is a dramatic change from the care that most medical personnel learned from 1960 to 2000 or so in the industrial world. As a resident physician covering the surgical service in 1987-89, it was common for me to personally have to change dressings and examine surgical and traumatic wounds twice a day. The lessons first taught during WWI and later relearned in the Spanish Civil War and WWII have come back around in these days of "super germs" that jump from patient to patient, to wit: dressing changes expose the tissues to new infection and slow the healing.
After the first forty-eight hours, delayed primary closure can be considered if there are no signs of infection. Otherwise, clean things up again, and apply a dressing that will stay on for one to several weeks while the wound heals by the natural process of granulation. This technique is called "healing by secondary intent," and can leave rather large scars. Dr. Trueta's advance was that he used a plaster of Paris cast to form the outer dressing, thereby keeping the fingers and instruments of well-meaning nurses and physicians out of the wound.[xxix] This was an advantage in treating open fractures of the limbs, as the limb had to be casted to prevent the movement of the bone ends.
Orthopedics
The use of plaster of Paris impregnated gauze cloth to form casts[xxx] to keep broken bones immobilized will be a significant advance over the rag-padded splints used by most bone-setters in the NTL. In OTL, the traditional padding and plaster gauze are made from cotton. Newer fiberglass casting materials used a synthetic padding. Linen gauze will do for the casting material, but the padding needs to be made from a lightly felted or flannel-type material. I'm not sure that the longer, stiffer fibers of linen will work for this. Possibly, Tom Stone had some Cannabis sativa, which produces higher quality fiber, stashed among the C. indica, which produces the higher quality resin so beloved of ladies with menstrual cramps. I believe that the hemp fibers have a soft enough "hand" to be woven into flannel (or made into the soft felt) that can be used for the padding. Cotton should be available in sufficient quantities for medical uses by 1634, based on imports from the Middle and Far East.
Among the simplest of orthopedic techniques, the bone-setters of the NTL already understand the closed reduction and splinting of simple long bone fractures. What the up-timers will bring will be the casting material and techniques, along with the use of radiographs to confirm that the bones have been brought back into natural alignment, and the aseptic techniques needed to care for fractures with wounds. As previously noted, once the injectable local anesthetic agents are again available, hematoma blocks will make bone setting more comfortable for the patient.
The bone-setters will probably also know that the joint above and below the fracture needs to be immobilized by the splint. Similarly, in cases of joint injury, the bone above and below the joint needs to be immobilized for treatment. Most fractures can be handled by these methods, although more complex fractures will take much longer to heal. Femoral neck ("hip") fractures and some femoral shaft fractures will not respond quickly to this level of treatment, and will be a major source of post trauma mortality for a long time after the RoF.
The next step in the management of more complex fractures will have to wait until stainless steel pins and rods are reintroduced. Known as skeletal traction, these pins act to transfer the force needed to maintain alignment directly to the bones. The pins are inserted through the skin to pierce the bone and come out the other side of the limb. Once inserted, traction is used to align all of the bone fragments into some close approximation of the natural bone. The pins are already in canon as of May 1634[xxxi], with the repair of a young boy's hand after he caught his fingers in a moving belt. I do not know if the pin used was from "old new stock" (left over from before the RoF), new stock (doubtful, as this is very early for even the smallest amounts of chromite to be returned to Grantville and appropriately refined to add to a batch of stainless steel) or a pin that was removed from another patient, cleaned and resterilized for reuse. This also argues that plain film radiographs are available at this point, as I doubt that Dr. Nichols would allow the use of this technique in a child this young without them[xxxii].
The traction will initially be provided by the hands of the surgeon's assistant and later continued by a system of pulleys, cords and weights, easily reproduced in the NTL, until the plaster hardens. Hip and femoral fractures will respond to this treatment, but may require three or more months in bed while the traction keeps things in line. "Spica" type casts, where not only one limb, but the pelvic or shoulder girdle is involved, with a strut passed between the limb cast and the body cast, can also be used for some hip and femoral fractures, but has the trade-off of weight versus freedom from traction. The pins can stabilize multiple bone fragments while the plaster cast holds the pins and the whole limb immobilized as the fracture heals. A somewhat more advanced system would use metal (even brass) rings and rods to form a system to provide the support needed to keep the pins in position, but this system will work best when the skin is left intact except for where the pins enter. Balancing the advantages and disadvantages of the systems is something that will have to be learned as the techniques develop.
To deal with fractures that are too complex or angulated to be reduced by traditional closed methods, or fractures that are already open due to wounds or the penetration of the sharp edge of bone through muscle, fat and skin, aseptic techniques allow the surgeon to clean and debride the tissues and to bring the bones back into alignment. Pins and traction are used to align the bones, the wounds are partially closed, and a plaster cast is again used to maintain the alignment of the pins (and therefore the bones) and immobilize the limb.