- Joshua Longmire
The Civil War led to numerous advancements in the field of orthopedics. Through extensive trial and error, and with limited understanding of germ theory, Civil War surgeons developed ideas and practices that still have a significant impact on how patients are cared for today. During the war, orthopedic treatment mainly consisted of conservative surgery, excisional surgery, or amputations. However, amputations were the most common method of treatment, with about 50% of extremity gunshot wounds that included fractures being treated with amputations, to best avoid further injury or death (Kuz). When it came to amputations, surgeons experimented with many different iterations; the anteroposterior flaps were found to be more useful than the circular or guillotine methods for retaining the most function while being the most effective (Kuz). As the war went on and surgeons gained more experience, they leaned more toward conservative surgeries and debridement rather than full amputation, unless secondary amputation was then deemed necessary. The most common conservative procedures were excision of the shoulder, elbow, and hip, with the hip being by far the least successful. After these excision surgeries, soldiers were commonly put into a splint and had passive motion started as soon as possible (Kuz).
Another advancement came with traction devices and splints, specifically Buck’s traction, which is used today with hip fractures, and plaster splints. Additionally, the first attempts at internal fixation of fractures were made during the Civil War. With only a couple of documented attempts, the main surgeon for this procedure was Dr. Benjamin Howard. He would “resect the comminuted ends of the fracture site, place the ends in opposition, and use a special drill and suture passer to hold the bone ends together using a wire” (Kuz). A development in orthopedic surgery and most surgeries in general during the Civil War was the best time after an injury to do surgery. While it was greatly debated amongst surgeons, the consensus seemed to be that primary surgery should be done within 48 hours of injury and secondary surgery should be done after 30 days. The time in between, the intermediate period, resulted in the most surgical deaths. An unlikely advancement in osteomyelitis and gangrene came when Confederate surgeons discovered that wounds with maggots became cured at much higher rates (Kuz). This became the primary form of treatment, with maggots being bred under sterile conditions.
With all the injuries and surgeries going on during the Civil War, there became a need for prosthetics. The Association for the Relief of Maimed Soldiers became the primary provider of prosthetics to soldiers with amputations, giving 769 prosthetics in total. The use of prosthetics also required that surgeons perform their amputations no more proximally than the distal ⅓ of the tibia and that they use anteroposterior flap amputations for the best outcomes. The more prosthetics that were made and the longer the war progressed, advancements in prosthetics included, “a single-axis ankle controlled by vulcanized rubber bumpers and a transfemoral prosthesis with a polycentric roller knee, multiarticulated foot, and endoskeletal construction” (Kuz).
The specialty of orthopedic surgery grew tremendously during the Civil War and shortly afterwards. The first orthopedics textbook is through to have been written about soldiers during the war by Louis Baur, the first orthopedic professorship was created in 1861 by Lewis Sayre, the first orthopedic residency was started in 1863 under James Knight, orthopedics was recognized as an especially by the first major hospital in 1872, and the American Orthopaedic Association was formed in 1887 as the first US orthopedic organization (Kuz). Orthopedic surgery started and grew from the heavy case load the surgeons were thrown into during the war, with many surgeons of the war using what they learned to treat patients and veterans after the war.
Looking at orthopedic surgery’s advancement and procedures today shows just how far the specialty and care for patients have come from what we saw in the beginning with the Civil War. Amputations during the Civil War resulted in a 26.3% mortality rate (Reilly). This is compared to current orthopedic surgery, where an above-the-knee amputation anywhere on the femur has the highest mortality rate at 7.22% (Ernst et al). What once was just a field solely defined by wound and trauma care has now grown into a specialty focused on many facets: preventative medicine, diagnosis and treatment of disorders and illnesses, and providing treatment, therapy, and recovery for musculoskeletal problems. Orthopedic surgeons now use a variety of tests, like X-rays, CT scans, MRIs, blood work, and physical exams, to be able to better determine the patient’s problem and best course of treatment (Liang et al). Once surgeons have their diagnosis, they now have a multitude of techniques and procedures they can use to best treat the patient. Orthopedic surgery uses arthroscopy, a surgical technique that is minimally invasive with the use of a camera, which allows surgeons to access and treat conditions in numerous joints with only a few small incisions. Another aspect of orthopedic surgery is joint replacement. Surgeons can remove diseased or injured joints and put in manufactured replacements to improve the use of the affected joints and the lives of their patients tremendously (Liang et al). Instead of simply amputating a limb or removing parts of joints like in the Civil War, surgeons now have the techniques and equipment to fix and replace affected body parts at a much higher frequency.
An area of orthopedic surgery that began during the Civil War was fracture repair. In addition to casting, external fixation, and internal fixation, which were done during the Civil War, surgeons can now do bone grafts and bone stimulation to replace bone and promote bone healing. Stemming from splints and traction devices in the Civil War, orthopedic surgeons today have many techniques for external fixation. Some of these techniques include the Ilizarov Technique, a set of wires and pins connected to a circular frame around the affected body part that corrects length discrepancies, and the Taylor Spatial Frame, a frame with struts and pins attached to the affected body part to also correct leg lengths or deformities (Liang et al). Orthopedic surgeons can also perform osteotomy procedures to help reshape and cut bones in patients that have certain conditions or deformities, as well as use bone fusion to relieve the pain and damage in joints to stabilize the patient. The field of orthopedic surgery has a much more expanded focus on soft tissue now, more than it did during the Civil War. Surgeons can use grafting techniques, percutaneous repair, arthroscopic repair, and open surgery to treat many other problems not related to bones (Liang et al).
Finally, orthopedic surgery now has aspects that could not have been thought of during the Civil War. The specialty is advancing toward the use of robotics in surgery, 3D printing of devices and implants, regenerative medicine, virtual reality, telemedicine, and artificial intelligence (Liang et al). Orthopedic surgery today can impact a much wider range of problems and offers more individualized diagnosis and treatments, many of which were developed and enhanced from the Civil War. Techniques like trauma management, amputations, Buck’s traction and plaster splints, open treatment of contaminated wounds, internal and external fixation, and resection and extraction of bone and fragments all stemmed from the Civil War and have led to the highly sophisticated orthopedic surgery field that we currently have today (Kuz).
References
1. Ernst, B. S., Kiritsis, N. R., Wyatt, P. B., Reiter, C. R., O’Neill, C. N., Satalich, J. R., & Vap, A. R. (2025). Ranking the Orthopedic Procedures With the Highest Morbidity and Mortality. Orthopedics, 48(1), e40–e44. https://doi.org/10.3928/01477447-20240913-02 (Original work published January 1, 2025)
2. Kuz J. E. (2004). The ABJS presidential lecture, June 2004: our orthopaedic heritage: the American Civil War. Clinical orthopaedics and related research, (429), 306–315.
3. Liang, W., Zhou, C., Bai, J., Zhang, H., Jiang, B., Wang, J., Fu, L., Long, H., Huang, X., Zhao, J., & Zhu, H. (2024). Current advancements in therapeutic approaches in orthopedic surgery: a review of recent trends. Frontiers in bioengineering and biotechnology, 12, 1328997. https://doi.org/10.3389/fbioe.2024.1328997
4. Reilly R. F. (2016). Medical and surgical care during the American Civil War, 1861-1865. Proceedings (Baylor University. Medical Center), 29(2), 138–142. https://doi.org/10.1080/08998280.2016.11929390
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