Professional Documents
Culture Documents
The
History of Fracture Treatment
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Christopher L. Colton, M.D., F.R.C.S., F.R.C.S.Ed.
FIGURE 1-1 A and B, Specimen of a fracture of an adolescent femur from circa 300 BC,
excavated at Naga-ed-Der in 1903. This injury was an open fracture, and
the absence of any callus (arrow in A) indicates early death.
Hubenthal had described its use in fractures of the forearm, the hand, and the clavicle, mixing the plaster powder with unsized paper (similar to blotting paper). He
encased the limb in a trough made of pasteboard, closed
FIGURE 1-5 Platre coule such as Eaton recorded seeing
in Turkey in the 18th century.
TRACTION
Although longitudinal traction of the limb to overcome
the overriding of fracture fragments had been described
as early as the writings of Galen (AD 130 to 200), in which
he described his own extension apparatus, or glossocomium
(Fig. 1-8), this traction was immediately discontinued once
splintage had been applied. The use of continuous traction in the management of diaphyseal fractures seems
to have appeared around the middle of the 19th century, although Guy de Chauliac (1300 to 1367) wrote in
Chirurgia Magna, After the application of splints,
I attach to the foot a mass of lead as a weight, taking care
to pass the cord which supports the weight over a
small pulley in such a manner that it shall pull on the leg
in a horizontal direction (Ad pedum ligo pondus plumbi
transeundo chordam super parvampolegeam; itaque tenebit
tibiam in sua longitudinae).27
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FIGURE 1-9 Forearm skin traction for the treatment of T fractures of the distal humerus. (From Helferich, H. Frakturen
und Luxationen. Munchen, Lehmann Verlag, 1906.)
FUNCTIONAL BRACING
Given that Gooch's description in 1767 of the first tibial
and femoral functional braces was to remain obscure for
more than two centuries, it is surprising that after the
intense discussion of the technical minutiae and principles
of splintage in the 19th century, there was no real modification of the standard plaster-of-Paris cast until the work
of Sarmiento,69 published 200 years after that of Gooch.
Following experience with patellar tendon-bearing
below-knee limb prostheses, Sarmiento developed a patellar tendon-bearing cast for the treatment of fractures of the
tibia, applied after initial standard cast treatment had been
used to permit the acute swelling to settle. This heralded
the renaissance of functional bracing, and in 1970 Mooney
and colleagues56 described hinged casts for the lower limb
in the management of femoral fractures treated initially
with some 6 weeks of traction.
Since the mid-1970s, the development of a variety of
casting materials and the use of thermoplastics in brace
construction have extended the ideas of these pioneers of
the 1960s and 1970s to the point where functional
OPEN FRACTURES
Until about 150 years ago, an open fracture was virtually
synonymous with death and generally necessitated immediate amputation. Amputation itself carried with it a very
high mortality rate, usually with death resulting from hemorrhage or sepsis. Until the 16th century, the traditional
method of attempting to control the hemorrhage after
amputation was cauterization of the wound, either with
hot irons or by the application of boiling pitch. This in
itself may well have caused tissue necrosis and encouraged
infection and secondary hemorrhage. The famous French
surgeon Ambroise Par (1510 to 1590), who served as surgeon to the Court of Henry II and Catherine de Medici
and is rightfully regarded as the father of military surgery,
was in 1564 the first to describe the ligation of the bleeding vessels after amputation. He developed an instrument
that he called the crow's beak (bec de corbin) for securing
the vessels and pulling them out of the cut surface of the
amputation stump in order to ligate them (Fig. 1-10).
Notwithstanding this advance, Le Petit, who in 1718
described the use of the tourniquet to control hemorrhage
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FIGURE 1-11 Illustration from Pares surgical text of 1564 of his own open tibial fracture
treated by splintage and open care of the wound. This is the first welldocumented cure of an open limb fracture without amputation.
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all the patients. It has been said of that era that it was
probably safer to have your leg blown off by a cannonball
than amputated by a surgeon!
During World War I, gunshot wounds of the femur carried a very high mortality rate in the early years. In 1916 the
death rate from gunshot wound of the femur was 80 percent
in the British army. Thereafter it became policy to use the
Thomas splint, with fixed traction applied via a clove hitch
around the booted foot, before transportation to the hospital. Robert Jones reported in 1925 that this simple change
of policy resulted in a reduction of the mortality rate to 20
percent by 1918. With progressive understanding of bacterial contamination and cross-infection after the pioneering
work of Pasteur, Koch, Lister, and Semmelweis; the use
of early splintage, as learned by the British forces in World
War I; and the application of open-wound treatment following wound extension and excision as advocated first by
Par and later by Larrey (Napoleon's surgeon and inventor
of the ambulance),57,78 the scourge of the open fracture, even
from a femoral gunshot wound, has been greatly reduced.
Screw Fixation
The use of screws in bone probably started around the late
1840s. Certainly in 1850, the French surgeons Cucuel and
Rigaud described two cases in which screws were used in
the management of fractures.19 In the first case, a man
of 64 sustained a depressed fracture of the superior part
of his sternum, into which a screw was then inserted to
permit traction to be applied to elevate the depressed sternal fragment into an improved position. In the second
case, a distracted fracture of the olecranon, Rigaud inserted
a screw into the ulna and into the displaced olecranon,
reduced the fragments, and wired the two screws together
(vissage de rappel ), thereafter leaving the arm entirely free
of splintage and obtaining satisfactory union of the
fracture. Rigaud also described a similar procedure for
the patella. In his extraordinarily detailed and comprehensive treatise on direct immobilization of bony fragments,
Brenger Fraud made no mention of interfragmentary
screw fixation, which was probably first practiced by
Lambotte (see following section).
Plate Fixation
The first account of plate fixation of bone was probably the
1886 report by Hansmann of Hamburg entitled A new
method of fixation of the fragments of complicated fractures.30 He illustrated a malleable plate, applied to the
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bone to span the fracture site, the end of the plate being
bent through a right angle so as to project through the
skin. The plate was then attached to each fragment by
one or more special screws, which were constructed with
long shanks that projected through the skin for ease of
removal (Fig. 1-13). He recorded that the apparatus was
removed approximately 4 to 8 weeks after insertion and
described its use in 15 fresh fractures, 4 pseudarthroses,
and 1 reconstruction of the humerus after removal of an
enchondroma.
George Guthrie28 discussed the current state of direct
fixation of fractures in 1903 and quoted Estes as having
described a nickel steel plate that he had been using to
maintain coaption in compound fractures for many years.
This plate, perforated with six holes, was laid across the
FIGURE 1-13 Redrawn from Hansmanns article of
1886, A new method of fixation of the
fragments of complicated fractures, the
first publication on plate fixation of
fractures. The bent end of the plate and
the long screw shanks were left protruding
through the skin to facilitate removal after
union.
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fracture, and holes were drilled into the bone to correspond to those of the plate. The plate was fixed to the
bone by ivory pegs, which protruded from the wound.
Removal was accomplished 3 or 4 weeks later by breaking
off the pegs and withdrawing the plate through a small
incision. Guthrie reported that in a recent letter Dr. Estes
had said, The little plate has given me great satisfaction
and has been quite successful in St. Luke's Hospital.
Guthrie also quoted Steinbach as reporting four cases of
fractured tibia in which he had used a silver plate by this
method and obtained good results. He removed the plate
using local anesthesia. Silver was greatly favored at this
time as an implant metal, as it was believed to possess antiseptic properties. Interestingly, in this article, Guthrie
referred to the use of rubber gloves during surgery, seemingly antedating the reputed first use of gloves by
Halstead.
The man who coined the term osteosynthesis was Albin
Lambotte (1866 to 1955), although Brenger Fraud
referred to the restoration of bone continuity by ligature
or bone suture as synthsisation. It is believed, however,
that by osteosynthesis Lambotte meant stable bone fixation
rather than simply suture. Lambotte is generally regarded
as the father of modern internal fixation, and in his foreword to a book commemorating the works of Lambotte,
Dr. Elst briefly discussed the early attempts in the 19th
century at surgical stabilization of bone and then
continued, Thus at the end of the last century, the idea
was floating among surgeons. As always in the field of
scientific progress, comes the right man in the right place,
a genial mind who collects the items spread here and there,
melts them into a solid block and forges the whole
together. So did Albin Lambotte in Belgium, a pioneer
of osteosynthesis.23
Lambotte (Fig. 1-14), the son of a professor of comparative anatomy, biology, and chemistry at the University of
Brussels, was taught almost exclusively by his brother Elie, a
brilliant young surgeon, who sadly died prematurely. Albin
had worked under the direction of his brother at the Schaerbeek Hospital in the suburbs of Brussels and then in 1890
became assistant surgeon at the Stuyvenberg Hospital in
Antwerp, rapidly progressing to become the head of the surgical department. From 1900, he tackled the surgical treatment
of fractures with great enthusiasm and much innovation. He
manufactured most of his early instruments and implants in
his own workshop, developing not only plates and screws for
rigid bone fixation in a variety of materials but also an external fixation device similar in principle to the ones in use
today. He met with much intellectual opposition, but his
excellent results were persuasive. In 1908, he reported 35
patients who had made a complete recovery after plate
fixation of the femur. His classical book on the surgical
treatment of fractures was published in 1913.42 His
legendary surgical skill was the product not only of a
keen intellect but also of his extraordinary manual
dexterity, which was also channeled into his great interest
in music. He became a skilled violinist, but this was not
enough for him, and he subsequently trained as a lute
maker. He, in fact, made 182 violins and his name is
listed in Vanne's Dictionnaire Universel des Luthiers.
Elst related the following anecdote as an indication of
Lambotte's manual skills:
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16
the neck, over which they applied gowns wet with carbolic
or Lysol solution, and similarly the patients were draped
with antiseptic towels introduced by Lane around 1889.
The instruments were also soaked in Lysol, but by 1904
dry sterilization of the gowns and the instruments was
Lane's routine.
Interestingly, Layton recorded the postmortem exploration of a fracture plated by Lane; the patient subsequently
died of an unrelated septicemia. Layton said, I cut down
onto the bone and found this firmly joined without the
throwing out of any callus around it. The plate was well
in place, the screws all firmly fixed without a suspicion of
any inflammation of the bone into which they had been
put.46 This surely must have been the first observation
of healing without external callus formation in the presence of rigid fixation. In addition, Lane is credited with
developing the nontouch technique of bone surgery and
devised many instruments to enable him to hold implants
without handling them directly. Of operative technique,
Lane wrote:
I will now relate the several steps which are involved in an
operation for simple fracture. I will do so in some detail as
apart from manual dexterity and skill the whole secret of
17
FIGURE 1-17 Sherman instrumentation from the Drapier (Paris) catalogue of the early
1950s.
EXTERNAL FIXATION
Traditionally, the first external fixation device was the
pointe mtallique conceived by Malgaigne in 1840 and subsequently documented in 1843 in the Journal de Chirurgie.5
This apparatus consisted of a hemicircular metal arc that
could be strapped around the limb in such a manner that
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19
FIGURE 1-21 The external fixation device invented by Keetley of the West
London Hospital, Englandprobably the first to be drilled
into the substance of the bone. (Redrawn from Lancet,
1893.)
20
FIGURE 1-24 Some of the instruments of Lambotte in the collection of the University Hospital of Ghent, Belgium, including
a Lambotte fixateur externe.
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INTRAMEDULLARY FIXATION
As previously discussed, pioneers such as von Langenbeck,
Koenig, Cheyne, Lambotte, and Lane had all used intramedullary screw fixation in the management of fractures
of the neck of the femur. In addition, there are a number
of reported instances of intramedullary devices in the neck
of the femur being used for the management of nonunion,
including the extensive operation of Gillette, who used the
transtrochanteric approach to perform an intracapsular fixation of ununited femoral neck fractures using intramedullary bone pegs.27 Curtis used a drill bitas, reputedly, had
Langenbeckin the neck of the femur, and Charles
Thompson used silver nails in 1899.7 Lambotte also
recorded the use of a long intramedullary screw in the
management of a displaced fracture of the neck of the
humerus in 1906.
In the late 19th century, attempts were made to secure
fixation of fractures using intramedullary ivory pegs, and
Bircher is credited with their first use in 1886.8 Short intramedullary devices of beef bone and of human bone were
also used by Hoglund.37 Toward the end of the first decade
of the century, Ernest Hey Groves, of Bristol, England,
was using massive three- and four-flanged intramedullary
nails for the fixation of diaphyseal fractures of the
femur, the humerus, and the ulna.66 Hey Groves's early
attempts at intramedullary fixations of this type were complicated by infection, earning him the epithet septic Ernie
among his West Country colleagues. Metallic intramedullary
fixation of bone was not at that time generally accepted.
In the late 1920s the work of Smith-Peterson,75 who used a
trifin nail for the intramedullary fixation of subcapital fractures of the femur, represented a great step forward in the
management of what has since been referred to as the unsolved
fracture, and that remained the standard management for
this type of injury for some 40 years.
The use of stout wires and thin solid rods in the intramedullary cavities of long bones was recommended by Lambrinudi in 1940.43 This technique was further developed in the
22
FIGURE 1-26 Professor Lorenz Bohler (in uniform) photographed during World War II,
talking to Adolph Lorenz.
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24
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FIGURE 1-30 Hans Willenegger, Maurice Muller, and Martin Allgower, three of the
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straighten out the limb by turning nuts on the fixator surrounding his limb. Ilizarov intended to insert a bone graft
into the resulting triangular bone defect when the knee
was straight. To his surprise, Ilizarov found a wedgeshaped mass of newly regenerated bone at the site of
osteotomy when distraction was finished.
Extending his observations, Ilizarov after that time
developed an entire system of orthopaedics and traumatology based on his axially stable tensioned wire circular
external fixator and the bone's ability to form a regenerate of newly formed osseous tissue within a widening distraction gap.
Employing his discovery of distraction osteogenesis, Ilizarov used various modifications of his apparatus to elongate, rotate, angulate, or shift segments of bones
gradually with respect to each other. The fixation system's
adaptability also permits the reduction and fixation of
many unstable fracture patterns.
Until his death in 1992, Professor Ilizarov headed a 1000bed clinical and research institute staffed by 350 orthopaedic
surgeons and 60 scientists with Ph.D. degrees, where patients
from Russia and the rest of the world come for the treatment
of birth defects, dwarfism, complications of traumatic injuries, and other disorders of the musculoskeletal system.
For many years, Professor Ilizarov and his co-workers
have trained surgeons from socialist countries in his techniques. Around 1980, Italian orthopaedists learned of Ilizarov's methods when others from their country returned
from Yugoslavia and nearby Eastern European countries
with circular fixators on their limbs. Soon thereafter, Italian, other European, and, more recently, North American
orthopaedic surgeons have ventured to Siberia for training
in the Ilizarov method.
The techniques and applications of the Ilizarov method
have continued to improve with time, both in Russia and
around the world. One important advance in the technique
of fixator application consists of the substitution of titanium
half pins for stainless steel wires in many locations, thereby
adding to patients' comfort and acceptance of the apparatus.
Nevertheless, much clinical and scientific work investigating the Ilizarov method remains to be done. Biomechanical and histochemical studies are needed. The health care
insurance industry has been slow to recognize the magnitude
of Ilizarov's discoveries. They must be educated. A generation of orthopaedic surgeons requires training in the
method. With time, however, Ilizarov's discoveries will
become fully integrated into modern clinical practice.
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Winter-Klemm. Let me share with you some of my memories of Dr. Klemm and look more into his story so you
will understand his importance to those in traumatology
whom he influenced.
Klaus Klemm was born into a comfortable Frankfurt
am Main family on May 19, 1932. He spent some of
World War II as part of a youth group at a rail station
in the Black Forest. He entered medical school in Frankfurt/Main in 1952, took a semester in Freiburg, and
finished his medical degree in 1958. He then went to
the Northern Westchester Hospital in Mount Kisco,
New York, from 1958 to 1960 and returned to Germany,
where he was licensed as a physician in 1962. Next, he
took a position as an assistant to Professor Junghans in
the new Workman's Hospital (BG) Frankfurt. At the
BG, he was part of the new Septic Unit. From 1966 to
1969, he took his training in Surgery at St. Markus Hospital, Frankfurt/Main, and became Oberarzt and Chief of
the Septic Unit at BG/Frankfurt first under Prof. Junghans and later with Prof. Contzen and finally until his
retirement in 1999 under the direction of his student, Professor Brner.
Therefore, Dr. Klemm trained during the confusion of
postwar Germany, spoke good English because of his
2 years in Westchester County, and accepted the task of
treating bone infection with limited resources in a rebuilding country. Conventional treatment for osteomyelitis was
SUMMARY
Christopher L. Colton, M.D.
As technology advances, so do the severity and frequency
of traumatic insult, and the demand for ever-increasing
skill on the part of the fracture surgeon grows likewise. It
is only by the study of the history of our surgical forebears
and by keeping in mind how they have striven, often in the
face of fierce criticism, to achieve the apparently unattainable that young surgeons will continue to be inspired to
emulate them and so carry forward the progress they have
achieved.
Any consideration of the history of 5000 years of
endeavor, confined of necessity within the strictures of a
publication such as this, is perforce eclectic. Nevertheless,
in deciding to highlight the achievements of some, I have
not in any way set out to minimize the pioneering work of
those whose activities have not been specifically detailed in
this overview, and with respect to these necessary omissions I ask the reader's indulgence.
REFERENCES
1. Amerasinghe, D.M.; Veerasingham, P.B. Early
weight bearing in tibial shaft fractures protected by
wooden splints. Proc Kandy Med Soc 4:(pp. unnum.),
1981.
2. Assen, J. van; Meyerding, H.W. Antonius Mathijsen,
the discoverer of the plaster bandage. J Bone Joint
Surg Am 30:1018, 1948.
3. Bacon, L.W. On the history of the introduction of
plaster of Paris bandages. Bull Soc Med Hist 3:122,
1923.
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4. Bell, B. System of Surgery, 7th ed., Vol. 2. Edinburgh, Bell and Bradfute, 1801, p. 21.
5. Brenger Fraud, L.J.B. De l'emploi de la pointe de
Malgaigne dans les fractures. Rev Ther Medicochir
15:228, 256, 1867.
6. Brenger Fraud, L.J.B. Trait de l'Immobilisation
Directe des Fragments Osseux dans les Fractures.
Paris, Delahaye, 1870, p. 371.
7. Billroth, W. Clinical Surgery. London, The New
Sydenham Society, 1881.
8. Bircher, H. Eine neue Methode unmittelbarer Retention bei Frakturen der Roehrenknochen. Arch Klin
Chir 34:91, 1886.
9. Bhler, L. Vorwort zur 1 bis 4 Auflage, Wien, im
Januar 1944. Technik der Knochenruchbehandlung
im Frieden und im den Kriege, 1944, pp. IV-V.
10. Bonnet Mmoire sur les fractures du fmur. Gaz Med
Paris, 1839.
11. Burny, F.; Bourgois, R. tude biomchanique de l'ostotaxis. In: La Fixation Externe en Chirurgie. Brussels, Imprimerie Mdicale et Scientifique, 1965.
12. Chalier, A. Nouvel appareil prothtique pour ostosynthse (crampon extensible). Presse Med 25:585,
1907.
13. Chassin Thse de Paris, 1852, p. 63.
14. Cleveland, M. Surgery in World War II: Orthopedic
Surgery in the European Theater of Operations.
Washington, DC, Office of the Surgeon General,
Dept. of the Army, 1956, p. 77.
15. Commeiras. J Soc Med Montpellier, 1847.
16. Conn, H.R. The internal fixation of fractures. J Bone
Joint Surg 13:261, 1931.
17. Cooper, A. Treatise on Dislocations and on Fractures
of the Joints. London, Longman, Hurst, Rees, Orme,
Brown and Green, 1822.
18. Crile, D.W. Fracture of the femur: A method of
holding the fragments in difficult cases. Br J Surg
4:458, 1919.
19. Cucuel; Rigaud. Des vis mtalliques enfonces dans le
tissue des os pour le traitement de certaines fractures.
Rev Medicochir Paris 8:113, 1850.
20. Danis, R. Thorie et Pratique de l'Ostosynthse.
Paris, Masson, 1949.
21. Dowden, J.W. The Principle of Early Active Movement in Treating Fractures of the Upper Extremity.
London, Oliver & Boyd, 1924.
22. Eaton, W. Survey of the Turkish Empire. London,
1798.
23. Elst, V.E. Les dbuts de l'ostosynthse en Belgique.
Private publication for Socit Belge de Chirurgie
Orthopdique et de Traumatologie. Brussels, Imp
des Sciences, 1971.
24. Evans, P.E.L. Cerclage fixation of a fractured
humerus in 1775: Fact or fiction? Clin Orthop
174:138, 1983.
25. Gersdorf, H. von. Feldtbuch der Wundartzney. Strasbourg, 1517.
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