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The use of longitudinal wires in bones in the treatment of fractures and dislocations
THE USE OF LONGITUDINAL WIRES IN BONES IN THE TREATMENT OF FRACTURES AND DISLOCATIONS GORDON MURRAY, M.D. Surgeon,Toronto GeneralHospital, University of Toronto TORONTO, CANADA
W
the original application of wires IongitudinalIy in the meduhary cavities of bones was applied to the clavicIe,l the principle has been found to be very effective in many other regions. It seems to be effective and to simplify the treatment of some fractures in which the resuhs of orthodox methods are not altogether satisfactory and in which the Stader and Roger Anderson methods of treatment are least effective. In long bones with Iarge medullary cavities such as the tibia and femur, the wire is of such smaII caliber that it allows too much latera dispIacement of the fragments, and especially in oblique fractures of these bones it allows too much shortening to be the method of choice. However, in the clavicle, scapula, both bones of the forearm, some cases of fracture of the humerus and Iong bones of the hands and feet, it provides a method by which greatly improved resuIts in these fractures can be expected. Acromio and coracoclavicuIar2 dislocations are easily controhed by this method. NaturaIIy, as in all procedures in which it is necessary to make an opening in the skin, the most rigid aseptic surgica1 technic must be observed. In our hands there has been one infection only in which it was necessary to remove the wire on this account. It would seem that the anatomy of the skeleton was arranged so that these wires could be applied with great ease, to the areas in which they are most effective. In the humerus the wire is passed through the greater tuberosity, and vertically down the shaft the wire is placed in an extra-articuIar position. Passed in this way it gives excehent contro1 of fractures of the high surgica1 neck or shaft. With such a wire in position the arm has been carried in a sling only, ursl! HILE
MURRAY-WIRES
IN BONES
FIG. I. Fracture disIocation of the surgical neck of the scapuIa and acromiocIavicuIar joint; cIosed reduction; wire across joint gave exceIIent reduction and fixation.
FIG. z. Fracture
of middIe finger metacarpal; wire.
fixation
with
158
MURRAY-WIRES
IN BONES
FIG. 3. Fracture through neck of proxima1 phalanx of great toe, with go per cent pIantar rotation; open reduction and lixation with longitudinal wire.
FIG. 4. Dislocation
of interphaIangea1 joint of thumb of three months’ duration; maintained in place by wire.
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and exceIIent union in a good position has resuhed. In the forearm with fractures of both bones, the subcutaneous oIecranon, provides a very easy approach, through which to pass the wire through the
FIG. 5. Fracture
index metacarpal;
fixation with IongitudinaI reduction.
wire foIlowing
open
proxima1 and into the distal fragment. In the radius, the subcutaneous styIoid process offers an easy and extra-articuIar approach, passing the wire through the dista1 and into the proxima1 fragment. If after reduction and fixation of the uIna with the wire, the radius can be reduced, it aIso is heId by passing a wire. If, however, the fragments are so engaged that cIosed reduction is impossible, a short incision over each bone shouId be made and accurate reduction obtained. The wires then passed as described, provide excehent fixation which is quite easy to apply. To date, all such fractures have been fixed in pIaster casts unti1 evidence of union has taken pIace. In the metacarpaIs and phaIanges, when reduction has been obtained, the wire can be passed, in the case of the metacarpa1, through the dista1 articuIar end, crossing the fracture Iine into the proxima1 fragment, with the proxima1 phaIanx flexed to an angIe of about forty-five degrees. If the fracture is at the neck or near the head of the metacarpa1, the wire is best passed through the dista1 articuIar end of the proxima1 phaIanx, through its meduhary cavity, crossing the metacarpophaIangea1 joint, through the distal fragment and we11 into the proximal. In fractures of the phaIanges, after reduction,
160
MURRAY-WIRES
IN BONES
the wire is passed either through the distal articular end of the affected phaIanx or through the tip of the finger and across the interphaIangea1 joint, if necessary. In none of these fractures has
Frc. 6. Coxa vara; cuneiform osteotomy (Gants’) with IongitudinaI wires; plaster cast.
; fixation
there been evidence of any iIl effect in the way of discomfort or disabihty as a resuIt of a fine wire traversing the articular cartiIages. In fractures of metacarpaIs, the method of transverse fixation by Kirschner wire as described in an articIe by Norman3 aIso gives exceIIent resuIts. Use of wires in a similar way offers exceIIent fixation in arthrodesis of interphaIangea1 or metacarpophaIangea1 joints in the hand or foot. There is no doubt that this form of fixation, as described by the author,’ is the most satisfactory from a11 points of view in fractures of the cIavicIe. In disIocations of the acromiocIavicuIar joint, fixation by two or more wires gives a most satisfactory resuIt with no permanent deformity. With acromiocIavicuIar and wide coracofixation of the acromiocIavicuIar joint by cIavicuIar2 separation, wires aIso provides a very easy and effective method of aIIowing repair of the coracocIavicuIar ligaments with subsequent exceIIent stabiIity and function of the shouIder girdle. 1161
MURRAY-WIRES
161
IN BONES
In fractures of the surgica1 neck of the scapuIa with gross deformity and projection of the axillary border of the scapuIa into the axilla, the best treatment is by an open reduction. A Iongitudinal
FIG. 7. High
shaft fracture of humerus with eighty angulation; fixation by Kirschner wire.
degrees
of
wire through the heavy axiIIary border of the scapuIa and up into the gIenoid fragment provides excellent fixation, which is difhcult to obtain and apply otherwise. Longitudinal wires aIso provide an easy and exceIIent method of fixation of interna and externa1 maIIeoIar fractures at the ankle when closed methods of reduction are not satisfactory. When an osteotomy of a long bone to correct aIignment or rotary deformity is about to be done, the question of the best method of fixation of the artificia1 fracture arises. In Gant’s subtrochanteric osteotomy to correct adduction deformity, the Iower fragment tends to be dispIaced mediaIIy when the femur is divided across, even though obIique or semicircuIar incisions are made across the bone. The procedure is greatIy faciIitated and the fixation is adequate when a IongitudinaI wire is passed through the tip of the great trochanter and down the shaft of the femur. When the base of the wedge or cuneiform osteotomy has been removed, the meduIIary
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162
IN BONES
cavity is exposed and the position of the wire can be verified. fracture is then completed and without fear of dispIacement
FIG. 8. Fracture
of anatomica
FIG. g. Comminuted
neck of humerus with dislocation tion by IongitudinaI wire.
fracture
of both bones of forearm; by wire fixation.
The the
of the head; fixa-
satisfactory
result
lower fragment of the femur can be abducted or rotated at wiII to correct the deformity. No further interna fixation of the fracture is required. Of course the usua1 externa1 pIaster cast is necessary to
MURRAY-WIRES
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163
maintain the corrected position. SimiIar principIes can be appIied in other areas. A series of iIIustrative cases is reported and the x-rays demon-
FIG. IO. Fracture
of jaw
(symphysis);
fixation
by IongitudinaI
wire.
strate the use of the wires and the end resuIts obtained. In a11 there have been 154 patients treated with IongitudinaI wires. There was one case of infection in which a wire was appIied IongitudinaIIy in the humerus for a fracture of the surgical neck. In this case the wire had been used by an inexperienced house officer, which may have been a factor in the subsequent infection. In none of the clavicIe or acromiocIavicuIar joints has there been any injury to the brachial pIexus or axiIIary or subcIavian vesseIs. None of the wires has drifted out of the fieId. From my experience in more than one hundred cIavicIes and acromiocIavicuIar joints, if the wire is pIaced where it is intended to be, it wiI1 not migrate. The presence of th e wire across the fracture Iine has not impeded the rate of union of the fracture and there have been no non-unions in this series. On the contrary, in most cases these fractures have united in a shorter time than ordinarily would have been expected. CONCLUSIONS
wires in bones have provided excelIent fixation I. LongitudinaI of certain seIected fractures and in particuIar those fractures in which it has been diffIcuIt to obtain satisfactory fixation by external spIinting either with or without skeIeta1 pins. UI9Jl
164
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2. There has been no evidence that a smaI1 or medium sized Kirschner wire which traverses articuIar cartiIage produces any deIetory effect on the joint. 3. When wires are appIied under good surgical conditions and divided to Iie beneath the skin, there shouId be very IittIe chance of infection resuIting from their use. (One case in our series.) 4. When the wires are pIaced in bones, even though they cross joints, there has been no evidence of migration of the wires in this series of cases. REFERENCES I, MURRAY, GORDON. A method of tixation for fracture of the cIavicle. J. Bone EYJoint Surg., 22: 616-620, rg4o. 2. MURRAY, GORDON. Fixation of disIocations of the acromiocIavicuIar joint and rupture of the CoracocIavicuIar ligaments. Canad. M. A. J., 43: 270-271, 1940. 3. NORMAN, H. R. C. Fractures of metacarpals treated by a new method. Canad. M. A. J., 49: 173-175, 1943. 4. MAZET, R. Migration of a Kirschner wire from the shouIder region into the Iung: report of two cases. J. Bone @ Joint Surg., 25: 477-483, 1943. DISCUSSION LIEUT. COL. MARTILLUS TODD (NorfoIk, Va.): In the first pIace I want to congratulate Dr. Murray for his very ingenious use of these wires. I think we are a11 famiIiar with the principle of using the wire, but I do not beIieve most of us have gone to as much troubIe in deveIoping this as he has. It seems to me that his resuIts in the fractured forearm particuIarIy speak for themseIves. It is a very difficult fracture to treat. I do not know how much troubIe he has getting those wires in pIace. I suppose it is done with the fluoroscope, but in any case when he has done it, the fracture evidentIy cannot get out of pIace, and it appears to be a method of treatment that is very we11 worth using. I want to caI1 attention to one difference. Of course, there are a number of differences in the case of fractured bones in the armed services. In civilian life if a man breaks his colIarbone it is of no particuIar importance because by any method of treatment, even though he has a big Iump of bone afterward with overlapping, some shortening, some deformity or angulation, it is not of any particular consequence to a civiIian. He simpIy has a Iump on his shouIder, but his arm is very strong and he is able to carry on without any troubIe. SoIdiers cannot do that. They have to wear a heavy pack, and the straps go right across the middIe of the cIavicIe where the break is apt to be. We have had to cIassify for Iimited assignment a good number of soIdiers who came to us after having broken their coIIarbones in civilian
U2oB
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65
Iife, after having been abIe to do their civilian work without any trouble at ah. But as soIdiers they are not able to wear the heavy pack; sometimes their shouIders are not strong enough to enable them to go over the obstacle course either. If these wires can be used without incision, it is better to avoid a scar anywhere near a spot where anything couId rub on it. So I suppose the subcutaneous method of putting the wires in is preferable. There are many other comments that couId be made; one is the matter of infection. Dr. Murray has had only one infection in 154 cases, which may be due to inaccurate technic on the part of a house officer. UnfortunateIy, I have had an infection or two myseIf in doing open work on bones. I remember one particuIarIy distressing case which had an infection in the shaft of the metacarpa1 bone of the ring finger, and it stiffened the metacarpophaIangea1 joint, so that the patient could not make a good round fist. Those fractures also, I think, are quite difficuIt to treat, and if Dr. Murray is able to treat them as successfuIIy as his x-rays indicate, I think it is a method that deserves our congratulations. KELLOGG SPEED: Mr. President, members and guests: This device I have known for severa years and have seen Dr. Murray use it. I have also used it successfuIIy in the acromiocIavicuIar, finger and metacarpal bones. I wish, however, to report very brieffy one case, hoping that no others of you may have the unfortunate experience which I had. A young boy with a SternocIavicuIar disIocation, which couId not be heId by ordinary means, was subjected to this procedure. It was done under general anesthesia. The Kirschner wire driII was rather cumbersome and heavy, and just as I was inserting the wire through the inner end of the clavicle into the sternum, the boy gave several convuIsive coughs and jerked his body as he lay on the table. My wire was forcibIy projected into the thoracic cavity and the aorta was punctured. A sIow Ieak occurred down inside the reffexion of the pericardium. Within ten hours a heart tamponade deveIoped and the boy passed away during my absence from the hospital. In operating on the SternocIavicuIar joints or those near the great vessels, I think we should be very sure about the rigidity and quiet of the patient, and the presence of compIeteIy reIaxing anesthesia. RICHEY L. WAUCH (Boston, Mass.): In support of this treatment I should like to show a few sIides which wiI1 speak for themseIves. These sIides cover some fractures other than the ones Dr. Murray showed. (Dr. Waugh then produced the foIIowing slides): I. A maIunion of the fifth metatarsal with about 40 degrees angulation. In this the IongitudinaI wire was passed up the shaft. uzrrl
MURRAY-WIRES
IN BONES
2. Malunion of the fifth metatarsa1 and non-union of the fourth and third metatarsaIs. This showed the marked dispIacement and angmation. 3. LongitudinaI wires passed up the shafts. 4. In this slide a disIocation of the proxima1 end of the first metacarpal was shown. This was reduced by open operation and a Kirschner wire used for fixation. 5. This was a compound cornminuted fracture in a patient who was admitted to the hospita1 about three weeks after the injury, with a Iarge open wound, and the dista1 end of the tibia and the interna malleolus sIoughed out. The defect was shown. The end of the tibia was approximated to the astragaIus with overriding o the fibuIar fragments, and as the wound cIosed in a thin osteotome was taken and the end of the tibia and top of the astragarus were squared off, bringing these together. Two IongitudinaI pins were passed up, not wires, through the caIcis, the astragaIus and the tibia. The final resuIt was fusion between the astragaIus and the dista1 end of the tibia. The foot was put up in slight equinus position and the boy is warking with a special shoe at the present time. 6. In this case we see not a simpIe Monteggia fracture but a rather complicated one. There were five fragments. The fragments were in a duckbiII arrangement. This patient was treated by open operation, not using a wire but a pin. The pin was inserted through the proximal fragment and then through the dista1 fragment, and the minor fragments were assembIed around the pin and heId by a circumferential wire. GROVERWEIL (Pittsburgh, Pa.) : We have found Dr. Murray’s method very appIicable in dispIaced fractures in the Iower end of the radius and the uIna. Instead of using the wire we use a threepenny nai1. After reposition of the dispIaced fragment we insert the nail into the distaI end of the fragment, and the protruding end rests upon the dista1 fragment, hording it in very exceIIent position. It can be easily discarded after union is obtained. This is done with a threepenny nail instead of the wire. FRASERB. GURD (MontreaI, Canada): (Dr. Gurd showed a number of slides that were self-expranatory) : I. Monteggia Fracture-In this fracture of the uIna the wire was pIaced into the upper fragment, then pushed a11 the way out so its blunt end wouId run into the distal fragment; it was then pushed in by hand. That seemed to do the trick. At the end of five months there was a synostosis. The removal of the head of the radius had been deferred until this time, and a month or so ago the head and neck of the radius were removed, the synostosis was divided and removed, and the resuIt is now fairIy satisfactory. 2. This was a fresh Monteggia, which was treated in exactIy the same way. It is stiI1 under treatment, and it seems as though it is hoIding and in a satisfactory position.
u22ll
MURRAY-WIRES
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3. This showed the use of a short wire which is put in through a compound injury in just the way in which Dr. Murray suggested. 4. This was an iilustration of a non-union of several years’ duration, in which pIating had been empIoyed; the screw hoIes were seen, with the fracture. The wire was pIaced in through the meduIIary cavity up and down, and then a period between operation and apposition of the bones was aIIowed to Iapse, about two weeks, at which time the sutures were taken out and then-and then only-were the bone ends jammed together. Although it was a four-year non-union prior to operation, union was firm and function of the limb was being recovered reasonabIy well within six months. 5. This was a subtrochanteric fracture of the trochanter with nonunion at the end of six months. It showed the use of multipIe wires following correction, simiIar to the way in which Dr. Murray suggested. I shouId Iike to make one comment with regard to Dr. Murray’s reference to the acromiocIavicuIar joint, and Dr. Speed’s reference to the sternocIavicuIar disIocation. I urge again, as I have done before, that a method which is associated with any risk whatever shouId not be empIoyed, but that in the case of the acromiocIavicuIar the outer third of the cIavicIe shouId be removed, and in al1 cases in which dislocation of the sternocIavicuIar joint requires any interference, that interference should be remova of the medial third or haIf of the cIavicIe. I beIieve the resuIts are much more satisfactory. JOHN A. CALDWELL (Cincinnati, Ohio): WiII Dr. Murray give his method of hand protection against the x-rays in this procedure? GORDON MURRAY (closing): I shouId Iike to thank the discussers for their comments and further eIaboration of the principIe mentioned here. Regarding the question of the fluoroscope, I do not work under the fluoroscope. Many of these things are done at open reduction, and the procedure is carried on according to anatomica detail. If we do use the fluoroscope, we take just a peep to see what has happened after we have done something. We do not work continuousIy under it. I get my hands out of the heId after we have done something and see if it is a11 right. If it is not, we shut off the screen and do it over again and take another Iook. I shouId Iike to make one further comment: Regarding the question of migration of wires, there have been some pubIications indicating that wires have gotten into pleural cavities and other obscene pIaces. It is my experience that if a wire is pIaced where it is intended to be, it wiI1 not migrate, and in none of these cases has it changed its position in the least. I wouId suggest, if it is in the pleura1 cavity, that somebody put it there. It did not go there by its own inteIIigence or otherwise.
W
the original application of wires IongitudinalIy in the meduhary cavities of bones was applied to the clavicIe,l the principle has been found to be very effective in many other regions. It seems to be effective and to simplify the treatment of some fractures in which the resuhs of orthodox methods are not altogether satisfactory and in which the Stader and Roger Anderson methods of treatment are least effective. In long bones with Iarge medullary cavities such as the tibia and femur, the wire is of such smaII caliber that it allows too much latera dispIacement of the fragments, and especially in oblique fractures of these bones it allows too much shortening to be the method of choice. However, in the clavicle, scapula, both bones of the forearm, some cases of fracture of the humerus and Iong bones of the hands and feet, it provides a method by which greatly improved resuIts in these fractures can be expected. Acromio and coracoclavicuIar2 dislocations are easily controhed by this method. NaturaIIy, as in all procedures in which it is necessary to make an opening in the skin, the most rigid aseptic surgica1 technic must be observed. In our hands there has been one infection only in which it was necessary to remove the wire on this account. It would seem that the anatomy of the skeleton was arranged so that these wires could be applied with great ease, to the areas in which they are most effective. In the humerus the wire is passed through the greater tuberosity, and vertically down the shaft the wire is placed in an extra-articuIar position. Passed in this way it gives excehent contro1 of fractures of the high surgica1 neck or shaft. With such a wire in position the arm has been carried in a sling only, ursl! HILE
MURRAY-WIRES
IN BONES
FIG. I. Fracture disIocation of the surgical neck of the scapuIa and acromiocIavicuIar joint; cIosed reduction; wire across joint gave exceIIent reduction and fixation.
FIG. z. Fracture
of middIe finger metacarpal; wire.
fixation
with
158
MURRAY-WIRES
IN BONES
FIG. 3. Fracture through neck of proxima1 phalanx of great toe, with go per cent pIantar rotation; open reduction and lixation with longitudinal wire.
FIG. 4. Dislocation
of interphaIangea1 joint of thumb of three months’ duration; maintained in place by wire.
MURRAY-WIRES
IN BONES
and exceIIent union in a good position has resuhed. In the forearm with fractures of both bones, the subcutaneous oIecranon, provides a very easy approach, through which to pass the wire through the
FIG. 5. Fracture
index metacarpal;
fixation with IongitudinaI reduction.
wire foIlowing
open
proxima1 and into the distal fragment. In the radius, the subcutaneous styIoid process offers an easy and extra-articuIar approach, passing the wire through the dista1 and into the proxima1 fragment. If after reduction and fixation of the uIna with the wire, the radius can be reduced, it aIso is heId by passing a wire. If, however, the fragments are so engaged that cIosed reduction is impossible, a short incision over each bone shouId be made and accurate reduction obtained. The wires then passed as described, provide excehent fixation which is quite easy to apply. To date, all such fractures have been fixed in pIaster casts unti1 evidence of union has taken pIace. In the metacarpaIs and phaIanges, when reduction has been obtained, the wire can be passed, in the case of the metacarpa1, through the dista1 articuIar end, crossing the fracture Iine into the proxima1 fragment, with the proxima1 phaIanx flexed to an angIe of about forty-five degrees. If the fracture is at the neck or near the head of the metacarpa1, the wire is best passed through the dista1 articuIar end of the proxima1 phaIanx, through its meduhary cavity, crossing the metacarpophaIangea1 joint, through the distal fragment and we11 into the proximal. In fractures of the phaIanges, after reduction,
160
MURRAY-WIRES
IN BONES
the wire is passed either through the distal articular end of the affected phaIanx or through the tip of the finger and across the interphaIangea1 joint, if necessary. In none of these fractures has
Frc. 6. Coxa vara; cuneiform osteotomy (Gants’) with IongitudinaI wires; plaster cast.
; fixation
there been evidence of any iIl effect in the way of discomfort or disabihty as a resuIt of a fine wire traversing the articular cartiIages. In fractures of metacarpaIs, the method of transverse fixation by Kirschner wire as described in an articIe by Norman3 aIso gives exceIIent resuIts. Use of wires in a similar way offers exceIIent fixation in arthrodesis of interphaIangea1 or metacarpophaIangea1 joints in the hand or foot. There is no doubt that this form of fixation, as described by the author,’ is the most satisfactory from a11 points of view in fractures of the cIavicIe. In disIocations of the acromiocIavicuIar joint, fixation by two or more wires gives a most satisfactory resuIt with no permanent deformity. With acromiocIavicuIar and wide coracofixation of the acromiocIavicuIar joint by cIavicuIar2 separation, wires aIso provides a very easy and effective method of aIIowing repair of the coracocIavicuIar ligaments with subsequent exceIIent stabiIity and function of the shouIder girdle. 1161
MURRAY-WIRES
161
IN BONES
In fractures of the surgica1 neck of the scapuIa with gross deformity and projection of the axillary border of the scapuIa into the axilla, the best treatment is by an open reduction. A Iongitudinal
FIG. 7. High
shaft fracture of humerus with eighty angulation; fixation by Kirschner wire.
degrees
of
wire through the heavy axiIIary border of the scapuIa and up into the gIenoid fragment provides excellent fixation, which is difhcult to obtain and apply otherwise. Longitudinal wires aIso provide an easy and exceIIent method of fixation of interna and externa1 maIIeoIar fractures at the ankle when closed methods of reduction are not satisfactory. When an osteotomy of a long bone to correct aIignment or rotary deformity is about to be done, the question of the best method of fixation of the artificia1 fracture arises. In Gant’s subtrochanteric osteotomy to correct adduction deformity, the Iower fragment tends to be dispIaced mediaIIy when the femur is divided across, even though obIique or semicircuIar incisions are made across the bone. The procedure is greatIy faciIitated and the fixation is adequate when a IongitudinaI wire is passed through the tip of the great trochanter and down the shaft of the femur. When the base of the wedge or cuneiform osteotomy has been removed, the meduIIary
MURRAY-WIRES
162
IN BONES
cavity is exposed and the position of the wire can be verified. fracture is then completed and without fear of dispIacement
FIG. 8. Fracture
of anatomica
FIG. g. Comminuted
neck of humerus with dislocation tion by IongitudinaI wire.
fracture
of both bones of forearm; by wire fixation.
The the
of the head; fixa-
satisfactory
result
lower fragment of the femur can be abducted or rotated at wiII to correct the deformity. No further interna fixation of the fracture is required. Of course the usua1 externa1 pIaster cast is necessary to
MURRAY-WIRES
IN BONES
163
maintain the corrected position. SimiIar principIes can be appIied in other areas. A series of iIIustrative cases is reported and the x-rays demon-
FIG. IO. Fracture
of jaw
(symphysis);
fixation
by IongitudinaI
wire.
strate the use of the wires and the end resuIts obtained. In a11 there have been 154 patients treated with IongitudinaI wires. There was one case of infection in which a wire was appIied IongitudinaIIy in the humerus for a fracture of the surgical neck. In this case the wire had been used by an inexperienced house officer, which may have been a factor in the subsequent infection. In none of the clavicIe or acromiocIavicuIar joints has there been any injury to the brachial pIexus or axiIIary or subcIavian vesseIs. None of the wires has drifted out of the fieId. From my experience in more than one hundred cIavicIes and acromiocIavicuIar joints, if the wire is pIaced where it is intended to be, it wiI1 not migrate. The presence of th e wire across the fracture Iine has not impeded the rate of union of the fracture and there have been no non-unions in this series. On the contrary, in most cases these fractures have united in a shorter time than ordinarily would have been expected. CONCLUSIONS
wires in bones have provided excelIent fixation I. LongitudinaI of certain seIected fractures and in particuIar those fractures in which it has been diffIcuIt to obtain satisfactory fixation by external spIinting either with or without skeIeta1 pins. UI9Jl
164
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2. There has been no evidence that a smaI1 or medium sized Kirschner wire which traverses articuIar cartiIage produces any deIetory effect on the joint. 3. When wires are appIied under good surgical conditions and divided to Iie beneath the skin, there shouId be very IittIe chance of infection resuIting from their use. (One case in our series.) 4. When the wires are pIaced in bones, even though they cross joints, there has been no evidence of migration of the wires in this series of cases. REFERENCES I, MURRAY, GORDON. A method of tixation for fracture of the cIavicle. J. Bone EYJoint Surg., 22: 616-620, rg4o. 2. MURRAY, GORDON. Fixation of disIocations of the acromiocIavicuIar joint and rupture of the CoracocIavicuIar ligaments. Canad. M. A. J., 43: 270-271, 1940. 3. NORMAN, H. R. C. Fractures of metacarpals treated by a new method. Canad. M. A. J., 49: 173-175, 1943. 4. MAZET, R. Migration of a Kirschner wire from the shouIder region into the Iung: report of two cases. J. Bone @ Joint Surg., 25: 477-483, 1943. DISCUSSION LIEUT. COL. MARTILLUS TODD (NorfoIk, Va.): In the first pIace I want to congratulate Dr. Murray for his very ingenious use of these wires. I think we are a11 famiIiar with the principle of using the wire, but I do not beIieve most of us have gone to as much troubIe in deveIoping this as he has. It seems to me that his resuIts in the fractured forearm particuIarIy speak for themseIves. It is a very difficult fracture to treat. I do not know how much troubIe he has getting those wires in pIace. I suppose it is done with the fluoroscope, but in any case when he has done it, the fracture evidentIy cannot get out of pIace, and it appears to be a method of treatment that is very we11 worth using. I want to caI1 attention to one difference. Of course, there are a number of differences in the case of fractured bones in the armed services. In civilian life if a man breaks his colIarbone it is of no particuIar importance because by any method of treatment, even though he has a big Iump of bone afterward with overlapping, some shortening, some deformity or angulation, it is not of any particular consequence to a civiIian. He simpIy has a Iump on his shouIder, but his arm is very strong and he is able to carry on without any troubIe. SoIdiers cannot do that. They have to wear a heavy pack, and the straps go right across the middIe of the cIavicIe where the break is apt to be. We have had to cIassify for Iimited assignment a good number of soIdiers who came to us after having broken their coIIarbones in civilian
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Iife, after having been abIe to do their civilian work without any trouble at ah. But as soIdiers they are not able to wear the heavy pack; sometimes their shouIders are not strong enough to enable them to go over the obstacle course either. If these wires can be used without incision, it is better to avoid a scar anywhere near a spot where anything couId rub on it. So I suppose the subcutaneous method of putting the wires in is preferable. There are many other comments that couId be made; one is the matter of infection. Dr. Murray has had only one infection in 154 cases, which may be due to inaccurate technic on the part of a house officer. UnfortunateIy, I have had an infection or two myseIf in doing open work on bones. I remember one particuIarIy distressing case which had an infection in the shaft of the metacarpa1 bone of the ring finger, and it stiffened the metacarpophaIangea1 joint, so that the patient could not make a good round fist. Those fractures also, I think, are quite difficuIt to treat, and if Dr. Murray is able to treat them as successfuIIy as his x-rays indicate, I think it is a method that deserves our congratulations. KELLOGG SPEED: Mr. President, members and guests: This device I have known for severa years and have seen Dr. Murray use it. I have also used it successfuIIy in the acromiocIavicuIar, finger and metacarpal bones. I wish, however, to report very brieffy one case, hoping that no others of you may have the unfortunate experience which I had. A young boy with a SternocIavicuIar disIocation, which couId not be heId by ordinary means, was subjected to this procedure. It was done under general anesthesia. The Kirschner wire driII was rather cumbersome and heavy, and just as I was inserting the wire through the inner end of the clavicle into the sternum, the boy gave several convuIsive coughs and jerked his body as he lay on the table. My wire was forcibIy projected into the thoracic cavity and the aorta was punctured. A sIow Ieak occurred down inside the reffexion of the pericardium. Within ten hours a heart tamponade deveIoped and the boy passed away during my absence from the hospital. In operating on the SternocIavicuIar joints or those near the great vessels, I think we should be very sure about the rigidity and quiet of the patient, and the presence of compIeteIy reIaxing anesthesia. RICHEY L. WAUCH (Boston, Mass.): In support of this treatment I should like to show a few sIides which wiI1 speak for themseIves. These sIides cover some fractures other than the ones Dr. Murray showed. (Dr. Waugh then produced the foIIowing slides): I. A maIunion of the fifth metatarsal with about 40 degrees angulation. In this the IongitudinaI wire was passed up the shaft. uzrrl
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2. Malunion of the fifth metatarsa1 and non-union of the fourth and third metatarsaIs. This showed the marked dispIacement and angmation. 3. LongitudinaI wires passed up the shafts. 4. In this slide a disIocation of the proxima1 end of the first metacarpal was shown. This was reduced by open operation and a Kirschner wire used for fixation. 5. This was a compound cornminuted fracture in a patient who was admitted to the hospita1 about three weeks after the injury, with a Iarge open wound, and the dista1 end of the tibia and the interna malleolus sIoughed out. The defect was shown. The end of the tibia was approximated to the astragaIus with overriding o the fibuIar fragments, and as the wound cIosed in a thin osteotome was taken and the end of the tibia and top of the astragarus were squared off, bringing these together. Two IongitudinaI pins were passed up, not wires, through the caIcis, the astragaIus and the tibia. The final resuIt was fusion between the astragaIus and the dista1 end of the tibia. The foot was put up in slight equinus position and the boy is warking with a special shoe at the present time. 6. In this case we see not a simpIe Monteggia fracture but a rather complicated one. There were five fragments. The fragments were in a duckbiII arrangement. This patient was treated by open operation, not using a wire but a pin. The pin was inserted through the proximal fragment and then through the dista1 fragment, and the minor fragments were assembIed around the pin and heId by a circumferential wire. GROVERWEIL (Pittsburgh, Pa.) : We have found Dr. Murray’s method very appIicable in dispIaced fractures in the Iower end of the radius and the uIna. Instead of using the wire we use a threepenny nai1. After reposition of the dispIaced fragment we insert the nail into the distaI end of the fragment, and the protruding end rests upon the dista1 fragment, hording it in very exceIIent position. It can be easily discarded after union is obtained. This is done with a threepenny nail instead of the wire. FRASERB. GURD (MontreaI, Canada): (Dr. Gurd showed a number of slides that were self-expranatory) : I. Monteggia Fracture-In this fracture of the uIna the wire was pIaced into the upper fragment, then pushed a11 the way out so its blunt end wouId run into the distal fragment; it was then pushed in by hand. That seemed to do the trick. At the end of five months there was a synostosis. The removal of the head of the radius had been deferred until this time, and a month or so ago the head and neck of the radius were removed, the synostosis was divided and removed, and the resuIt is now fairIy satisfactory. 2. This was a fresh Monteggia, which was treated in exactIy the same way. It is stiI1 under treatment, and it seems as though it is hoIding and in a satisfactory position.
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3. This showed the use of a short wire which is put in through a compound injury in just the way in which Dr. Murray suggested. 4. This was an iilustration of a non-union of several years’ duration, in which pIating had been empIoyed; the screw hoIes were seen, with the fracture. The wire was pIaced in through the meduIIary cavity up and down, and then a period between operation and apposition of the bones was aIIowed to Iapse, about two weeks, at which time the sutures were taken out and then-and then only-were the bone ends jammed together. Although it was a four-year non-union prior to operation, union was firm and function of the limb was being recovered reasonabIy well within six months. 5. This was a subtrochanteric fracture of the trochanter with nonunion at the end of six months. It showed the use of multipIe wires following correction, simiIar to the way in which Dr. Murray suggested. I shouId Iike to make one comment with regard to Dr. Murray’s reference to the acromiocIavicuIar joint, and Dr. Speed’s reference to the sternocIavicuIar disIocation. I urge again, as I have done before, that a method which is associated with any risk whatever shouId not be empIoyed, but that in the case of the acromiocIavicuIar the outer third of the cIavicIe shouId be removed, and in al1 cases in which dislocation of the sternocIavicuIar joint requires any interference, that interference should be remova of the medial third or haIf of the cIavicIe. I beIieve the resuIts are much more satisfactory. JOHN A. CALDWELL (Cincinnati, Ohio): WiII Dr. Murray give his method of hand protection against the x-rays in this procedure? GORDON MURRAY (closing): I shouId Iike to thank the discussers for their comments and further eIaboration of the principIe mentioned here. Regarding the question of the fluoroscope, I do not work under the fluoroscope. Many of these things are done at open reduction, and the procedure is carried on according to anatomica detail. If we do use the fluoroscope, we take just a peep to see what has happened after we have done something. We do not work continuousIy under it. I get my hands out of the heId after we have done something and see if it is a11 right. If it is not, we shut off the screen and do it over again and take another Iook. I shouId Iike to make one further comment: Regarding the question of migration of wires, there have been some pubIications indicating that wires have gotten into pleural cavities and other obscene pIaces. It is my experience that if a wire is pIaced where it is intended to be, it wiI1 not migrate, and in none of these cases has it changed its position in the least. I wouId suggest, if it is in the pleura1 cavity, that somebody put it there. It did not go there by its own inteIIigence or otherwise.