- Email: [email protected]
700 BROKEN LEGS
205 the whims of his elderly patients. inessential By conceding every point he will better his chance of prevailing where, in his patient’s own interest, he must.
separated, was any damage apparent) and the unfavourable significance of an intact fibula (most fractures in which this bone was not broken united rapidly, since they seldom involved much comminution or displacement). The shape of the fracture emerges as unimportant, for oblique
700 BROKEN LEGS
lesions united at the same rate. And one which examination candidates for generations influence, have invoked when discussing non-union, is dismissed: 28 patients who had positive Wassermann reactions showed nothing distinctive about the behaviour of their fractures. The results suggest that non-union, residual deformity, and joint contractures are no more common after conservative treatment than after internal fixation. There is, indeed, an indication that internal fixation (using conventional plates) sometimes delays union. Nicoll does not include a statistical comparison between conservative and operative treatment; but he does show how a convincing comparison could be made. Even more important is the example he gives of the way in which collaboration between several hospitals, in different countries, can clarify old problems.
to
bow when he
can to
probably no common injury which causes longer disability among working men than a fracture of the shaft of the tibia. Such a fracture usually takes four months to unite, the patients are almost always completely unemployed for a much longer period, and 1 in 10 is left with a permanent deformity or disability. Surprisingly perhaps, the treatment of so common an injury is by no means standardised. One reason is the difficulty of comparing published reports about the treatment of an injury which may take very many different forms. Many past series have been, to some extent, selected: for example, primary amputation is sometimes the best and occasionally the only possible treatment for an extensive injury; but THERE is
a surgeon who amputates more often than another will have fewer cases of delayed and non-union. Nicoll’s paper1 is important because it describes over 700 cases of tibial shaft fracture, and illustrates how to overcome the pitfalls of making deductions from a large and
heterogenous
group.
exerted less influence than might have been but Nicoll points out that the series included very few elderly patients. Other shibboleths which are disturbed include the reputed danger of continuous traction (only rarely, when the bone ends were actually
Age also
expected,
Nicoll,
E. A.
transverse
THE STATE OF SCHOOLS
long-awaited School Building Survey 19621 appeared last week, with a lengthy memorandum intended to explain the statistical assumptions on which it was carried out. The end-result is a set of figures about the age of schools, the standard of accommodation which they provide, and the cost of bringing all schools up to standardwhich, by the time they have been fully explained away, are of limited value. The survey gained remarkable notoriety before the General Election. Its publication was delayed, almost certainly because the last Government THE
Two-thirds of the patients were South Africans, the remainder British. When a number treated by internal fixation had been excluded, 674 remained for analysis. In 62% the fracture united after less than sixteen weeks’ immobilisation: in 7% more than ten months was required. Of all the factors which retarded union, infection was by far the most potent, for 60% of fractures associated with an infected wound went on to delayed union or non-union. Even clean wounds seemed to prolong healing-in proportion to their size. Any displacement of the bone ends prejudiced healing: when displacement was considerable, union was delayed in 27% (compared with 9% in cases with slight or no displacement). Comminution had a similar but less striking influence-it doubled the incidence of delayed union or non-union. The effect of these complications was not, of course, as simply determined as these figures may suggest. Displacement, comminution, and soft-tissue laceration often come together, so their effects cannot be dissociated. Nicoll’s series differs from most others in that its size enabled him to extract a significant number of instances in which one factor operated without the other two. One unexpected finding is the significance of the level at which the bone is broken. Fractures at the junction of the middle and distal thirds are commonly held to heal more slowly than those elsewhere. In fact, Nicoll’s figures (again corrected, to take account of the fact that fractures of the lower segments are more likely to be compound, or severely displaced, than those near the knee) show that there was surprisingly little variation in the incidence of delayed union between one part of the tibia and another. Delay was rather more common in the middle of the bone than elsewhere, it was seen less often in the proximal parts, and it was actually least common in the distal fractures.
1.
and
J. Bone Jt Surg. 1964, 46B, 373.
believed it would prove
embarrassment to them in the political atmosphere engendered by the election campaign. There is nothing in the document as published to justify this belief. The statistics for the age of schools reveal no surprises. For the purpose of the survey a school was deemed to be as old as the oldest main building still in use. This is so obviously a misleading criterion that little is gained by knowing that a sixth of all primary-school children are in schools which date back beyond 1875. They may be in bad schools or in excellent schools-there is no way of telling. Much more useful is the result of an inquiry into the defects in schools-things like prevalence of thirteen main " no piped water " or sanitation mainly outdoor ". One primary school in four lacks a supply of warm water for the pupils. Two out of three rely on outside sanitation. Two out of five lack a staff-room. On the whole, the church primary schools are older than the county schools and show up worse in the survey. In the main, it is the small schools, including the village schools, which have the poorest amenities. Some 20% of the primary schools (attended by 30% of the pupils) have none of the thirteen defects. As for the secondary schools, 50% of them (attended by 56% of the pupils) get a clean bill. The third part of the survey is an attempt to calculate an
"
how much it would cost to bring all schools up to standard -and the figure works out at El 368 million. But, like everything else, this sum has to be carefully construed: this was the 1962 figure for bringing all schools up to standard, adding enough accommodation to eliminate 1. The School
Building Survey, 1962.
H.M.
Stationery Office. 7s.
6d.
separated, was any damage apparent) and the unfavourable significance of an intact fibula (most fractures in which this bone was not broken united rapidly, since they seldom involved much comminution or displacement). The shape of the fracture emerges as unimportant, for oblique
700 BROKEN LEGS
lesions united at the same rate. And one which examination candidates for generations influence, have invoked when discussing non-union, is dismissed: 28 patients who had positive Wassermann reactions showed nothing distinctive about the behaviour of their fractures. The results suggest that non-union, residual deformity, and joint contractures are no more common after conservative treatment than after internal fixation. There is, indeed, an indication that internal fixation (using conventional plates) sometimes delays union. Nicoll does not include a statistical comparison between conservative and operative treatment; but he does show how a convincing comparison could be made. Even more important is the example he gives of the way in which collaboration between several hospitals, in different countries, can clarify old problems.
to
bow when he
can to
probably no common injury which causes longer disability among working men than a fracture of the shaft of the tibia. Such a fracture usually takes four months to unite, the patients are almost always completely unemployed for a much longer period, and 1 in 10 is left with a permanent deformity or disability. Surprisingly perhaps, the treatment of so common an injury is by no means standardised. One reason is the difficulty of comparing published reports about the treatment of an injury which may take very many different forms. Many past series have been, to some extent, selected: for example, primary amputation is sometimes the best and occasionally the only possible treatment for an extensive injury; but THERE is
a surgeon who amputates more often than another will have fewer cases of delayed and non-union. Nicoll’s paper1 is important because it describes over 700 cases of tibial shaft fracture, and illustrates how to overcome the pitfalls of making deductions from a large and
heterogenous
group.
exerted less influence than might have been but Nicoll points out that the series included very few elderly patients. Other shibboleths which are disturbed include the reputed danger of continuous traction (only rarely, when the bone ends were actually
Age also
expected,
Nicoll,
E. A.
transverse
THE STATE OF SCHOOLS
long-awaited School Building Survey 19621 appeared last week, with a lengthy memorandum intended to explain the statistical assumptions on which it was carried out. The end-result is a set of figures about the age of schools, the standard of accommodation which they provide, and the cost of bringing all schools up to standardwhich, by the time they have been fully explained away, are of limited value. The survey gained remarkable notoriety before the General Election. Its publication was delayed, almost certainly because the last Government THE
Two-thirds of the patients were South Africans, the remainder British. When a number treated by internal fixation had been excluded, 674 remained for analysis. In 62% the fracture united after less than sixteen weeks’ immobilisation: in 7% more than ten months was required. Of all the factors which retarded union, infection was by far the most potent, for 60% of fractures associated with an infected wound went on to delayed union or non-union. Even clean wounds seemed to prolong healing-in proportion to their size. Any displacement of the bone ends prejudiced healing: when displacement was considerable, union was delayed in 27% (compared with 9% in cases with slight or no displacement). Comminution had a similar but less striking influence-it doubled the incidence of delayed union or non-union. The effect of these complications was not, of course, as simply determined as these figures may suggest. Displacement, comminution, and soft-tissue laceration often come together, so their effects cannot be dissociated. Nicoll’s series differs from most others in that its size enabled him to extract a significant number of instances in which one factor operated without the other two. One unexpected finding is the significance of the level at which the bone is broken. Fractures at the junction of the middle and distal thirds are commonly held to heal more slowly than those elsewhere. In fact, Nicoll’s figures (again corrected, to take account of the fact that fractures of the lower segments are more likely to be compound, or severely displaced, than those near the knee) show that there was surprisingly little variation in the incidence of delayed union between one part of the tibia and another. Delay was rather more common in the middle of the bone than elsewhere, it was seen less often in the proximal parts, and it was actually least common in the distal fractures.
1.
and
J. Bone Jt Surg. 1964, 46B, 373.
believed it would prove
embarrassment to them in the political atmosphere engendered by the election campaign. There is nothing in the document as published to justify this belief. The statistics for the age of schools reveal no surprises. For the purpose of the survey a school was deemed to be as old as the oldest main building still in use. This is so obviously a misleading criterion that little is gained by knowing that a sixth of all primary-school children are in schools which date back beyond 1875. They may be in bad schools or in excellent schools-there is no way of telling. Much more useful is the result of an inquiry into the defects in schools-things like prevalence of thirteen main " no piped water " or sanitation mainly outdoor ". One primary school in four lacks a supply of warm water for the pupils. Two out of three rely on outside sanitation. Two out of five lack a staff-room. On the whole, the church primary schools are older than the county schools and show up worse in the survey. In the main, it is the small schools, including the village schools, which have the poorest amenities. Some 20% of the primary schools (attended by 30% of the pupils) have none of the thirteen defects. As for the secondary schools, 50% of them (attended by 56% of the pupils) get a clean bill. The third part of the survey is an attempt to calculate an
"
how much it would cost to bring all schools up to standard -and the figure works out at El 368 million. But, like everything else, this sum has to be carefully construed: this was the 1962 figure for bringing all schools up to standard, adding enough accommodation to eliminate 1. The School
Building Survey, 1962.
H.M.
Stationery Office. 7s.
6d.