- Email: [email protected]
Fractures of both bones of the leg
FRACTURES
OF BOTH BONES OF THE LEG
J. SIMS NORMAN, M.D.,
P.A.C.S.
Orthopedic Surgeon, Corwin, St. Mary’s and CoIorado State Hospitals PUEBLO,
T
AND
DAVID
W. BOYER,
M.D.
Assistant Orthopedic Surgeon, Corwin Hospital
COLORADO
HERE are on the market, at the hoping that it may prove of some value to present time, a Iarge number of com- others. phcated instruments and devices deIn the treatment of simpIe fractures insigned to aid the surgeon in the care of volving both the tibia and fibuIa, or in Iess fractures. Undoubtedly a11 have proved severeIy cornminuted fractures, we are inuseful and vaIuable to certain ones of us clined to a position of considerable conserin particuIar cases, though some of them vatism. In many of these cases, particularly have since been discarded for simpler where they have been handIed carefuIIy methods. There aIso have been many prior to their presentation at the hospital, methods described for the care of fractures the position wiI1 be found to be satisfactory. of this type. Many surgeons seIdom use In such cases we apply a snug-fitting, Ionginternal fixation, and others almost rou- Ieg cast, extending we11 up on the thigh, at tinely use it; some treat compound fracthe earliest possible time, without unnecestures by maintaining them as open wounds, sary handIing or manipuIation, and withwhiIe others prefer to close them as out unnecessary attempts to improve promptly as possibIe and convert the slightly the position, Iest a simpIe fracture compound fracture into a closed fracture. be converted into a diffrcuIt one. FreThis multiplicity of appliances and ideas quentIy, when there is a slight anguIation as to methods of treatment is certainly at the fracture site-and particuIarIy with evidence that no singIe method is entirely an oblique fracture where there is possisatisfactory in al1 cases and among a11 biIity of dispIacement-it may not be coroperators. rected until three weeks later, after healing Corwin HospitaI, of The CoIorado Fuel has started and displacement is Iess likely. & Iron Corporation, serves as a concentraAt this time, the cast is wedged to bring tion point for diseases and injuries of Comthe fracture into proper alignment. pany employees and their dependents. The For those cases where position cannot Corporation operates a large steel pIant in be considered satisfactory, we fee1 that Pueblo, Colorado, iron mines in Wyoming, the simpIest type of procedure which will and coal mines and Iime quarries throughaccompIish the desired result is preferable. out CoIorado. AI1 fractures of consequence Therefore, under genera1 anesthesia, we are splinted by the IocaI physician and have found that the majority of these cases can be manipulated into satisfactory posisent to us immediately. As a resuIt of this, we see many fractures and each week we tion and secured in plaster immediateIy average more than one fracture of both upon admission, providing the patient’s bones of the leg. genera1 condition does not preclude this It is not our purpose in this paper to procedure. If the patient is in shock, that present any radical departure from ac- condition should be treated immediateIy, cepted methods of treatment of fractures and the fracture cared for thereafter as of both bones; but we wiIl endeavor brieffy soon as possibIe. We use IocaI anesthesia to point out some of the considerations in some of these cases, and have in the we have found to be important and valupast used spinal anesthesia for many of abIe in the treatment of this ‘condition, them, though we feel that a genera1 anes7016
NEW SERIES VOL. XXXVIII,
No. 3
Norman,
Boyer-Fractures
thetic is preferabIe. We have found that the earlier such restoration of anatomical position and immobilization can be accomphshed, the quicker and better will be the result which wiII foIIow. We have found open reduction with interna fixation unnecessary in most of these cases, and do not favor the use of traction in such cases as can be handled without. We have aImost compTeteIy abandoned the use of the BijhIer waIking iron, as we have faiIed to see much benefit from it. We have found that in the majority of cases where there is an oblique or spiral fracture of the tibia, with fracture of the fibuIa, they can be satisfactorily reduced and maintained in plaster. We do feel, however, that with spira1 fracture of the tibia and with the fibula fractured high, time, suffering, and disability are reduced by open operation. We fee1 that the CarroIIGirard screw wiI1 be very helpful in these cases, but our experience does not, as yet, permit a definite opinion as to its value in our hands. AI1 cases are folIowed carefuIIy by x-ray before and after reduction, and at intervaIs during the progress of healing. In the reIativeIy smaI1 percentage of cases where it is not possibIe to obtain satisfactory reduction or maintain position by these conservative procedures, and in cases which are more severeIy cornminuted, we do not hesitate to proceed immediately with reduction by other means. Traction is frequently used, in which case we prefer to empIoy a smaII Steinman pin in the OS calcis. We onIy rareIy use a Kirschner wire or ice-tong calipers. We use a HawIey suspension spIint, or Brauns frame, and foIIow it with a cast, incorporating the pin in the cast. In some cases we empIoy internal fixation. Here we prefer to use an autogenous bone graft, or merely heavy chromic sutures. We rareIy employ pIates or other foreign substance which may subsequently have to be removed, necessitating a second operation and further time 10s~. In cases of this type, where traction is necessary, we occasionaIIy use the automatic spIint designed by Dr. Roger Ander-
of Leg
A merican
Journal
of Surgery
707
son, of SeattIe. This is an exceIIent too1 for reduction and maintenance of such cases and since the Ieg can be incorporated in pIaster with the pins in place, it serves a most usefu1 purpose. We feeI, however, with the discussion of traction in these cases, that we shouId warn particuIarIy against the danger of over-traction. Nonunion occurs more frequently in the tibia than in any other of the common fractures, and most frequently at the junction of the middIe and lower thirds. We feel that overtraction is a frequent causative factor in this non-union. Fractures of the tibia and fibula are more frequentIy compounded than any other major fracture, probabIy because of the cIose proximity of these bones to the surface and because of their inherent strength and the great force required to fracture them. Our first consideration in a severe fracture with extensive soft tissue injury, is regarding the viabiIity of the limb as a whoIe. We are extremeIy conservative at this point and where there seems to be any reasonable chance to save the Iimb we endeavor to do so, though Iater it may be an imperfectly functioning leg. We fee1 that every compound fracture should be converted to a cIosed fracture by immediate surgery. It is our practice that every such case, seen within approximateIy twenty-four hours of the time of injury, is taken immediateIy to the operating room, providing the patient’s genera1 condition wiI1 permit, and the wound closed. In our procedure for cIosing such a wound, we first cover the wound itself with steriIe gauze to prevent further contamination while the surrounding skin areas are being prepared. We shave the area and wash it thoroughly with ether to remove a11 fat soIubIe materia1. We then wash the entire area thoroughIy with soap and water, and foIlow this with 334 per cent iodine. With the surrounding skin areas prepared to prevent further contamination of the wound, we proceed to the wound itseIf. In this we wouId Iike to
708
A merican Journal of Surgery
Norman,
Boyer-Fractures
emphasize the importance of mechanica sterilization. Any gross contaminating substances are removed from the wound and it is irrigated thoroughly with Iarge quantities of sterile sahne solution, care being taken to penetrate all the recesses of the wound. All devitalized tissue must be removed by sharp dissection, with the utmost care being taken Iest the scalpel graft potential infection to clean tissue. If the bones have been ground into dirt, or otherwise grossly contaminated, the ends of the bone are trimmed. Pieces of entirely detached bone are removed. Adherent fragments are pIaced in a position advantageous for heaIing. We carry out the entire debridement, as we do with our other bone surgery, with a no-finger contact technique. It was formerly our procedure, after the wound had been carefuIIy cleaned, to apply iodine in the open wound. We feel that, while this procedure perhaps has certain bacteriocidal action, its beneficial effect is neutralized by the destruction of delicate tissues within the wound, thus forming a coating of necrotic tissue through our entire wound and destroying the effect of our carefu1 excision of al1 necrotic tissue. This procedure has, therefore, been abandoned, and with good resuIts. In such cases we pay very particular attention to hemostasis. We fee1 that an absoIuteIy dry wound shouId be obtained before it is closed. Either devitalized tissue left in a wound, or a hematoma formed by bleeding into a wound, serve as an exceIIent media for the growth of bacteria, and, protected from the bacterioIytic activities of the blood elements and tissue elements as they exist in living tissue, it furnishes an ideal opportunity for the growth of bacteria and the development of a fulminating infection which might necessitate a later opening of the wound or even endanger the patient’s
of Leg
DECEMBER, 1937
life. This method has, of course, been criticized because of this possibility, though we fee1 that where the proper care has been used in the preparation and closure of the wound it is done with perfect safety. In fact, we feel that by its complete closure without drainage the principal avenue of serious infection is closed, that further treatment wiI1 be greatIy simphfied, the healing period will be shortened, and the possibilities of a good resuIt improved. If any internal fixation is going to be necessary, it is done at the time the wound is originaIIy cleaned and sutured, but if at a11 possible this is done without the use of non-absorbabIe foreign material. AI1 soft tissue structures, nerves, tendons, and muscIes are accurately repaired, the wound is never pulIed together under tension. Where there has been considerable Ioss of tissue and skin, incisions are made at some distance to aIIow the skin to be closed without tension. The skin edges are never undermined. The wound having once been closed, the fracture can then be treated as a cIosed fracture. CONCLUSIONS I. Providing the patient’s condition wiI1 permit it, all fractures of both bones of the leg should be reduced and immobilized as soon after injury as possibIe. 2. Where traction is used, particular attention should be given to avoidance of over-traction. We fee1 that separation of the bone fragments is a very common cause of non-union. 3. Compound fractures seen within the first twenty-four hours should undergo thorough mechanica sterilization, compIete hemostasis shouId be secured, and the wounds closed to factIitate further handIing of the fracture and minimize the danger of infection.
OF BOTH BONES OF THE LEG
J. SIMS NORMAN, M.D.,
P.A.C.S.
Orthopedic Surgeon, Corwin, St. Mary’s and CoIorado State Hospitals PUEBLO,
T
AND
DAVID
W. BOYER,
M.D.
Assistant Orthopedic Surgeon, Corwin Hospital
COLORADO
HERE are on the market, at the hoping that it may prove of some value to present time, a Iarge number of com- others. phcated instruments and devices deIn the treatment of simpIe fractures insigned to aid the surgeon in the care of volving both the tibia and fibuIa, or in Iess fractures. Undoubtedly a11 have proved severeIy cornminuted fractures, we are inuseful and vaIuable to certain ones of us clined to a position of considerable conserin particuIar cases, though some of them vatism. In many of these cases, particularly have since been discarded for simpler where they have been handIed carefuIIy methods. There aIso have been many prior to their presentation at the hospital, methods described for the care of fractures the position wiI1 be found to be satisfactory. of this type. Many surgeons seIdom use In such cases we apply a snug-fitting, Ionginternal fixation, and others almost rou- Ieg cast, extending we11 up on the thigh, at tinely use it; some treat compound fracthe earliest possible time, without unnecestures by maintaining them as open wounds, sary handIing or manipuIation, and withwhiIe others prefer to close them as out unnecessary attempts to improve promptly as possibIe and convert the slightly the position, Iest a simpIe fracture compound fracture into a closed fracture. be converted into a diffrcuIt one. FreThis multiplicity of appliances and ideas quentIy, when there is a slight anguIation as to methods of treatment is certainly at the fracture site-and particuIarIy with evidence that no singIe method is entirely an oblique fracture where there is possisatisfactory in al1 cases and among a11 biIity of dispIacement-it may not be coroperators. rected until three weeks later, after healing Corwin HospitaI, of The CoIorado Fuel has started and displacement is Iess likely. & Iron Corporation, serves as a concentraAt this time, the cast is wedged to bring tion point for diseases and injuries of Comthe fracture into proper alignment. pany employees and their dependents. The For those cases where position cannot Corporation operates a large steel pIant in be considered satisfactory, we fee1 that Pueblo, Colorado, iron mines in Wyoming, the simpIest type of procedure which will and coal mines and Iime quarries throughaccompIish the desired result is preferable. out CoIorado. AI1 fractures of consequence Therefore, under genera1 anesthesia, we are splinted by the IocaI physician and have found that the majority of these cases can be manipulated into satisfactory posisent to us immediately. As a resuIt of this, we see many fractures and each week we tion and secured in plaster immediateIy average more than one fracture of both upon admission, providing the patient’s bones of the leg. genera1 condition does not preclude this It is not our purpose in this paper to procedure. If the patient is in shock, that present any radical departure from ac- condition should be treated immediateIy, cepted methods of treatment of fractures and the fracture cared for thereafter as of both bones; but we wiIl endeavor brieffy soon as possibIe. We use IocaI anesthesia to point out some of the considerations in some of these cases, and have in the we have found to be important and valupast used spinal anesthesia for many of abIe in the treatment of this ‘condition, them, though we feel that a genera1 anes7016
NEW SERIES VOL. XXXVIII,
No. 3
Norman,
Boyer-Fractures
thetic is preferabIe. We have found that the earlier such restoration of anatomical position and immobilization can be accomphshed, the quicker and better will be the result which wiII foIIow. We have found open reduction with interna fixation unnecessary in most of these cases, and do not favor the use of traction in such cases as can be handled without. We have aImost compTeteIy abandoned the use of the BijhIer waIking iron, as we have faiIed to see much benefit from it. We have found that in the majority of cases where there is an oblique or spiral fracture of the tibia, with fracture of the fibuIa, they can be satisfactorily reduced and maintained in plaster. We do feel, however, that with spira1 fracture of the tibia and with the fibula fractured high, time, suffering, and disability are reduced by open operation. We fee1 that the CarroIIGirard screw wiI1 be very helpful in these cases, but our experience does not, as yet, permit a definite opinion as to its value in our hands. AI1 cases are folIowed carefuIIy by x-ray before and after reduction, and at intervaIs during the progress of healing. In the reIativeIy smaI1 percentage of cases where it is not possibIe to obtain satisfactory reduction or maintain position by these conservative procedures, and in cases which are more severeIy cornminuted, we do not hesitate to proceed immediately with reduction by other means. Traction is frequently used, in which case we prefer to empIoy a smaII Steinman pin in the OS calcis. We onIy rareIy use a Kirschner wire or ice-tong calipers. We use a HawIey suspension spIint, or Brauns frame, and foIIow it with a cast, incorporating the pin in the cast. In some cases we empIoy internal fixation. Here we prefer to use an autogenous bone graft, or merely heavy chromic sutures. We rareIy employ pIates or other foreign substance which may subsequently have to be removed, necessitating a second operation and further time 10s~. In cases of this type, where traction is necessary, we occasionaIIy use the automatic spIint designed by Dr. Roger Ander-
of Leg
A merican
Journal
of Surgery
707
son, of SeattIe. This is an exceIIent too1 for reduction and maintenance of such cases and since the Ieg can be incorporated in pIaster with the pins in place, it serves a most usefu1 purpose. We feeI, however, with the discussion of traction in these cases, that we shouId warn particuIarIy against the danger of over-traction. Nonunion occurs more frequently in the tibia than in any other of the common fractures, and most frequently at the junction of the middIe and lower thirds. We feel that overtraction is a frequent causative factor in this non-union. Fractures of the tibia and fibula are more frequentIy compounded than any other major fracture, probabIy because of the cIose proximity of these bones to the surface and because of their inherent strength and the great force required to fracture them. Our first consideration in a severe fracture with extensive soft tissue injury, is regarding the viabiIity of the limb as a whoIe. We are extremeIy conservative at this point and where there seems to be any reasonable chance to save the Iimb we endeavor to do so, though Iater it may be an imperfectly functioning leg. We fee1 that every compound fracture should be converted to a cIosed fracture by immediate surgery. It is our practice that every such case, seen within approximateIy twenty-four hours of the time of injury, is taken immediateIy to the operating room, providing the patient’s genera1 condition wiI1 permit, and the wound closed. In our procedure for cIosing such a wound, we first cover the wound itself with steriIe gauze to prevent further contamination while the surrounding skin areas are being prepared. We shave the area and wash it thoroughly with ether to remove a11 fat soIubIe materia1. We then wash the entire area thoroughIy with soap and water, and foIlow this with 334 per cent iodine. With the surrounding skin areas prepared to prevent further contamination of the wound, we proceed to the wound itseIf. In this we wouId Iike to
708
A merican Journal of Surgery
Norman,
Boyer-Fractures
emphasize the importance of mechanica sterilization. Any gross contaminating substances are removed from the wound and it is irrigated thoroughly with Iarge quantities of sterile sahne solution, care being taken to penetrate all the recesses of the wound. All devitalized tissue must be removed by sharp dissection, with the utmost care being taken Iest the scalpel graft potential infection to clean tissue. If the bones have been ground into dirt, or otherwise grossly contaminated, the ends of the bone are trimmed. Pieces of entirely detached bone are removed. Adherent fragments are pIaced in a position advantageous for heaIing. We carry out the entire debridement, as we do with our other bone surgery, with a no-finger contact technique. It was formerly our procedure, after the wound had been carefuIIy cleaned, to apply iodine in the open wound. We feel that, while this procedure perhaps has certain bacteriocidal action, its beneficial effect is neutralized by the destruction of delicate tissues within the wound, thus forming a coating of necrotic tissue through our entire wound and destroying the effect of our carefu1 excision of al1 necrotic tissue. This procedure has, therefore, been abandoned, and with good resuIts. In such cases we pay very particular attention to hemostasis. We fee1 that an absoIuteIy dry wound shouId be obtained before it is closed. Either devitalized tissue left in a wound, or a hematoma formed by bleeding into a wound, serve as an exceIIent media for the growth of bacteria, and, protected from the bacterioIytic activities of the blood elements and tissue elements as they exist in living tissue, it furnishes an ideal opportunity for the growth of bacteria and the development of a fulminating infection which might necessitate a later opening of the wound or even endanger the patient’s
of Leg
DECEMBER, 1937
life. This method has, of course, been criticized because of this possibility, though we fee1 that where the proper care has been used in the preparation and closure of the wound it is done with perfect safety. In fact, we feel that by its complete closure without drainage the principal avenue of serious infection is closed, that further treatment wiI1 be greatIy simphfied, the healing period will be shortened, and the possibilities of a good resuIt improved. If any internal fixation is going to be necessary, it is done at the time the wound is originaIIy cleaned and sutured, but if at a11 possible this is done without the use of non-absorbabIe foreign material. AI1 soft tissue structures, nerves, tendons, and muscIes are accurately repaired, the wound is never pulIed together under tension. Where there has been considerable Ioss of tissue and skin, incisions are made at some distance to aIIow the skin to be closed without tension. The skin edges are never undermined. The wound having once been closed, the fracture can then be treated as a cIosed fracture. CONCLUSIONS I. Providing the patient’s condition wiI1 permit it, all fractures of both bones of the leg should be reduced and immobilized as soon after injury as possibIe. 2. Where traction is used, particular attention should be given to avoidance of over-traction. We fee1 that separation of the bone fragments is a very common cause of non-union. 3. Compound fractures seen within the first twenty-four hours should undergo thorough mechanica sterilization, compIete hemostasis shouId be secured, and the wounds closed to factIitate further handIing of the fracture and minimize the danger of infection.