- Email: [email protected]
Methods of treatment and results in compound fractures of the femur
METHODS OF TREATMENT FRACTURES
AND RESULTS IN COMPOUND OF THE FEMUR
H. WINNETT ORR, M.D. LINCOLN,
I
N rgr7 and Igr8 a miIitary committee recommended standardized spbnts for the use of the American army in France. If the use of those spIints had been carried over into civi1 practice and if there had been Iess modification of spIints and of methods of treatment, our resuIts in compound fractures of the femur wouId be better than they are. The commercial and scientific exhibits at our meetings indicate how far the modification of spIints and methods has been carried. Standardized splint methods and rules for treatment wouId contribute to the welfare of the patient and to the reIief of everyone concerned in such cases. When he is confronted with a compound fracture of the femur, a surgeon often permits himself to be diverted from the fundamental requirements of the case (i.e., restoration of length and position) by such detaiIs as shock, hemorrhage, swelling, and pain, any or all of which might be relieved at once by prompt immobilization of the injured part in a proper spbnt. The application of Thomas splints on the battle fieId was proposed by Sir Robert Jones in 1914. The great success of this plan is now a matter of history. This was the first time that first aid and correct treatment had been combined on a general pian. The compound fracture femur cases were protected at once and shock, pain, swelling and the other severe symptoms were prevented or relieved by this plan of immediate reduction of the fracture and immobibzation of the fractured Iimb. During rgr8 the death rate in casuaity clearing stations from gunshot fractures of the femur had been reduced to 1736 per cent. This represented an improvement of between 40 and 50 per cent from the first
NEBRASKA
BowIby days of the war. Sir Anthony pointed out that there was a secondary death rate in the base hospitals of about IO per cent and of approximateIy 3 per cent Iater in the home hospitals. So the eventua1 death rate was about 30 per cent in gunshot fractures of the thigh. The American Orthopedic Association should insist upon certain minimum requirements for both emergency and subsequent treatment of compound fractures of the femur. We shouId set up standards as to methods and equipment and shouId encourage a present tendency to demand specia1 qualifications of those who are to undertake the care of these difficuft cases. If our program of nationa certification of speciaIists is to do the greatest good, the treatment of such conditions as compound fractures of the femur, the internal fixation of fractures and eIective major amputations should be undertaken onIy by those surgeons who have been certified by the National Boards in Genera1 and Orthopedic Surgery. One factor that has interfered with idea1 fracture treatment has been the antiseptic treatment of wounds. It has now been demonstrated that frequent changes of antiseptic dressings and antiseptic irrigations are unnecessary. Early and complete fixation of fractures in correct position can now be carried out. My own efforts in this direction originated in rgr8-rg2o with the Thomas doubIe abduction splint as taught by Sir Robert Jones. To this spIint as we11 as to the singIe ring caIiper splint several surgeons at that time added the use of skeletal traction. Ice tongs and pins were employed in such a way that, even with frequent dressings, gunshot fractures of the femur were kept at fuII Iength and in correct position. Such a
190
American
Journal
of Surgery
Orr-Compound
Fractures
FIG. I. The patient is pIaced upon the traction tahIe in such a way that immobilization of the parts to be operated upon can be maintained throughout the operation, and a plaster of Paris cast put on following the operation without any undue movement or disturbance of parts. When corrective manipuIations or traction are necessary they can be carried out during or in connection with the operative procedure. The method of fixing the traction in the cast is indicated on the patient’s Ieft Ieg where moleskin adhesive pIaster has been put on. The left hand of the operator rests at the point where adhesive pIaster straps are to be turned back around the Iower end of the plaster of Paris cast after that has been appIied. In this way the traction is Iocked against the tower end of the cast before the foot portion of the cast is finished. This Ieaves the foot free so that it can be dorsiflexed to any degree desired as the tina portion of the cast is put on. (From Orr, in “The CycIopedia of Medicine,” Davis.)
FIG. 2. The infected portion of the femur has been wideIy exposed, the soft parts are puIIed gentIy apart by means of the retractor, and the entire area is being HIed with Vaseline gauze. No stitches, tubes or other materials are empIoyed in the interior of the wound. (From Orr, in “The Cyclopedia of Medicine,” Davis.)
FIG. 3. The Vaseline dressing has been completed by filling the entire wound area \rith gauze, then applying a Aat dressing over the surface which extends to some distance beyond the edges of the wound. This brings whatever drainage there is out to the edges of this vaseIine pad, where it can be taken up by the cotton and gauze dressing. (From Orr, in “The Cyclopedia of Medicine,” Davis.)
FIG. 4. The area of the operation and alI of the other parts are now covered with cotton and bandages as a final preparation for the application of the pIaster of Paris cast. It will be observed that the position of the patient has made no change at any time. Traction is maintained upon the feet and with the patient firmIy against the perineal post until the upper portion of the cast is a11 finished and until the moleskin adhesive plaster straps have been turned back into the cast or until the skeIeta1 traction OI fixation devices have become secure in the hardening cast. (From Orr, in “The Cyclepedia of Medicine,” Davis.)
192
American JournalofSurgery
Orr-Compound
program, however, ;nvoIved much Iabor as we11 as disturbance of the patient. In the hands of those who were Iess expert, there
Fractures
JULY, 1940
incIuded the feet, knees and skeIeta1 fixation devices in pIaster of Paris after the patient had been properIy adjusted in the
FIG. 5. The upper portion of the cast has now been finished, and the moIeskin adhesive straps are being turned back around the edge of the cast and are being rocked into the cast before the traction upon the feet is released. FuII Iength and immobiIization are stiI1 being maintained unti1 this fixed traction has been completed. (From Orr, in “The CycIopedia of Medicine,” Davis.)
FIG. 6. The compIeted cast with a11 parts in correct position and compIeteIy immobiIized indicates how efficiently Iength, position and contro1 of a11 the parts are maintained in the finished cast. With patients who are incIined to muscIe spasm or to be active, additiona security is obtained by attaching a fairIy heavy weight to the cross bar and having this weight hung over the foot of the bed, which is eIevated to a height of from 8 to IZ inches. (From Orr, in “The CycIopedia of Medicine,” Davis.)
were ineffrcient spIinting and many poor resuIts. During and after our war experience, I added pIaster of Paris to this pIan of treatAt first I ment in Thomas spIints.
spIint. Roger Anderson has recentIy caIIed this “we11 leg traction.” From this it was a short step to the pIan I have empIoyed ever since, i.e., the use of skeIeta1 fixation pins in doubIe leg casts or spicas. The infrequent
NI u ‘YEHIES
VW, NLIX,
No.
I
Orr-Compound
dressing method since 19x1 has made it possible for me to treat al1 our patients by this plan. We do not employ weight and puIIey traction except as an adjunct for balancing the patient in the bed. Ice tongs, Kirschner wires and other Iess efficient fixation devices are no Ionger empIoyed. SmaII rigid pins, imbedded in the pIaster of Paris cast are routine with us in these, as we11 as in a11 other cases in which fixed Iength and position are desired. The importance of consistency as to infrequent dressings has often been emphasized. Primary reduction of the fracture and skeIeta1 fixation in pIaster in correct Iength and position depend upon the attending specialist. But insistence upon correct after-care must permeate to every attending doctor, resident, intern, nurse and even to members of the famiIy. Loss of contro1 in the cast or exposure of the wound to secondary infection wiI1 often disturb the patient’s progress toward recovery. Sometime ago I had the foIIowing interesting cIinica1 account from Dr. CaIvin Smyth, Jr. of Philadelphia: “A colored man stevedore of $0 sustained a compound comminuted fracture of the femur just above the knee joint when a heavy packing case fell on him. In addition to the fracture of the femur he sustained fractures of the nose and maxilla, and multiple lacerations of the face. He was in profound shock upon admission. The upper fragment of the femur was protruding through his overaIls. After instituting measures for the relief of shock, the wound on the outer aspect of the thigh was flooded with iodine and covered with a steriIe dressing. At the end of twenty-four hours under local anesthesia the wound was cleaned, the protruding hone replaced and the wound packed lightly with iodoform gauze. Tongs extension was applied and the limb suspended in a Thomas splint. Plaster was not applied because of the necessity of using tongs; we had at that time no experience with Orr’s plan of incorporating the tongs in the pIaster. During the following three weeks the wound \vas not disturbed by any sort of dressing and the patient had no eIevation of temperature
Fractures whatever. During the fourth week, the house officer, becoming aIarmed by the odor of the dressing, removed the packing, swabbed the wound with mercurochrome and repacked with plain gauze. On the folIowing day the temperature rose sharply to 103 degrees and from that point the patient was septic and required multiple operations for relief. Union of the fracture occurred, but the infection in the depths of the wound prolonged hospitalization for many months.”
Dr. Smyth commented, “This case serves to demonstrate an instance where earIy treatment was effectual, and in which infection appeared on1y after three weeks, folIowing a meddIesome dressing. From our experience with other cases, we believe that had this man been in pIaster with no dressing for five or six weeks, no infection wouId have taken pIace.” I treated a patient in Mexico City with Dr. FariII two years ago in which the patient had been in bed for over a year with maIunion of a femora1 fracture just above the knee. She had severa draining sinuses about the knee and equinus deformity of the foot. At our operation skeIeta1 traction and manipuIation were empIoyed to correct the fracture deformity and bring the Iimb down to correct Iength and position. The draining sinuses were enIarged. Tenotomy of the AchiIIes tendon had to be done to bring the foot to a right angIe with the leg. This patient had no postoperative complications. She recovered completely in a few months and has been walking on a useful Iimb ever since. EarIy in my experience with infrequent dressings, I suggested consideration of this method for miIitary surgery. However, in Washington, my proposals were considered too radica1 a departure from usual surgica1 practice. My own experiences with gunshot wounds had convinced me that drainage and packing of compound fractures and skeletal fixation in plaster of Paris casts were just as feasible in gunshot fractures as in other infected wounds. It has been a matter of some satisfaction to me, there-
194
American
Journal
of Surgery
Orr-Compound
fore, that recent communications from the military areas in Spain have borne out my views in regard to this matter. Dr. J. Trueta RaspaII, who was on duty in the vicinity of Barcelona and iri CataIonia, wrote to me some months ago and sent a copy of his book on “The Treatment of War Fractures,” first pubIished at BarceIona. He reported a Iarge number of cases successfuIIy treated by the methods which I have described. I have since received another Ietter from Dr. Raspall, written in London, after his departure from the BarceIona area upon the entrance of General France. His Ietter, dated ApriI I I,
Fractures
JULY, 1940
1939, states: “I am very gratefu1 to you for your Iast Ietter. Here I am in London advertising your method which I used 1,073 times, out of which onIy six patients died. Soon there wiI1 appear in the London Lancet an articIe teIIing about the part I took in the Spanish War, where, as Director of BarceIona, I had a big chance for putting into practice your method. In the army, where I insisted that the method shouId be used in a11 cases, the number of times that I put it into practice amounts to 10,000. The gas gangrene that made so many victims suffer at the beginning of the war, has now aImost disappeared.
THE primary aim of debridement is the remova of tissue which has been so damaged that it will no Ionger heaI readiIy, and not, as is sometimes thought, the remova of bacteria. From-“Surgery of the Hand” by Couch (University of Toronto Press).
AND RESULTS IN COMPOUND OF THE FEMUR
H. WINNETT ORR, M.D. LINCOLN,
I
N rgr7 and Igr8 a miIitary committee recommended standardized spbnts for the use of the American army in France. If the use of those spIints had been carried over into civi1 practice and if there had been Iess modification of spIints and of methods of treatment, our resuIts in compound fractures of the femur wouId be better than they are. The commercial and scientific exhibits at our meetings indicate how far the modification of spIints and methods has been carried. Standardized splint methods and rules for treatment wouId contribute to the welfare of the patient and to the reIief of everyone concerned in such cases. When he is confronted with a compound fracture of the femur, a surgeon often permits himself to be diverted from the fundamental requirements of the case (i.e., restoration of length and position) by such detaiIs as shock, hemorrhage, swelling, and pain, any or all of which might be relieved at once by prompt immobilization of the injured part in a proper spbnt. The application of Thomas splints on the battle fieId was proposed by Sir Robert Jones in 1914. The great success of this plan is now a matter of history. This was the first time that first aid and correct treatment had been combined on a general pian. The compound fracture femur cases were protected at once and shock, pain, swelling and the other severe symptoms were prevented or relieved by this plan of immediate reduction of the fracture and immobibzation of the fractured Iimb. During rgr8 the death rate in casuaity clearing stations from gunshot fractures of the femur had been reduced to 1736 per cent. This represented an improvement of between 40 and 50 per cent from the first
NEBRASKA
BowIby days of the war. Sir Anthony pointed out that there was a secondary death rate in the base hospitals of about IO per cent and of approximateIy 3 per cent Iater in the home hospitals. So the eventua1 death rate was about 30 per cent in gunshot fractures of the thigh. The American Orthopedic Association should insist upon certain minimum requirements for both emergency and subsequent treatment of compound fractures of the femur. We shouId set up standards as to methods and equipment and shouId encourage a present tendency to demand specia1 qualifications of those who are to undertake the care of these difficuft cases. If our program of nationa certification of speciaIists is to do the greatest good, the treatment of such conditions as compound fractures of the femur, the internal fixation of fractures and eIective major amputations should be undertaken onIy by those surgeons who have been certified by the National Boards in Genera1 and Orthopedic Surgery. One factor that has interfered with idea1 fracture treatment has been the antiseptic treatment of wounds. It has now been demonstrated that frequent changes of antiseptic dressings and antiseptic irrigations are unnecessary. Early and complete fixation of fractures in correct position can now be carried out. My own efforts in this direction originated in rgr8-rg2o with the Thomas doubIe abduction splint as taught by Sir Robert Jones. To this spIint as we11 as to the singIe ring caIiper splint several surgeons at that time added the use of skeletal traction. Ice tongs and pins were employed in such a way that, even with frequent dressings, gunshot fractures of the femur were kept at fuII Iength and in correct position. Such a
190
American
Journal
of Surgery
Orr-Compound
Fractures
FIG. I. The patient is pIaced upon the traction tahIe in such a way that immobilization of the parts to be operated upon can be maintained throughout the operation, and a plaster of Paris cast put on following the operation without any undue movement or disturbance of parts. When corrective manipuIations or traction are necessary they can be carried out during or in connection with the operative procedure. The method of fixing the traction in the cast is indicated on the patient’s Ieft Ieg where moleskin adhesive pIaster has been put on. The left hand of the operator rests at the point where adhesive pIaster straps are to be turned back around the Iower end of the plaster of Paris cast after that has been appIied. In this way the traction is Iocked against the tower end of the cast before the foot portion of the cast is finished. This Ieaves the foot free so that it can be dorsiflexed to any degree desired as the tina portion of the cast is put on. (From Orr, in “The CycIopedia of Medicine,” Davis.)
FIG. 2. The infected portion of the femur has been wideIy exposed, the soft parts are puIIed gentIy apart by means of the retractor, and the entire area is being HIed with Vaseline gauze. No stitches, tubes or other materials are empIoyed in the interior of the wound. (From Orr, in “The Cyclopedia of Medicine,” Davis.)
FIG. 3. The Vaseline dressing has been completed by filling the entire wound area \rith gauze, then applying a Aat dressing over the surface which extends to some distance beyond the edges of the wound. This brings whatever drainage there is out to the edges of this vaseIine pad, where it can be taken up by the cotton and gauze dressing. (From Orr, in “The Cyclopedia of Medicine,” Davis.)
FIG. 4. The area of the operation and alI of the other parts are now covered with cotton and bandages as a final preparation for the application of the pIaster of Paris cast. It will be observed that the position of the patient has made no change at any time. Traction is maintained upon the feet and with the patient firmIy against the perineal post until the upper portion of the cast is a11 finished and until the moleskin adhesive plaster straps have been turned back into the cast or until the skeIeta1 traction OI fixation devices have become secure in the hardening cast. (From Orr, in “The Cyclepedia of Medicine,” Davis.)
192
American JournalofSurgery
Orr-Compound
program, however, ;nvoIved much Iabor as we11 as disturbance of the patient. In the hands of those who were Iess expert, there
Fractures
JULY, 1940
incIuded the feet, knees and skeIeta1 fixation devices in pIaster of Paris after the patient had been properIy adjusted in the
FIG. 5. The upper portion of the cast has now been finished, and the moIeskin adhesive straps are being turned back around the edge of the cast and are being rocked into the cast before the traction upon the feet is released. FuII Iength and immobiIization are stiI1 being maintained unti1 this fixed traction has been completed. (From Orr, in “The CycIopedia of Medicine,” Davis.)
FIG. 6. The compIeted cast with a11 parts in correct position and compIeteIy immobiIized indicates how efficiently Iength, position and contro1 of a11 the parts are maintained in the finished cast. With patients who are incIined to muscIe spasm or to be active, additiona security is obtained by attaching a fairIy heavy weight to the cross bar and having this weight hung over the foot of the bed, which is eIevated to a height of from 8 to IZ inches. (From Orr, in “The CycIopedia of Medicine,” Davis.)
were ineffrcient spIinting and many poor resuIts. During and after our war experience, I added pIaster of Paris to this pIan of treatAt first I ment in Thomas spIints.
spIint. Roger Anderson has recentIy caIIed this “we11 leg traction.” From this it was a short step to the pIan I have empIoyed ever since, i.e., the use of skeIeta1 fixation pins in doubIe leg casts or spicas. The infrequent
NI u ‘YEHIES
VW, NLIX,
No.
I
Orr-Compound
dressing method since 19x1 has made it possible for me to treat al1 our patients by this plan. We do not employ weight and puIIey traction except as an adjunct for balancing the patient in the bed. Ice tongs, Kirschner wires and other Iess efficient fixation devices are no Ionger empIoyed. SmaII rigid pins, imbedded in the pIaster of Paris cast are routine with us in these, as we11 as in a11 other cases in which fixed Iength and position are desired. The importance of consistency as to infrequent dressings has often been emphasized. Primary reduction of the fracture and skeIeta1 fixation in pIaster in correct Iength and position depend upon the attending specialist. But insistence upon correct after-care must permeate to every attending doctor, resident, intern, nurse and even to members of the famiIy. Loss of contro1 in the cast or exposure of the wound to secondary infection wiI1 often disturb the patient’s progress toward recovery. Sometime ago I had the foIIowing interesting cIinica1 account from Dr. CaIvin Smyth, Jr. of Philadelphia: “A colored man stevedore of $0 sustained a compound comminuted fracture of the femur just above the knee joint when a heavy packing case fell on him. In addition to the fracture of the femur he sustained fractures of the nose and maxilla, and multiple lacerations of the face. He was in profound shock upon admission. The upper fragment of the femur was protruding through his overaIls. After instituting measures for the relief of shock, the wound on the outer aspect of the thigh was flooded with iodine and covered with a steriIe dressing. At the end of twenty-four hours under local anesthesia the wound was cleaned, the protruding hone replaced and the wound packed lightly with iodoform gauze. Tongs extension was applied and the limb suspended in a Thomas splint. Plaster was not applied because of the necessity of using tongs; we had at that time no experience with Orr’s plan of incorporating the tongs in the pIaster. During the following three weeks the wound \vas not disturbed by any sort of dressing and the patient had no eIevation of temperature
Fractures whatever. During the fourth week, the house officer, becoming aIarmed by the odor of the dressing, removed the packing, swabbed the wound with mercurochrome and repacked with plain gauze. On the folIowing day the temperature rose sharply to 103 degrees and from that point the patient was septic and required multiple operations for relief. Union of the fracture occurred, but the infection in the depths of the wound prolonged hospitalization for many months.”
Dr. Smyth commented, “This case serves to demonstrate an instance where earIy treatment was effectual, and in which infection appeared on1y after three weeks, folIowing a meddIesome dressing. From our experience with other cases, we believe that had this man been in pIaster with no dressing for five or six weeks, no infection wouId have taken pIace.” I treated a patient in Mexico City with Dr. FariII two years ago in which the patient had been in bed for over a year with maIunion of a femora1 fracture just above the knee. She had severa draining sinuses about the knee and equinus deformity of the foot. At our operation skeIeta1 traction and manipuIation were empIoyed to correct the fracture deformity and bring the Iimb down to correct Iength and position. The draining sinuses were enIarged. Tenotomy of the AchiIIes tendon had to be done to bring the foot to a right angIe with the leg. This patient had no postoperative complications. She recovered completely in a few months and has been walking on a useful Iimb ever since. EarIy in my experience with infrequent dressings, I suggested consideration of this method for miIitary surgery. However, in Washington, my proposals were considered too radica1 a departure from usual surgica1 practice. My own experiences with gunshot wounds had convinced me that drainage and packing of compound fractures and skeletal fixation in plaster of Paris casts were just as feasible in gunshot fractures as in other infected wounds. It has been a matter of some satisfaction to me, there-
194
American
Journal
of Surgery
Orr-Compound
fore, that recent communications from the military areas in Spain have borne out my views in regard to this matter. Dr. J. Trueta RaspaII, who was on duty in the vicinity of Barcelona and iri CataIonia, wrote to me some months ago and sent a copy of his book on “The Treatment of War Fractures,” first pubIished at BarceIona. He reported a Iarge number of cases successfuIIy treated by the methods which I have described. I have since received another Ietter from Dr. Raspall, written in London, after his departure from the BarceIona area upon the entrance of General France. His Ietter, dated ApriI I I,
Fractures
JULY, 1940
1939, states: “I am very gratefu1 to you for your Iast Ietter. Here I am in London advertising your method which I used 1,073 times, out of which onIy six patients died. Soon there wiI1 appear in the London Lancet an articIe teIIing about the part I took in the Spanish War, where, as Director of BarceIona, I had a big chance for putting into practice your method. In the army, where I insisted that the method shouId be used in a11 cases, the number of times that I put it into practice amounts to 10,000. The gas gangrene that made so many victims suffer at the beginning of the war, has now aImost disappeared.
THE primary aim of debridement is the remova of tissue which has been so damaged that it will no Ionger heaI readiIy, and not, as is sometimes thought, the remova of bacteria. From-“Surgery of the Hand” by Couch (University of Toronto Press).