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Open reduction a report of 122 cases
OPEN REDUCTION A REPORT OF 122 CASES JAMES A. JACKSON, M.D., AND C. KENNETH COOK, M.D. Divisionof Surgery,JacksonCIinic MADISON,
0
WISCONSIN
PEN
and this is eIiminated to a great extent when proper technique is employed. Few, if any, cases with infection end fataIIy if adequate drainage is estabIished and the CarreI-Dakin treatment instituted. The infection wiI1 cIear up and union wiI1 result without any permanent disabiIity, but there wiI1 be a Iarger scar on the skin. We use various means of fixation of the fragments in our cases of reduction; these incIude Sherman pIates and seIf-tapping screws, naiIs, boIts, phosphobronze wire, Martin-Parham bands, stapIes, kangarootendon, and chromicized catgut. We do not use bone screws, bone pIates and ivory inIays in our own cases, but they are used successfuIIy by some. When a cIosed reduction insures good approximation and the possibiIity of satisfactory function the open operation is not considered. In our opinion, open reduction is indicated when a closed reduction wiI1 give Iess than 60 per cent approximation in the weight-bearing bones, and when deformity and Ioss of function can be diminished. In this connection the roentgenogram is a vaIuabIe aid in diagnosis, but it is not regarded without considering cIinica1 findings as weI1. Open reduction is aIso the method of choice in case of compound fracture with extensive Iaceration and poor approximation of fragments. In these cases, however, the wound is Ieft open and Dakin’s soIution appIied for as Iong a time as is necessary to get union, When union has taken pIace the pIate is removed and the wound aIIowed to cIose. In the past fifteen years in this CIinic, 122 patients with fracture were treated by the open method. There was infection in the case of three of these patients, two of whom died. They were among the first of
reduction or operative treatment of fractures is both praised and condemned by men of the In this report of 122 medica profession. cases (tabuIation), we shaI1 endeavor to show why we have praised rather than condemned this type of treatment. The procedure of cIosed reduction in doubtfu1 cases has IittIe in its favor except that there is Iess danger of infection. ResuIts are not so satisfactory as in the the heaIing time is reduction, open increased, and adjustment of spIints and braces must be made more frequentIy. The time spent in doing the reduction may or may not be shorter. Open reduction aIIows absoIute approximation of fragments, shortens the heaIing peripd, aIIows earIier manipuIation and motion, a greater percentage of anatomica positions and better functiona resuIts. Open reductions are aImost universaIIy satisfactory in the hands of surgeons who are famiIiar with the technique, and who have at their disposa1 proper instruments and other faciIities necessary for this procedure.l,2,3,*,5,” The surgeons who condemn the open reduction are usuaIIy those who have not tried it, or those who have tried it, but, because of fauIty technique, have met with compIications that shouId have been avoided. This procedure cannot be carried out as simply as the closed reduction, but there shouId be no fear of untoward resuIts if the surgeon has trained assistants, the necessary instruments, and above aI1, a knowIedge of the technique. The technique, which at first appears complicated, is quite simpIe in actua1 practice and can be carried out by any good operating-room staff. Infection is the bugbear which is most to be feared 57
58
American Journal of Surgery
Jackson,
Cook-Open
the series; the third patient was treated about six years ago. Since that time there has been no case of infection. In the first of these 3 cases the patient infected the wound with feces; the second case was that of a cachectic patient who was in poor condition. In the third case the infection was due to contamination of instruments and was the only one of the three that was treated by the Dakin-Carrel method. In
Reduction
site of operation is thoroughIy cIeaned by using aIcoho1 and ether and appIying a 3 per cent soIution of iodine or a 5 per cent aIcohoIic solution of picric acid. This renders the skin Iess septic aIthough it is far from sterile. The incision is made over the site of fracture. This shouId be suffrcientIy Iong to facihtate handling of instruments and to avoid the necessity of enIarging the incision
a
FIG. I. Fracture of cIavicIe: a, before reduction;
this case there was rapid convaIescence, with perfect union and function. We fee1 that in most cases of open reduction the period of recovery is shortened to about two-thirds as compared with the closed method; in some it is reduced even more. This factor is of sufficient economic importance to demand serious attention in industria1 and insurance cases as we11 as in private cases. TECHNIQUE
To prepare
the patient,
the skin at the
JANUARY, rgz8
b b, after reduction.
Iater. BIeeding vesseIs are Iigated and the skin margins are covered with toweIs heId in pIace by Bacchus or Moynihan towe MichaeI wound cIips. In some instances clips may be used to advantage, but in our experience the Moynihan cIamp has been the most satisfactory. These are pIaced at intervaIs of not more than I inch. The compIete bIock of a11 skin margins is essentia1. Whenever possibIe, the scaIpe1 shouId be pIunged to the bone and the muscIes divided from within outward, aIthough this is not practica1 in a11
NEW
SERIES VOL.
IV,
No.
Jackson,
I
Cook-
approaches. The cut muscIes are separated by retractors to permit a view of the bone ends. The bone ends are freed from muscle with a periostea1 eIevator. The bones are grasped near the site of fracture with Lane cIamps; Berg cIamps are substituted when a Berg extension cIamp is to be used. The bone ends are freed from bIood cIots and muscle fragments by curettage, and enough extension is applied to overcome
a
Open
Reduction
American
Journal
of Surgery
59
pIate is then applied and heId in place whiIe hoIes are drilled into the bone with a No. 32 Brown and Sharp driI1. One or more screws in each fragment should pass through both cortices of the fragment. The Sherman seIf-tapping transfixion screws of the right Iength are then driven into the hoIes to hold the pIate. CaIipers are used to determine the diameter of the bone, so that the screws for transfixion may be of sufi-
b
FIG. z. Fracture of right humerus in middIe third: a, before reduction; b, after reduction.
any overriding. This is easiIy accompIished when the Berg cIamp is used. The Berg cIamp maintains its reduction as Iong as it is applied. When the overriding is reduced without the Berg cIamp, it may be done by bringing both bone ends out of the wound, approximating the fractured ends and then returning the bone to the norma position. Once a reduction has been accompIished, it shouId be maintained by some suitabIe cIamp such as the Lane cIamp. A Sherman
cient Iength to hoId in both cortices and not extend beyond into soft tissue. After a11 the screws have been driven in firmIy, the cIamp maintaining the reduction shouId be removed and the incision closed with as Iittle catgut as possibIe. The skin is cIosed with MichaeI wound cIips or with silk. A dressing is appIied and aIso a supporting spIint, cast, or whatever is indicated in the individua1 case. EarIy mobiIization of the joints is advisabIe in these cases and mas-
60
American Journal of Surgery
Jackson,
Cook--n-~nvpcu
sage and passive manipuIation is instituted within ten days. It is imperative that the surgeon, in doing this type of work, shouId have a complete armamentarium and a sufficient number of assistants. The rigid Lane technique which is essentia1 may be a point
of both condyles before reduction.
of Ieft humerus:
of troubIe for some surgeons. It simpIified if the surgica1 nurse instruments from her table to the with forceps. When the surgeon has with an instrument he drops it into
may be hands surgeon finished a basin
JANUARY,
1gm
containing hychIorite or steriIe water. The second nurse removes it from the basin and washes it in steriIe water if it is taken from hychIorite, or steriIizes it in aIcoho1 if it is removed from water, and returns it to the instrument tabIe. The entire procedure is carried out by the use of forceps, the surgeon being the onIy one to touch the instruments with gIoved hands. In fracture of the tibia or cIavicIe, or in any compound fractures, the pIates are removed routineIy. In a11 other cases they are Ieft in pIace. In one of our cases (Case 6) a roentgenogram, taken ten years after the open reduction, shows the naiIs stiI1 in place. SELECTION
FIG. 3~. Fracture
1
R wr..fi+:,-
A\CUULl,I”II
OF CASES
UntiI recentIy the genera1 surgeon and genera1 practitioner have been concerned more with union than with functiohal resuIts. If in a case of fracture of the femur the patient couId waIk, even though he Iimped and had pain, the resuIt was considered good. Since cases of industria1 injury and automobiIe accidents have become more numerous, this is not a satisfactory functiona resuIt. We must consider whether or not the patient can resume his former occupation with sufficient function to perform his work without distress or pain. If the patient Iimps and has pain he does not consider himseIf functionaIIy normaI, even though union may be solid and approximation fair. Corrective measures must be taken in the first week or ten days by either the cIosed or open method. If the cIosed method is unsatisfactory during the first week there is stiI1 ampIe time for the open method. To wait for from six weeks to six months combecause during that matters, pIicates period some damage may have been done that cannot be corrected. It is our practice in the case of simpIe fracture to consider the cIosed reduction first. When this is not satisfactory we wait for from eight to ten days from the time of the fracture before doing open reduction. This aIIows time for sweIIing to decrease,
NEW SERIESVOL. IV, No. I
Jackson,
Cook-Open
bIood cIots to be absorbed, and smaI1 vesseIs to hea that may have been traumatized at the time of the fracture. At the end of ten days the tissues have deveIoped more resistance, and if extension has been carried on during this period, reduction is more easiIy accompIished and the tissues are in
FIG. 3b. Fracture
much better infection.
condition
of both
to combat
condyles
possibIe
COMMENT
Sherman,4 in more than 1300 cases of open reduction, found infection no more prevaIent than in any eIective operation. He repeatedIy emphasizes the necessity of correct technique. He considers the Iaparotomy technique of the genera1 surgeon not onIy insuffIcient but dangerous. GIoved hands shouId never come in contact with the skin or be introduced into the incision. Proper instruments wiII suffice for the necessary steps and Iessen the danger of contamination. He further maintains that open reduction is contraindicated except when the armamentarium and operative technique are avaiIabIe. Sherman has probabIy done more than any other one man to promote the suc1
Reduction
American
JOWLY
of surgery
61
cessfu’l treatment of fracture. Acknowledgment is made to him for his wiIIingness in aiding us to gain more experience in this method of treatment, for improvement in our technique, and for suggestions regarding postoperative treatment. We are reporting here 9 cases from our
of Ieft humerus: after reduction.
series which represent the more common fractures that have been treated by the operative method. These are the more typica cases in which open reduction is easiIy done by the genera1 surgeon with proper armamentarium and technique. In the treatment of these cases pIates, boIts and naiIs were used. Our series is smaI1, but coming from a non-industria1 IocaIity it is of some vaIue, we trust, in showing the advantage of the open reduction when faciIities permit. REPORT
OF
CASES
CASE I. A woman, aged thirty-six, sustained a fracture of the cIavicIe on December 23, 1926, in an automobiIe accident. On December 28, after three unsuccessfu1 attempts at reduction, open reduction was done and a fourscrew Sherman pIate appIied. ConvaIescence was uneventfu1. On January 6, 1927, the patient Ieft the hospita1, and returned on
62
American Journal of Surgery
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Cook-Open
Reduction
b
a FIG. 4. ObIique
fracture
of upper
end
of uIna incIuding okranon b, after reduction.
from
shaft of left uIna: a, before
b
a FIG. 5. Fracture
JANUARY, 1928
of both bones of Icft forearm:
a, before
reduction;
b, after reduction.
reduction
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VW..IV, No. I
Jackson,
Open
Cook-
March g for remova of the plate. On March 14, when she was dismissed from observation, function and position were norma (Fig. I).
American
Reduction
The
patient
Journal of
Surgery
63
Ieft the hospita1 on January 17, physiotherapy at the Chnic. was dismissed from observation
1924, to continue
When
she
b FIG. 6. Fracture
of neck of Ieft femur: a, before reduction;
CASE II. This patient feI1 on December 21, 1923, and broke the right humerus in the middie third. Her IocaI physician tried to reduce the fracture but was unabIe to maintain reduc-
b, after reduction.
on February 8, function perfect (Fig. 2).
7. Fracture
of middle
position
were
CASE III. A boy, aged seventeen, fell on February 18, IgIg, and struck the left elbow.
b
a
FIG.
and
third
of right
tion. After three unsuccessfu1 attempts she was brought to the Clinic, and on December 31 open reduction was done with a six-screw Sherman pIate. ConvaIescence was uneventfu1.
femur:
a, before
reduction;
b, after reduction.
Both condyIes of the Ieft humerus were fractured. On February 22 open reduction was done. One boIt was passed through both condyIes of the Ieft humerus. Convalescence was
64
American Journal of surgery
Jackson,
Cook-Open
Reduction
a
FIG. 8. Fracture
of lower third of right femur: a, before reduction;
b b, after reduction.
b
a
FIG. g. Transverse
JANUARY,
fracture
of left
pateIIa:
a, before
reduction;
b, after
reduction.
NEW SERIES VOL. IV, No. I
Jackson,
Cook--Open
uneventfu1. On March 3 he left the hospita1 and came to the CIinic for physiotherapy, and on ApriI 7 he was dismissed from observation with normaI function and position (Fig. 3). CASE IV. A man, aged thirty, was injured in a motorcyIe accident on ApriI 16, 1927. He sustained obIique fracture of the upper end of the ulna, incIuding the oIecranon, from the shaft of the Ieft uIna. It was impossibIe to maintain approximation of the fragments because of sweIIing and interposed tissue. On ApriI 26 open reduction was done; one Sherman screw was transfixed through the fragment to the shaft. Convaiescence was uneventfu1. On May 6 the patient Ieft the hospita1 and came to the CIinic for physiotherapy. He was dismissed with norma function and position (Fig. 4). CASE v. A woman, aged twenty-seven, feI1 down stairs on May 4, 1922, and fractured both bones of the Ieft forearm. Because of sweIIing, position couId not be maintained. On May 17 open reduction was done and a four-screw Sherman pIate appIied to the radius; the region of the uIna was not opened. ConvaIescence was uneventfu1. On June 7 the patient Ieft the hospita1 and came to the CIinic for physiotherapy. When she was dismissed from observation on JuIy 26 there was good function and position of the radius, and fair position of the uIna (Fig. 3). CASE VI. A woman, aged seventy-one, feI1 on the ice on February 6, 1916, and injured the Ieft hip and fractured the neck of the Ieft femur. Open reduction was done on February 14; the neck of the femur was naiIed through the greater trochanter to the head of the femur. ConvaIescence was uneventfu1. She Ieft the hospita1 on June 8, waIking; function was norma and there was no shortening (Fig. 6).
CASE VII. A boy, aged eight, in an automobiIe accident on September 4, 1924, fractured the middIe third of the right femur. Open reduction was done on September 18, and a four-screw Sherman pIate appIied. ConvaIescence was uneventfu1. He Ieft the hospita1 on October 3 and came to the CIinic for physiotherapy. By November 13 he was dismissed from observation with norma function and position (Fig. 7). CASE VIII. A girl, aged eIeven, was struck by an automobiIe on JuIy 23, 1924, and fractured the Iower third of the right femur. Two
Reduction
American Journal of Surgery
65
atTempts at reduction under the fluoroscope were unsuccessfu1. Open reduction was done on August 7, and a six-screw Sherman pIate was applied. ConvaIescence was uneventfu1. The patient Ieft the hospita1 on September 17, to continue physiotherapy at the CIinic. She \vas dismissed from observation on December 10 with norma function and position (Fig. 8). C.\SE IX. A man, aged fifty-five, feI1 on ApriI 12, 1923, whiIe crossing a raiIroad track and struck his Ieft knee on the rai1. He sustained transverse fracture of the Ieft pateIIa. Open reduction was done on ApriI 14, and the pateIIa was sutured. ConvaIescence was uneventfu1. He Ieft the hospita1 on June 27 and came to the CIinic for physiotherapy. He was dismissed from observation on JuIy IO with good position and 93 per cent function; there was about 3 per cent Iimitation in extension (Fig. 9). CONCLUSION$
From the resuks of our series of cases of open reduction it may be concIuded that: I. The open reduction with proper armamentarium and technique is no more dangerous than ordinary Iaparotomy. 2. It is Iess painfu1. 3. There is more certainty of the patient’s returning to his former occupation. 4. The patient returns to his work sooner than when the cIosed method is used. 5. There is Iess IikeIihood of the deveIopment of extensive caIIus, pain, and disabiIity. CASES SELECTED FOR TREATMENT Fractures Bone
Jpperl
I
Mid- Lower’ I die 1rhird Third rhird : TotaI /
Humerus........ Radius. Radius and uIna. UIna........... Femur, Tibia. Tibia and fibuIa. ClavicIe
PatelIa. TotaI.
~ I2
IO
26
: ~ 1: 8i 3 3 1 I6 0, 2 0 I 4
2
1:
4
-
-
0
II
7 3’
26 3 16
I2
IO
-
I22
7
66
American Journal of Surgery
Jackson,
Cook-Open
6. It is easier to obtain correct approximation, better weight-bearing, and function. 7. Open reduction is favorabIe to early manipuIation and motion. BIBLIOGRAPHY
I. ASHHURST, A. P. C., and CKOSSAN, E. T. Prognosis and treatment of fractures of the femur: report of one hundred and eIeven cases. Arch. Surg., 1926, xii, 453-493.
2. HITZROT, J. M. Fracture disrocation
at the shouIderjoint. Ann. Surg., 1926, Ixxxiii, 562-566.
Reduction
JANURY, Igz8
3. SHERMAN, W. 0. N. The CarreI method of wound sterikation: its use in mikary, industria1, and civi1 practice. Surg., Gynec., @ O&t., 1917, xxiv, 255-274. 4. SHERMAN, W. 0. N. The industria1 surgica1 probIem. Boston hf. w S. J., 1926, cxciv, 139-1.46. 5. SHERMAN, W. 0. N. Compound fractures of the femur and open fractures into joints. J. Bone C+_Y Joint Surg., 1924, vi, 344-349. 6. SHERMAN, W. 0. N. Operative treatment of fractures of the shaft of the femur with maximum fixation. J. Bone CT Joint Surg., 1926, viii, 494.
0
WISCONSIN
PEN
and this is eIiminated to a great extent when proper technique is employed. Few, if any, cases with infection end fataIIy if adequate drainage is estabIished and the CarreI-Dakin treatment instituted. The infection wiI1 cIear up and union wiI1 result without any permanent disabiIity, but there wiI1 be a Iarger scar on the skin. We use various means of fixation of the fragments in our cases of reduction; these incIude Sherman pIates and seIf-tapping screws, naiIs, boIts, phosphobronze wire, Martin-Parham bands, stapIes, kangarootendon, and chromicized catgut. We do not use bone screws, bone pIates and ivory inIays in our own cases, but they are used successfuIIy by some. When a cIosed reduction insures good approximation and the possibiIity of satisfactory function the open operation is not considered. In our opinion, open reduction is indicated when a closed reduction wiI1 give Iess than 60 per cent approximation in the weight-bearing bones, and when deformity and Ioss of function can be diminished. In this connection the roentgenogram is a vaIuabIe aid in diagnosis, but it is not regarded without considering cIinica1 findings as weI1. Open reduction is aIso the method of choice in case of compound fracture with extensive Iaceration and poor approximation of fragments. In these cases, however, the wound is Ieft open and Dakin’s soIution appIied for as Iong a time as is necessary to get union, When union has taken pIace the pIate is removed and the wound aIIowed to cIose. In the past fifteen years in this CIinic, 122 patients with fracture were treated by the open method. There was infection in the case of three of these patients, two of whom died. They were among the first of
reduction or operative treatment of fractures is both praised and condemned by men of the In this report of 122 medica profession. cases (tabuIation), we shaI1 endeavor to show why we have praised rather than condemned this type of treatment. The procedure of cIosed reduction in doubtfu1 cases has IittIe in its favor except that there is Iess danger of infection. ResuIts are not so satisfactory as in the the heaIing time is reduction, open increased, and adjustment of spIints and braces must be made more frequentIy. The time spent in doing the reduction may or may not be shorter. Open reduction aIIows absoIute approximation of fragments, shortens the heaIing peripd, aIIows earIier manipuIation and motion, a greater percentage of anatomica positions and better functiona resuIts. Open reductions are aImost universaIIy satisfactory in the hands of surgeons who are famiIiar with the technique, and who have at their disposa1 proper instruments and other faciIities necessary for this procedure.l,2,3,*,5,” The surgeons who condemn the open reduction are usuaIIy those who have not tried it, or those who have tried it, but, because of fauIty technique, have met with compIications that shouId have been avoided. This procedure cannot be carried out as simply as the closed reduction, but there shouId be no fear of untoward resuIts if the surgeon has trained assistants, the necessary instruments, and above aI1, a knowIedge of the technique. The technique, which at first appears complicated, is quite simpIe in actua1 practice and can be carried out by any good operating-room staff. Infection is the bugbear which is most to be feared 57
58
American Journal of Surgery
Jackson,
Cook-Open
the series; the third patient was treated about six years ago. Since that time there has been no case of infection. In the first of these 3 cases the patient infected the wound with feces; the second case was that of a cachectic patient who was in poor condition. In the third case the infection was due to contamination of instruments and was the only one of the three that was treated by the Dakin-Carrel method. In
Reduction
site of operation is thoroughIy cIeaned by using aIcoho1 and ether and appIying a 3 per cent soIution of iodine or a 5 per cent aIcohoIic solution of picric acid. This renders the skin Iess septic aIthough it is far from sterile. The incision is made over the site of fracture. This shouId be suffrcientIy Iong to facihtate handling of instruments and to avoid the necessity of enIarging the incision
a
FIG. I. Fracture of cIavicIe: a, before reduction;
this case there was rapid convaIescence, with perfect union and function. We fee1 that in most cases of open reduction the period of recovery is shortened to about two-thirds as compared with the closed method; in some it is reduced even more. This factor is of sufficient economic importance to demand serious attention in industria1 and insurance cases as we11 as in private cases. TECHNIQUE
To prepare
the patient,
the skin at the
JANUARY, rgz8
b b, after reduction.
Iater. BIeeding vesseIs are Iigated and the skin margins are covered with toweIs heId in pIace by Bacchus or Moynihan towe MichaeI wound cIips. In some instances clips may be used to advantage, but in our experience the Moynihan cIamp has been the most satisfactory. These are pIaced at intervaIs of not more than I inch. The compIete bIock of a11 skin margins is essentia1. Whenever possibIe, the scaIpe1 shouId be pIunged to the bone and the muscIes divided from within outward, aIthough this is not practica1 in a11
NEW
SERIES VOL.
IV,
No.
Jackson,
I
Cook-
approaches. The cut muscIes are separated by retractors to permit a view of the bone ends. The bone ends are freed from muscle with a periostea1 eIevator. The bones are grasped near the site of fracture with Lane cIamps; Berg cIamps are substituted when a Berg extension cIamp is to be used. The bone ends are freed from bIood cIots and muscle fragments by curettage, and enough extension is applied to overcome
a
Open
Reduction
American
Journal
of Surgery
59
pIate is then applied and heId in place whiIe hoIes are drilled into the bone with a No. 32 Brown and Sharp driI1. One or more screws in each fragment should pass through both cortices of the fragment. The Sherman seIf-tapping transfixion screws of the right Iength are then driven into the hoIes to hold the pIate. CaIipers are used to determine the diameter of the bone, so that the screws for transfixion may be of sufi-
b
FIG. z. Fracture of right humerus in middIe third: a, before reduction; b, after reduction.
any overriding. This is easiIy accompIished when the Berg cIamp is used. The Berg cIamp maintains its reduction as Iong as it is applied. When the overriding is reduced without the Berg cIamp, it may be done by bringing both bone ends out of the wound, approximating the fractured ends and then returning the bone to the norma position. Once a reduction has been accompIished, it shouId be maintained by some suitabIe cIamp such as the Lane cIamp. A Sherman
cient Iength to hoId in both cortices and not extend beyond into soft tissue. After a11 the screws have been driven in firmIy, the cIamp maintaining the reduction shouId be removed and the incision closed with as Iittle catgut as possibIe. The skin is cIosed with MichaeI wound cIips or with silk. A dressing is appIied and aIso a supporting spIint, cast, or whatever is indicated in the individua1 case. EarIy mobiIization of the joints is advisabIe in these cases and mas-
60
American Journal of Surgery
Jackson,
Cook--n-~nvpcu
sage and passive manipuIation is instituted within ten days. It is imperative that the surgeon, in doing this type of work, shouId have a complete armamentarium and a sufficient number of assistants. The rigid Lane technique which is essentia1 may be a point
of both condyles before reduction.
of Ieft humerus:
of troubIe for some surgeons. It simpIified if the surgica1 nurse instruments from her table to the with forceps. When the surgeon has with an instrument he drops it into
may be hands surgeon finished a basin
JANUARY,
1gm
containing hychIorite or steriIe water. The second nurse removes it from the basin and washes it in steriIe water if it is taken from hychIorite, or steriIizes it in aIcoho1 if it is removed from water, and returns it to the instrument tabIe. The entire procedure is carried out by the use of forceps, the surgeon being the onIy one to touch the instruments with gIoved hands. In fracture of the tibia or cIavicIe, or in any compound fractures, the pIates are removed routineIy. In a11 other cases they are Ieft in pIace. In one of our cases (Case 6) a roentgenogram, taken ten years after the open reduction, shows the naiIs stiI1 in place. SELECTION
FIG. 3~. Fracture
1
R wr..fi+:,-
A\CUULl,I”II
OF CASES
UntiI recentIy the genera1 surgeon and genera1 practitioner have been concerned more with union than with functiohal resuIts. If in a case of fracture of the femur the patient couId waIk, even though he Iimped and had pain, the resuIt was considered good. Since cases of industria1 injury and automobiIe accidents have become more numerous, this is not a satisfactory functiona resuIt. We must consider whether or not the patient can resume his former occupation with sufficient function to perform his work without distress or pain. If the patient Iimps and has pain he does not consider himseIf functionaIIy normaI, even though union may be solid and approximation fair. Corrective measures must be taken in the first week or ten days by either the cIosed or open method. If the cIosed method is unsatisfactory during the first week there is stiI1 ampIe time for the open method. To wait for from six weeks to six months combecause during that matters, pIicates period some damage may have been done that cannot be corrected. It is our practice in the case of simpIe fracture to consider the cIosed reduction first. When this is not satisfactory we wait for from eight to ten days from the time of the fracture before doing open reduction. This aIIows time for sweIIing to decrease,
NEW SERIESVOL. IV, No. I
Jackson,
Cook-Open
bIood cIots to be absorbed, and smaI1 vesseIs to hea that may have been traumatized at the time of the fracture. At the end of ten days the tissues have deveIoped more resistance, and if extension has been carried on during this period, reduction is more easiIy accompIished and the tissues are in
FIG. 3b. Fracture
much better infection.
condition
of both
to combat
condyles
possibIe
COMMENT
Sherman,4 in more than 1300 cases of open reduction, found infection no more prevaIent than in any eIective operation. He repeatedIy emphasizes the necessity of correct technique. He considers the Iaparotomy technique of the genera1 surgeon not onIy insuffIcient but dangerous. GIoved hands shouId never come in contact with the skin or be introduced into the incision. Proper instruments wiII suffice for the necessary steps and Iessen the danger of contamination. He further maintains that open reduction is contraindicated except when the armamentarium and operative technique are avaiIabIe. Sherman has probabIy done more than any other one man to promote the suc1
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cessfu’l treatment of fracture. Acknowledgment is made to him for his wiIIingness in aiding us to gain more experience in this method of treatment, for improvement in our technique, and for suggestions regarding postoperative treatment. We are reporting here 9 cases from our
of Ieft humerus: after reduction.
series which represent the more common fractures that have been treated by the operative method. These are the more typica cases in which open reduction is easiIy done by the genera1 surgeon with proper armamentarium and technique. In the treatment of these cases pIates, boIts and naiIs were used. Our series is smaI1, but coming from a non-industria1 IocaIity it is of some vaIue, we trust, in showing the advantage of the open reduction when faciIities permit. REPORT
OF
CASES
CASE I. A woman, aged thirty-six, sustained a fracture of the cIavicIe on December 23, 1926, in an automobiIe accident. On December 28, after three unsuccessfu1 attempts at reduction, open reduction was done and a fourscrew Sherman pIate appIied. ConvaIescence was uneventfu1. On January 6, 1927, the patient Ieft the hospita1, and returned on
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b
a FIG. 4. ObIique
fracture
of upper
end
of uIna incIuding okranon b, after reduction.
from
shaft of left uIna: a, before
b
a FIG. 5. Fracture
JANUARY, 1928
of both bones of Icft forearm:
a, before
reduction;
b, after reduction.
reduction
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VW..IV, No. I
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Open
Cook-
March g for remova of the plate. On March 14, when she was dismissed from observation, function and position were norma (Fig. I).
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The
patient
Journal of
Surgery
63
Ieft the hospita1 on January 17, physiotherapy at the Chnic. was dismissed from observation
1924, to continue
When
she
b FIG. 6. Fracture
of neck of Ieft femur: a, before reduction;
CASE II. This patient feI1 on December 21, 1923, and broke the right humerus in the middie third. Her IocaI physician tried to reduce the fracture but was unabIe to maintain reduc-
b, after reduction.
on February 8, function perfect (Fig. 2).
7. Fracture
of middle
position
were
CASE III. A boy, aged seventeen, fell on February 18, IgIg, and struck the left elbow.
b
a
FIG.
and
third
of right
tion. After three unsuccessfu1 attempts she was brought to the Clinic, and on December 31 open reduction was done with a six-screw Sherman pIate. ConvaIescence was uneventfu1.
femur:
a, before
reduction;
b, after reduction.
Both condyIes of the Ieft humerus were fractured. On February 22 open reduction was done. One boIt was passed through both condyIes of the Ieft humerus. Convalescence was
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a
FIG. 8. Fracture
of lower third of right femur: a, before reduction;
b b, after reduction.
b
a
FIG. g. Transverse
JANUARY,
fracture
of left
pateIIa:
a, before
reduction;
b, after
reduction.
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uneventfu1. On March 3 he left the hospita1 and came to the CIinic for physiotherapy, and on ApriI 7 he was dismissed from observation with normaI function and position (Fig. 3). CASE IV. A man, aged thirty, was injured in a motorcyIe accident on ApriI 16, 1927. He sustained obIique fracture of the upper end of the ulna, incIuding the oIecranon, from the shaft of the Ieft uIna. It was impossibIe to maintain approximation of the fragments because of sweIIing and interposed tissue. On ApriI 26 open reduction was done; one Sherman screw was transfixed through the fragment to the shaft. Convaiescence was uneventfu1. On May 6 the patient Ieft the hospita1 and came to the CIinic for physiotherapy. He was dismissed with norma function and position (Fig. 4). CASE v. A woman, aged twenty-seven, feI1 down stairs on May 4, 1922, and fractured both bones of the Ieft forearm. Because of sweIIing, position couId not be maintained. On May 17 open reduction was done and a four-screw Sherman pIate appIied to the radius; the region of the uIna was not opened. ConvaIescence was uneventfu1. On June 7 the patient Ieft the hospita1 and came to the CIinic for physiotherapy. When she was dismissed from observation on JuIy 26 there was good function and position of the radius, and fair position of the uIna (Fig. 3). CASE VI. A woman, aged seventy-one, feI1 on the ice on February 6, 1916, and injured the Ieft hip and fractured the neck of the Ieft femur. Open reduction was done on February 14; the neck of the femur was naiIed through the greater trochanter to the head of the femur. ConvaIescence was uneventfu1. She Ieft the hospita1 on June 8, waIking; function was norma and there was no shortening (Fig. 6).
CASE VII. A boy, aged eight, in an automobiIe accident on September 4, 1924, fractured the middIe third of the right femur. Open reduction was done on September 18, and a four-screw Sherman pIate appIied. ConvaIescence was uneventfu1. He Ieft the hospita1 on October 3 and came to the CIinic for physiotherapy. By November 13 he was dismissed from observation with norma function and position (Fig. 7). CASE VIII. A girl, aged eIeven, was struck by an automobiIe on JuIy 23, 1924, and fractured the Iower third of the right femur. Two
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65
atTempts at reduction under the fluoroscope were unsuccessfu1. Open reduction was done on August 7, and a six-screw Sherman pIate was applied. ConvaIescence was uneventfu1. The patient Ieft the hospita1 on September 17, to continue physiotherapy at the CIinic. She \vas dismissed from observation on December 10 with norma function and position (Fig. 8). C.\SE IX. A man, aged fifty-five, feI1 on ApriI 12, 1923, whiIe crossing a raiIroad track and struck his Ieft knee on the rai1. He sustained transverse fracture of the Ieft pateIIa. Open reduction was done on ApriI 14, and the pateIIa was sutured. ConvaIescence was uneventfu1. He Ieft the hospita1 on June 27 and came to the CIinic for physiotherapy. He was dismissed from observation on JuIy IO with good position and 93 per cent function; there was about 3 per cent Iimitation in extension (Fig. 9). CONCLUSION$
From the resuks of our series of cases of open reduction it may be concIuded that: I. The open reduction with proper armamentarium and technique is no more dangerous than ordinary Iaparotomy. 2. It is Iess painfu1. 3. There is more certainty of the patient’s returning to his former occupation. 4. The patient returns to his work sooner than when the cIosed method is used. 5. There is Iess IikeIihood of the deveIopment of extensive caIIus, pain, and disabiIity. CASES SELECTED FOR TREATMENT Fractures Bone
Jpperl
I
Mid- Lower’ I die 1rhird Third rhird : TotaI /
Humerus........ Radius. Radius and uIna. UIna........... Femur, Tibia. Tibia and fibuIa. ClavicIe
PatelIa. TotaI.
~ I2
IO
26
: ~ 1: 8i 3 3 1 I6 0, 2 0 I 4
2
1:
4
-
-
0
II
7 3’
26 3 16
I2
IO
-
I22
7
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6. It is easier to obtain correct approximation, better weight-bearing, and function. 7. Open reduction is favorabIe to early manipuIation and motion. BIBLIOGRAPHY
I. ASHHURST, A. P. C., and CKOSSAN, E. T. Prognosis and treatment of fractures of the femur: report of one hundred and eIeven cases. Arch. Surg., 1926, xii, 453-493.
2. HITZROT, J. M. Fracture disrocation
at the shouIderjoint. Ann. Surg., 1926, Ixxxiii, 562-566.
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3. SHERMAN, W. 0. N. The CarreI method of wound sterikation: its use in mikary, industria1, and civi1 practice. Surg., Gynec., @ O&t., 1917, xxiv, 255-274. 4. SHERMAN, W. 0. N. The industria1 surgica1 probIem. Boston hf. w S. J., 1926, cxciv, 139-1.46. 5. SHERMAN, W. 0. N. Compound fractures of the femur and open fractures into joints. J. Bone C+_Y Joint Surg., 1924, vi, 344-349. 6. SHERMAN, W. 0. N. Operative treatment of fractures of the shaft of the femur with maximum fixation. J. Bone CT Joint Surg., 1926, viii, 494.