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The double pin method in the treatment of fractures of the tibia and fibula
THE DOUBLE PIN METHOD IN THE TREATMENT OF FRACTURES OF THE TIBIA AND FIBULA* MILTON
J.
WILSON,
AND
M.D.
Associate Professor of Orthopedic Surgery, MrdicaI
New York CoIIege and FIower Fifth Avenue Hospital
ALAN Instructor
R.
CANTWELL,
M.D.
in Orthopedics, New York Medical CoIIege
NEW YORK, NEW YORK
T
HE economic trends in the past few years and the introduction of speed mto our civilization have brought about rapid and drastic changes in our treatment of fractures invoIving the tibia and fibuIa. In 1937, fractures of both bones of the leg with displacement were being treated by the introduction of a singIe Steinman pin through the OS calcis and skeIeta1 tractionThis did not appea1 to us suspension. because it required weeks of recumbency in bed and proIonged hospitahzation. At this time many apparatuses for traction and distraction appeared on the market, so we decided to try the method. Instead of pIacing one Steinman pin through the OS caIcis for direct skeIeta1 traction we began to pIace an additiona pin through the upper end of the tibia in order to obtain distraction of the fragments. We beIieve, as do others, that too much emphasis has been pIaced on the open reduction of fractures for the purpose of accurately approximating bony fragments. In so doing the uItimate functiona results obtained by conservative measures have been lost sight of. Many men have so keyed their senses that nothing but a perfect anatomica reduction appeaIs to them. While anatomica reposition of the bones is desirable, it is not a prime requisite to a good functional resuIt. The x-ray has made us conscious of our inability to secure perfect anatomic resuIts, and has aIso made our patients conscious of sIight discrepancies which, as a matter of fact, are unimportant from a functiona stand point. * From the Orthopedic
and Fracture
Service
To quote Dr. Paul Magnuson, “ PIates do not reduce fractures. The fracture is reduced not by the apparatus but by the inteIIigent appIication of the fundamental principIes underIying the treatment. This impIies a knowIedge of the anatomy, pathoIogy, and the mechanica principles invoIved.” ROUTINE
PROCEDURES
I. Given a fracture of the tibia and fibuIa, preliminary immobiIization in a Thomas splint or two IateraI and one posterior bass wood splints to the upper thigh is necessary. If x-ray examination reveaIs a fracture of the shaft of the tibia and IibuIa with a tendency to displacement of the fragments, the patient is anesthetized under genera1 anesthesia. 2. The skin is prepared with iodine and aIcoho1 from the toes to the upper thigh. A Steinman pin is introduced through the OS caIcis by making a smaI1 vertica1 incision through the skin, one thumb’s breath beIow the externa1 (frbular) malleolus and on a Iine with the posterior margin of the fibuIa. The Steinman pin is then introduced through the OS caIcis with the aid of a Steinman pin holder. When the point is seen to protrude through the skin of the media1 aspect of the OS calcis, a simiIar vertica1 incision is made. If the incision penetrates too deepIy, a moderate amount of bIeeding occurs due to the venous anastomosis over the heel. A second pin is passed through the upper end of the tibia at the IeveI of the tibia1 tubercIe about one inch behind the anterior surface of the
of the Flower Fifth Avenue and MetropoIitan City. 445
Hospitals,
New \‘ork
446
American Journal of Surgery
W&on,
CantweII-DoubIe
bone. The Steinman pin wiI1 not produce pain unIess there is a drag on the skin. It is, therefore, important to check on the skin tension after the pins are inserted. FoIIowing the insertion of the Steinman pins the incisions are seaIed over with cotton impregnated with cohodion. No diffrcuIty wiI1 be experienced inserting the pins at these IeveIs if sufficient rotary pressure is used, because the bone of the OS caIcis offers no resistance to the introduction of the Steinman pin. However, if the pin is pIaced too low in the tibia, the hard cortica1 bone may bend the pin or break off its sharp point. These pins are stainIess steel and not vitaIlium. 3. The limb is then pIaced in the apparatus (MacMiIIan), and pins lixed in position. Traction is appIied to the dista1 pin through the OScaIcis. The proximal pin, through the upper end of the tibia merely maintains countertraction. Most cases are reduced with the aid of the Auoroscope. The fragments can be feIt by manipuIation; and if too much traction is made, the fracture Iine wiI1 gape. The reduction shouId be checked under the Auoroscope or by portabIe x-ray before the cast is applied. Rotation of the Iimb is checked by drawing a tape or narrow piece of bandage from the anterior superior iIiac spine to the cIeft between the first and second toes. This Iine shouId in most instances bisect the pateIIa. This, however, is compared with the normal Iimb. Posterior bowing is the most common deformity foIIowing reduction, but this can be corrected easiIy by wedging the cast. If a mechanica device is not avaiIabIe, the reduction may be accompIished by using a fracture tabIe. The patient is pIaced on the table, the symphysis pubis against the upright perineal bar. The distal pin is fastened to the foot piece and traction is made. The proxima1 pin is steadied with a pin cIamp or attached to the overhead bar on the fracture tabIe. A portabIe x-ray is taken to check on the reduction and to be certain that too much traction has not been apphed.
Pin Method
MAY, rgq*
4. Sheet wadding (splint cotton) is pIaced on the Ieg from the toes to the upper thigh. A circular pIaster of Paris cast is then appIied to the Ieg extending from the toes to the upper thigh, incorporating a thin moIded pIaster of Paris spIint. The pIaster is pIaced snugIy around the pins incorporating them hrmly in the cast. 5. The Iimb remains in the apparatus unti1 the cast is hard, usuaIIy about fifteen minutes. Ordinary corks are then pIaced over the sharp ends of the Steinman pins and fastened in position with pIaster bandage. After the patient is returned to his bed, the Iimb is elevated on piIIows to overcome the edema. 6. Further check-up x-rays may be taken after the pIaster is set. If the radiographic studies are satisfactory and the fragments are in good position, a waIking iron is incorporated in the cast and the patient is made ambuIatory in a few days. To give the patient added height, a shoe, not a sIipper, is worn on the we11 foot, and some weight bearing is then aIIowed on the fractured Iimb with the walking iron. These patients are usuaIIy ready for discharge in about eight or ten days. MentaI, economic and a famiIia1 hazards are overcome, and when advised as to earIy discharge we find that patients are more co-operative. UsuaIIy the cast and the pins are removed at the end of six weeks and the amount of motion at the site of fracture is estimated. It may be graded one, two, three or four pIus in both anteroposterior and IateraI directions. Very rareIy union is lirm at the sixth week, more frequentIy it is two plus in both directions. A new cast is now appIied extending from the toe to the midthigh at this time. Very IittIe wadding is used, usuaIIy a stockinette, with a turn of splint cotton around the ankIe, knee and upper thigh. At the end of three weeks, the patient is re-examined. If no motion is present, a circuIar cast is appIied from the knee to the ankIe and weight bearing increased. If the amount of motion remains stationary for a period of live to six weeks, the case is considered to be one of delayed
~~~ sERIEsvol. LVI. No. 2 Wilson,
Cantwell-Double
union. A drihing operation is then performed to stimuIate caIIus formation. There is no hard and fast ruIe as to the length of time it takes a fractured tibia to unite. Except in chiIdren, the time varies from eight to tweIve weeks. Compound fractures, however, may take as Iong as sixteen weeks. One case in our series resuIted in nonunion because of the Ioss of a large fragment of bone at the time of injury. This case eventuahy came to surgery, bony union taking pIace fohowing a sliding bone inlay operation. In compound fractures in which doubIe Steinman pins are indicated, they are introduced before the dkbridement is done. The fracture, however, is not reduced until after the wound has been thoroughly irrigated. Plenty of warm sahne, in an irrigating can and not a buIb syringe, is used to hood and wash out the wound properIy. QuestionabIe devitaIized tissue is removed. The skin edges are aIways resected, i.e., a thin edge of skin is removed with a scaIpe1. Those compound fractures operated upon within six hours of injury are cIosed primarily. The skin only is sutured with interrupted bIack siIk. No drains are used. In our series no surfanilamide nor prophyIactic gas grangrene antitoxin was used. Tetanus r,soo to 3,000 units, is given antitoxin, intramuscuIarIy. WhiIe we give tetanus antitoxin routinely, we no longer advocate prophylactic gas antitoxin. Since we have been treating our compound fractures by the doubIe pin method, debridement and plaster encasement, we have not observed any gas bacihus infection. We are convinced that compIete rest of the wound in pIaster of Paris prevents further irritation to already injured tissues. In December, 1940, we reported results obtained in a series of eighty-five consecutive cases of compound fractures. Fortythree of these were treated by primary immediate closure of the wound. TWO of these patients developed infections. One patient not infected died. SuIfaniIamide, by mouth was used in onIy one case.
Pin
Method
A me&an
Journal of Surgery
447
Since September, 1937, we have treated eighty-nine patients by the doubIe pin method at the FIower-Fifth Avenue Hospitals and the MetropoIitan Hospital, New York City. We beIieve that the resuIts have been uniformIy good. There has been no case of pin infection. The ambuIatory treatment has not interfered with the fracture healing and yet has markedly reduced the cost of hospitaIization. At this time of nationa hysteria, when methods for the management of civilian casuaIties are to be considered, this method for handIing slipping fractures of the tibia and libuIa offers a timely solution. It is simple and rapid in execution. The patients are made ambuIatory earIy and the hospitalization time is short. SUMMARY
In fractures of the tibia and hbula with displacement, and those that have a tendency toward dispIacement, the double pin method is indicated. The advantages of this method are: (I) uniformity of procedure; (2) no operative team is necessary. EIaborate technic for reduction of fracture is done away with. (3) In our series, there has been no case of infection at the site of the Steinman pins. (4) Inasmuch as this method produces firm fixation, it has a particular advantage in the treatment of compound fractures. (5) The time and cost of hospitaIization have been drasticaIIy reduced as compared with previous methods employed. (6) With the use of the double pin method we obtain firm immobilization of the fractured fragments as compared to the previous method of skeletal traction--suspension with one pin through the OS calcis. REFERENCES K. A. and HOLMES, G. CV. Double pin skeIeta1 fixation in fractures of the leg. Sur,q., Gynec. e* Obst., 68: 573-575, 1939. hlac~uso~, P. Anatomy versus gadgets in fracture reduction digest of treatment. Vol. 3, no. 9. p. 8o, &larch, 1940. Bulletin, New York MedicaI CoIlege-Flower and Fifth Avenue Hospitals. Vol. 3, no. 4, pp. 219-222, December, r94.o.
GRISWOLD,
J.
WILSON,
AND
M.D.
Associate Professor of Orthopedic Surgery, MrdicaI
New York CoIIege and FIower Fifth Avenue Hospital
ALAN Instructor
R.
CANTWELL,
M.D.
in Orthopedics, New York Medical CoIIege
NEW YORK, NEW YORK
T
HE economic trends in the past few years and the introduction of speed mto our civilization have brought about rapid and drastic changes in our treatment of fractures invoIving the tibia and fibuIa. In 1937, fractures of both bones of the leg with displacement were being treated by the introduction of a singIe Steinman pin through the OS calcis and skeIeta1 tractionThis did not appea1 to us suspension. because it required weeks of recumbency in bed and proIonged hospitahzation. At this time many apparatuses for traction and distraction appeared on the market, so we decided to try the method. Instead of pIacing one Steinman pin through the OS caIcis for direct skeIeta1 traction we began to pIace an additiona pin through the upper end of the tibia in order to obtain distraction of the fragments. We beIieve, as do others, that too much emphasis has been pIaced on the open reduction of fractures for the purpose of accurately approximating bony fragments. In so doing the uItimate functiona results obtained by conservative measures have been lost sight of. Many men have so keyed their senses that nothing but a perfect anatomica reduction appeaIs to them. While anatomica reposition of the bones is desirable, it is not a prime requisite to a good functional resuIt. The x-ray has made us conscious of our inability to secure perfect anatomic resuIts, and has aIso made our patients conscious of sIight discrepancies which, as a matter of fact, are unimportant from a functiona stand point. * From the Orthopedic
and Fracture
Service
To quote Dr. Paul Magnuson, “ PIates do not reduce fractures. The fracture is reduced not by the apparatus but by the inteIIigent appIication of the fundamental principIes underIying the treatment. This impIies a knowIedge of the anatomy, pathoIogy, and the mechanica principles invoIved.” ROUTINE
PROCEDURES
I. Given a fracture of the tibia and fibuIa, preliminary immobiIization in a Thomas splint or two IateraI and one posterior bass wood splints to the upper thigh is necessary. If x-ray examination reveaIs a fracture of the shaft of the tibia and IibuIa with a tendency to displacement of the fragments, the patient is anesthetized under genera1 anesthesia. 2. The skin is prepared with iodine and aIcoho1 from the toes to the upper thigh. A Steinman pin is introduced through the OS caIcis by making a smaI1 vertica1 incision through the skin, one thumb’s breath beIow the externa1 (frbular) malleolus and on a Iine with the posterior margin of the fibuIa. The Steinman pin is then introduced through the OS caIcis with the aid of a Steinman pin holder. When the point is seen to protrude through the skin of the media1 aspect of the OS calcis, a simiIar vertica1 incision is made. If the incision penetrates too deepIy, a moderate amount of bIeeding occurs due to the venous anastomosis over the heel. A second pin is passed through the upper end of the tibia at the IeveI of the tibia1 tubercIe about one inch behind the anterior surface of the
of the Flower Fifth Avenue and MetropoIitan City. 445
Hospitals,
New \‘ork
446
American Journal of Surgery
W&on,
CantweII-DoubIe
bone. The Steinman pin wiI1 not produce pain unIess there is a drag on the skin. It is, therefore, important to check on the skin tension after the pins are inserted. FoIIowing the insertion of the Steinman pins the incisions are seaIed over with cotton impregnated with cohodion. No diffrcuIty wiI1 be experienced inserting the pins at these IeveIs if sufficient rotary pressure is used, because the bone of the OS caIcis offers no resistance to the introduction of the Steinman pin. However, if the pin is pIaced too low in the tibia, the hard cortica1 bone may bend the pin or break off its sharp point. These pins are stainIess steel and not vitaIlium. 3. The limb is then pIaced in the apparatus (MacMiIIan), and pins lixed in position. Traction is appIied to the dista1 pin through the OScaIcis. The proximal pin, through the upper end of the tibia merely maintains countertraction. Most cases are reduced with the aid of the Auoroscope. The fragments can be feIt by manipuIation; and if too much traction is made, the fracture Iine wiI1 gape. The reduction shouId be checked under the Auoroscope or by portabIe x-ray before the cast is applied. Rotation of the Iimb is checked by drawing a tape or narrow piece of bandage from the anterior superior iIiac spine to the cIeft between the first and second toes. This Iine shouId in most instances bisect the pateIIa. This, however, is compared with the normal Iimb. Posterior bowing is the most common deformity foIIowing reduction, but this can be corrected easiIy by wedging the cast. If a mechanica device is not avaiIabIe, the reduction may be accompIished by using a fracture tabIe. The patient is pIaced on the table, the symphysis pubis against the upright perineal bar. The distal pin is fastened to the foot piece and traction is made. The proxima1 pin is steadied with a pin cIamp or attached to the overhead bar on the fracture tabIe. A portabIe x-ray is taken to check on the reduction and to be certain that too much traction has not been apphed.
Pin Method
MAY, rgq*
4. Sheet wadding (splint cotton) is pIaced on the Ieg from the toes to the upper thigh. A circular pIaster of Paris cast is then appIied to the Ieg extending from the toes to the upper thigh, incorporating a thin moIded pIaster of Paris spIint. The pIaster is pIaced snugIy around the pins incorporating them hrmly in the cast. 5. The Iimb remains in the apparatus unti1 the cast is hard, usuaIIy about fifteen minutes. Ordinary corks are then pIaced over the sharp ends of the Steinman pins and fastened in position with pIaster bandage. After the patient is returned to his bed, the Iimb is elevated on piIIows to overcome the edema. 6. Further check-up x-rays may be taken after the pIaster is set. If the radiographic studies are satisfactory and the fragments are in good position, a waIking iron is incorporated in the cast and the patient is made ambuIatory in a few days. To give the patient added height, a shoe, not a sIipper, is worn on the we11 foot, and some weight bearing is then aIIowed on the fractured Iimb with the walking iron. These patients are usuaIIy ready for discharge in about eight or ten days. MentaI, economic and a famiIia1 hazards are overcome, and when advised as to earIy discharge we find that patients are more co-operative. UsuaIIy the cast and the pins are removed at the end of six weeks and the amount of motion at the site of fracture is estimated. It may be graded one, two, three or four pIus in both anteroposterior and IateraI directions. Very rareIy union is lirm at the sixth week, more frequentIy it is two plus in both directions. A new cast is now appIied extending from the toe to the midthigh at this time. Very IittIe wadding is used, usuaIIy a stockinette, with a turn of splint cotton around the ankIe, knee and upper thigh. At the end of three weeks, the patient is re-examined. If no motion is present, a circuIar cast is appIied from the knee to the ankIe and weight bearing increased. If the amount of motion remains stationary for a period of live to six weeks, the case is considered to be one of delayed
~~~ sERIEsvol. LVI. No. 2 Wilson,
Cantwell-Double
union. A drihing operation is then performed to stimuIate caIIus formation. There is no hard and fast ruIe as to the length of time it takes a fractured tibia to unite. Except in chiIdren, the time varies from eight to tweIve weeks. Compound fractures, however, may take as Iong as sixteen weeks. One case in our series resuIted in nonunion because of the Ioss of a large fragment of bone at the time of injury. This case eventuahy came to surgery, bony union taking pIace fohowing a sliding bone inlay operation. In compound fractures in which doubIe Steinman pins are indicated, they are introduced before the dkbridement is done. The fracture, however, is not reduced until after the wound has been thoroughly irrigated. Plenty of warm sahne, in an irrigating can and not a buIb syringe, is used to hood and wash out the wound properIy. QuestionabIe devitaIized tissue is removed. The skin edges are aIways resected, i.e., a thin edge of skin is removed with a scaIpe1. Those compound fractures operated upon within six hours of injury are cIosed primarily. The skin only is sutured with interrupted bIack siIk. No drains are used. In our series no surfanilamide nor prophyIactic gas grangrene antitoxin was used. Tetanus r,soo to 3,000 units, is given antitoxin, intramuscuIarIy. WhiIe we give tetanus antitoxin routinely, we no longer advocate prophylactic gas antitoxin. Since we have been treating our compound fractures by the doubIe pin method, debridement and plaster encasement, we have not observed any gas bacihus infection. We are convinced that compIete rest of the wound in pIaster of Paris prevents further irritation to already injured tissues. In December, 1940, we reported results obtained in a series of eighty-five consecutive cases of compound fractures. Fortythree of these were treated by primary immediate closure of the wound. TWO of these patients developed infections. One patient not infected died. SuIfaniIamide, by mouth was used in onIy one case.
Pin
Method
A me&an
Journal of Surgery
447
Since September, 1937, we have treated eighty-nine patients by the doubIe pin method at the FIower-Fifth Avenue Hospitals and the MetropoIitan Hospital, New York City. We beIieve that the resuIts have been uniformIy good. There has been no case of pin infection. The ambuIatory treatment has not interfered with the fracture healing and yet has markedly reduced the cost of hospitaIization. At this time of nationa hysteria, when methods for the management of civilian casuaIties are to be considered, this method for handIing slipping fractures of the tibia and libuIa offers a timely solution. It is simple and rapid in execution. The patients are made ambuIatory earIy and the hospitalization time is short. SUMMARY
In fractures of the tibia and hbula with displacement, and those that have a tendency toward dispIacement, the double pin method is indicated. The advantages of this method are: (I) uniformity of procedure; (2) no operative team is necessary. EIaborate technic for reduction of fracture is done away with. (3) In our series, there has been no case of infection at the site of the Steinman pins. (4) Inasmuch as this method produces firm fixation, it has a particular advantage in the treatment of compound fractures. (5) The time and cost of hospitaIization have been drasticaIIy reduced as compared with previous methods employed. (6) With the use of the double pin method we obtain firm immobilization of the fractured fragments as compared to the previous method of skeletal traction--suspension with one pin through the OS calcis. REFERENCES K. A. and HOLMES, G. CV. Double pin skeIeta1 fixation in fractures of the leg. Sur,q., Gynec. e* Obst., 68: 573-575, 1939. hlac~uso~, P. Anatomy versus gadgets in fracture reduction digest of treatment. Vol. 3, no. 9. p. 8o, &larch, 1940. Bulletin, New York MedicaI CoIlege-Flower and Fifth Avenue Hospitals. Vol. 3, no. 4, pp. 219-222, December, r94.o.
GRISWOLD,