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The use of internal fixation in compound fractures
THE USE OF JNTERNAL FIXATION IN COMPOUND FRACTURES* BARBARA
B.
STIMSON,
M.D.
Assistant Professor of Clinical Orthopedic Surgery, College of Physicians and Surgeons, Columbia University; Associate Attending Surgeon, Presbyterian Hospital andvanderbik Clinic New York, New York With this purpose in mind an anaIysis has been made of the compound fractures of the shafts of femur and tibia treated on the Fracture Service of the Columbia-Presbyterian Medical Center for the years 1932 through 1942
OMPOUND fractures can be pIated. Whether they should be so treated is c stiII a matter for debate. Many arguments for and against have been heard, especially during the war years, and it seemed wise
B
A
FIG. I. A and
B,
to see if impressions could be substantiated facts or if a revision of these impressions necessary.
original injury, compound
fracture.
incIusive. As there is no ambuIance service for the hospita1 the number of such cases from I932 through 1941 is smaII. In 1942, a study of com-
by was
* From the Fracture Service of The Presbyterian HospitaI and the Department of Orthopedic Surgery, College of Physicians
and Surgeons, Columbia 697
University,
New York City.
American
Journal
of
Surgery
Stimson-InternaI
Fixation
947
VW_. IAXIV.
No.
5
Stimson--Internal
Fixation
American
Journal
of Surgrry
699
7-o
Stimson-Internal
American Journal of Surgery
Fixation
D
FIG.
2.
D, result;
all
wounds
pound fractures was made for the Sub-Committee on SurgicaI Infections of the NationaI Research Council and cases were brought from al1 over the city, hence the Iarger number treated. (Table I.) What is the rationaIe underlying the use of meta pIates and screws for fixation of a compound fracture? If the bone ends are rigidIy fixed, further damage to the surrounding soft parts is eliminated. Without rigid fixation any slight motion of the jagged fracture wiI1 tear tissue and cause further bIeeding which, aIthough minute in amount, may be sufficient to lower the IocaI tissue resistance and provide a suitabIe medium for bacterial growth. This is not theory. The writer has seen infected compound fractures in which the systemic reaction and the drainage dropped to a minimum as soon as the sIight amount of movement at the fracture site was eIiminated by a pIate. In one such case the patient, who had been running a septic temperature and had no appetite because of pain, announced as soon as he had recovered from the anesthesia “the pain has gone-when can I eat?” His subsequent course
healed with full function.
was entirely uneventfu1 except for the pre-existing and easiIy controlled IocaI osteomyelitis. Rigid internal fixation also reduces the necessity of worrying about subsequent deformity. (Fig. I.) Norma1 length and axes are maintained without the need, for readjustment of apparatus or pIaster. There have been no cases of non-union in this series in which the fixation was rigid. Is the method safe? That is the first question to be answered in evaIuating a method of treatment. During the period under review there were no deaths in any way attributabIe to the use of internal fixation. There was one case of spreading infection necessitating amputation. This case wiI1 be discussed in detail later..Therewere minor disasters (Table I) Iike broken pIates and refractures but none that jeopardized life or Iimb. It is justifiabIe, therefore, to consider the method worthy of further anaIysis. One of the principal arguments against the use of interna fixation is that it introduces or promotes infection. There are enough recorded cases of infection foIIowing plating to make this
V<,I
Stimson--Internal
LXXIV, NO. F
Fixation
AwericilnJo~trwrl(115~ra:rr.v
“0
I
no idle criticism. But the metal, if properly sterilized, does not in itseIf introduce bacteria nor does it provide a medium for their growth. If, however, it is improperly applied so that motion occurs and erosion of bone around the screws takes place, bacteria will muhiply in the areas of necrosis so formed. The result is at best a low grade Iocalized osteomyehtis, at worst a spreading infection. But the fault lies not with the metal but with the surgeon. It took us a Iong time to learn that an adequate length of plate and one or more transfixion screws to stop torsion strain were necessary and the two nonunions were a result of our ignorance. Transhxion screws were not used in our series until late in 1938. The amount of meta used, if rigidly applied with even distribution of strain upon the screws, does not increase nor predispose to infection. (Fig. 2.) TABLE I FRACTURES-FEMUR AND TIBIA-65 TOTALCOMPOUND 1932-4r-30 ‘942-35
Deaths--4 Children not included-6 Deaths-3 Children not included-z Cases anaIysed-zo ‘932-4’ Internal fixation-r6 ’ 942 Cases analysed-3o InternaI fixation-2 1 Pin fixation-9
I Disasters.
None
I
I
I
2
0
0
I __-._ Amputations.. Non-union. Broken plates.. Refractures. Sequestrectomy
---
I:
’ 942
Internal Fixation
Internal Fixation
-
T
1932-41
None
___
; I
0
0
2 6
o 2
-.___ 1942
‘5
i Rigidity is, therefore, the first principIe underlying the use of internal fixation in compound fractures. Piates of adequate length, screws through both cortices pIaced at right angIes to the pIate and inserted through drill holes of the correct diameter, and transfixion screws across the fracture line, all are essential features of fixation. If there is Ioss of bone
FIG. 3. Compound wound healed except area showing exposed plate; no infection.
for small
substance or marked comminution, other methods of treatment of the fracture should be seriously considered. If rigidity has been obtained, the need for external splmting has been reduced to a minimum and maintenance of function of the adjacent joints can be accomplished with the concomittant improvement of circulation and muscle action. Wound heahng in these cases is much more rapid than if circulatory stasis and edema persist. The initial treatment of the compound wound in all the cases analysed was essentially the same. Surgical debridement and copious lavage with water or saline was done in each case. Separate instruments were used for the plating and gloves and gowns were changed. From 1932 through 1941 a11 wounds were left open with sutures pIaced but not tied. Most of them were packed with Vaseline gauze. The
702
American
Journal
of Surgery
Stimson-InternaI
sutures were tied, usualIy without anesthetic, in from four to ten days, in no case compIetely closing the skin edges. Healing was uniformly sIow, pinch grafts being necessary in a majority of the cases. In the 1942 series, because of the nature of the study, some of the wounds were closed initiaIIy. The resuIts are tabulated in TabIe II. Where rigid fixation was not obtained and where pIaster encasement were required, the healing was deIayed. TABLE II WOUND HEALING-1942 INITIAL CLOSURE InternaI Fixation I (0) healed at 21 days I (S) healed at 21 days I (S) healed at 25 days I (0) healed at 9 days, broke down 7 weeks I (0) healed at 8% months months I (S) healed at 9 I (S) not heaIed 3 years Pins I (S) healed 2% months months I (S) healed 3 I (S) healed 3% months months I (S) heaIed 4 I (S) healed 4% months 0 = No chemotherapy S = SuIfaniIamide in wound and orally
In a number of cases the wounds, though not cIinicalIy infected, did not hea compIeteIy unti1 the hardware was removed. (Fig. 3.) Because of the position of the compound wound pIates and screws were pIaced on the bone surface presenting to avoid excess exposure. Such plates are used as temporary splints and remova after the fracture has united is not considered a faiIure of the method. Chemotherapy in the Iight of present experience is not discussed because it was not used. Undoubtedly peniciIIin and other antibiotics make the surgeon sIeep better at night but repIace neither careful surgery nor mechanica principles. The case mentioned earIier in which amputation was necessary had an undkbrided and undrained area of damaged tissue in the posterior compartment of the leg and had the fascia1 layers sutured over the plate. Five days Iater the wound was wideIy opened and the necrotic muscIe excised. Gas-forming organisms were found in the excised tissues. In spite of wide excision the mixed infection was not controIIed and amputation was performed six weeks Iater. This result was due to inadequate d&bridement and tight closure. The presence of
Fixation
NOYEM,J~H, ,<,1-
the meta did not jeopardize the management of the infection but actuaIIy made it easier. The foIIow-up resuIts of five years or more are shown in TabIe III. In order to incIude some of the experience gained in the war the writer (thanks to the courtesy of coIIeagues in Great Britain) has been abIe to obtain Iate results on fourteen war injuries of femur and tibia that had some form of interna fixation. The operations were perTABLE III RESULTS ‘932-1942 T
Interna Fixation
4-4-4 3-4-4 4-3-4 3-3-4 3-3-3
10
9 2 9
2 2 2
Death due to other causes.. Amputations. Lost...........................
i-
-
In recording foltow-up figures the findings are listed according to anatomic, functional and economic results: 4 = roe%, 3 = 75 to 99%.
formed at intervaIs varying from three days to six weeks after wounding, usuaIIy through a separate incision. AI1 wounds were Ieft open for five days then sutured under an anesthetic. There were no deaths, no amputations, no spreading infections and no non-unions. Of the nine compound fractured femurs four were stiII in the army in 1947. The other five were employed at fuI1 time jobs but two had Iimited knee motion. These two had been in pIaster spicas for some months. AI1 wounds were soIidIy healed. The five men with compound fractures of the tibia were a11empIoyed but two had limitation of knee motion. Four of the fourteen had received systemic penicillin but almost a11 had had calcium peniciIIin suIfathiazole powder in the wounds. AIthough these figures are too smaI1 to warrant sweeping generalizations, after anaIysis of the cases used for this paper the writer is of the firm conviction that certain compound fractures of the Iower extremity should be plated. The criteria essentia1 for satisfactory results are correct surgica1 treatment of the
VIM. LXXIV,
wound
Stimson-Internal
No. 5
which
should
include
no initia1
skin
closure but adequate suture under anesthetic at five days and rigid mechanical fixation of the fracture. In conclusion, the impressions gathered over the past eighteen years have been strengthened b? this study. Compound fractures of the shafts ot femur and tibia, suitably selected and properly plated, are best treated by internal fixation. DISCUSSION
HENRY C. MARBLE (Boston, Mass.): I want to say that I consider this a privilege and an honor. This is the first paper that has ever been presented to this Society by a lady member and this is the first lady member. I read her paper and I was reminded then onIy of the first time that this matter was proposed in my surgical experience. Dr. O’NeiII Sherman, of Pittsburgh, gave a paper not unlike this before a part of the American College of Surgeons, and I believe it was in Montreal. Dr. Sherman finished his paper and the audience arose aImost to a man and what happened to Dr. Sherman was very much like what happened to the merchant of Venice. They tore his raiment, they spit on his garline, and when he was through, with one or two notable exceptions, poor Dr. Sherman’s paper was torn to bits. Two or three decades have brought about a wondrous change, and now Dr. Stimson comes and reiterates what Dr. Sherman then said and we sit here quietly and bIandIy in our seats and agree. Of course, one cannot but agree with what she has said. There are several factors which we have learned in these years. The first factor is how to do a proper, careful, accurate debridement. I might add that Dr. Stimson did not teI1 you but she probably does it-nameIy, that portions of the dbbrided tissue may to advantage be put into test tubes and subjected to the bacteriologist’s wiles to see if they are benign or if they are maIignant. It is a great comfort to have the bacteriologist tell you the day after you have sewn up such a fracture that as far as he can see, there are no cIostridia1 organisms and not too many streptococci in the wound, aIthough parentheticaIIy I have had gas-forming organisms in wounds in which there was no clincial evidence whatsoever. However, that is good for peace of mind. We have also added to our armamentarium certain other drugs which Dr. Stimson says make her sIeep better. Peace of mind for a surgeon is a grand thing. Off the record, sulfa drugs do not give me peace of mind, and giving a11 of my patients penicillin does not help my peace of mind either. I Firmly believe that a careful, thorough, painstaking
Fixation
American
Journnl
of Surgrry
“03
carefuIIy controlled by bacteriodkbridement, Iogic test, wiI1 give you a11 the peace of mind you need. If the bacteriologist shows you that there are organisms in there that require attention, then we have the sulfa drugs and we also have peniciIIin. Added to that, we then must fix the fracture, as she has toId you, and we must close the wound. 1 want to add that in closing the tibia1 wounds, which I think are difficult, the old expedient, which Dr. Fred Cotton taught me, of making lateral incisions far to the side of the leg so that the tibia1 wound over the pIate can be compIeteIy closed, is useful and helpful and these lateral incisions can then or Iater be closed by skin graft. OSCAR P. HAnlnroN, JR. (St. Louis, Mo.): It is a privilege to discuss Dr. Stimson’s paper. It was my privilege to see some of her excellent work in Italy. When the American Army turned down Major Barbara Stimson, with a11 of her knowIedge of bone and joint surgery, it was a British gain, because she certainty contributed a great deal to the management of soldiers of the British Army who were bone and joint casuaIties. I might say that, without disrespect to our British aIIies, she certainly rocked them on their heeIs in the earIy days because she wanted to put metal on bone in compound fractures. That was heresy. When she came to North Africa but after she had moved to ItaIy and carried on there, others of the British MedicaI Corps were doing it, too. She carried her point and her concepts wcrc we11 received when she was through. Of course, the use of hardware in compound fractures really requires consideration in two phases. ReIativeIy speaking, its use in fractures soon after injury has been accepted. I say “rclatively speaking.” There are still some who do not or wouId not use it, but there are many others who aIways or frequently do. 1 wouId like to point out that in her use of the metal in compound battle fractures, Dr. Stimson was placing this meta in compound wounds several days, perhaps several weeks, after wounding. I know that she thought the idea1 time was five days after wounding, but the majority of the internal fixation were done from tive to ten days after wounding. I believe we can draw an anaIogy to comparable fractures seen in civiIian life. We receive them from distant places or we may have them under our care from the beginning. Unreduced fractures with open wounds, Iivc to ten days after injury-that is the problem. Now, Dr. Stimson stated it frankly, that the problem of the use of metal presents itseIf in this way: Does it produce infection? I would like to present again for your consideration the concept that wound sepsis results from the septic decomposition of dead tissue, including blood clot in dead space. ParticuIarIy is this true in the presence an effective antibacterial agent to protect Iiving
704
American Journal of Surgery
Stimson--Internal
tissue from invasive infection of organisms recognized as stiIl present in the retained devitalized tissue and in the open wound; so that if a wound can be rid of devitalized tissue by a meticulous dgbridement, of which Dr. Marble spoke, and the surgery is good enough to put on the metal without creating additiona devitalized tissue and to eliminate residual dead space, how is the meta going to predispose to sepsis. It does not if this concept is accepted. I wouId like to speak briefly about the use of meta in septic wounds. Often, the rigid internal fixation of a fracture may be an important factor in overcoming a septic compound fracture. A septic compound fracture presents two probIems: one, contro1 of sepsis and wound heaIing; the other, maintenance of reduction of the fracture projected toward healing in as near an anatomic position as possibIe. Now, if one accepts the concept which I outlined, the use of meta is not going to proIong that sepsis
Fixation
NOYEMBBH,,941
and, as Dr. Stimson said, by holding the fragments stiI1, continuing trauma and subsequent devitalized tissue is minimized. I aIso wouId Iike to point out that dead space about the unreduced fracture is eIiminated. BARBARA B. STIWSON (cIosing): I want to thank the discussers for their courteous handIing of the paper. I agree entireIy with Dr. MarbIe that skin closure is essential as soon as it is safe. We found that in five days, most of the very bad wounds couId be cIosed with not much tension. We have used the Iateral reIeasing incisions with a great dea1 of interest and help, because I agree with him that it is essentia1 to cover the tibia, if possibIe. Of course, I agree with Dr. Hampton. We have seen a number of septic compound fractures that progressed very satisfactoriIy with the use of interna fixation. We have pIated them at a month and a month and a half, in the presence of pus, and the bones unite and the sepsis is controIIed.
B.
STIMSON,
M.D.
Assistant Professor of Clinical Orthopedic Surgery, College of Physicians and Surgeons, Columbia University; Associate Attending Surgeon, Presbyterian Hospital andvanderbik Clinic New York, New York With this purpose in mind an anaIysis has been made of the compound fractures of the shafts of femur and tibia treated on the Fracture Service of the Columbia-Presbyterian Medical Center for the years 1932 through 1942
OMPOUND fractures can be pIated. Whether they should be so treated is c stiII a matter for debate. Many arguments for and against have been heard, especially during the war years, and it seemed wise
B
A
FIG. I. A and
B,
to see if impressions could be substantiated facts or if a revision of these impressions necessary.
original injury, compound
fracture.
incIusive. As there is no ambuIance service for the hospita1 the number of such cases from I932 through 1941 is smaII. In 1942, a study of com-
by was
* From the Fracture Service of The Presbyterian HospitaI and the Department of Orthopedic Surgery, College of Physicians
and Surgeons, Columbia 697
University,
New York City.
American
Journal
of
Surgery
Stimson-InternaI
Fixation
947
VW_. IAXIV.
No.
5
Stimson--Internal
Fixation
American
Journal
of Surgrry
699
7-o
Stimson-Internal
American Journal of Surgery
Fixation
D
FIG.
2.
D, result;
all
wounds
pound fractures was made for the Sub-Committee on SurgicaI Infections of the NationaI Research Council and cases were brought from al1 over the city, hence the Iarger number treated. (Table I.) What is the rationaIe underlying the use of meta pIates and screws for fixation of a compound fracture? If the bone ends are rigidIy fixed, further damage to the surrounding soft parts is eliminated. Without rigid fixation any slight motion of the jagged fracture wiI1 tear tissue and cause further bIeeding which, aIthough minute in amount, may be sufficient to lower the IocaI tissue resistance and provide a suitabIe medium for bacterial growth. This is not theory. The writer has seen infected compound fractures in which the systemic reaction and the drainage dropped to a minimum as soon as the sIight amount of movement at the fracture site was eIiminated by a pIate. In one such case the patient, who had been running a septic temperature and had no appetite because of pain, announced as soon as he had recovered from the anesthesia “the pain has gone-when can I eat?” His subsequent course
healed with full function.
was entirely uneventfu1 except for the pre-existing and easiIy controlled IocaI osteomyelitis. Rigid internal fixation also reduces the necessity of worrying about subsequent deformity. (Fig. I.) Norma1 length and axes are maintained without the need, for readjustment of apparatus or pIaster. There have been no cases of non-union in this series in which the fixation was rigid. Is the method safe? That is the first question to be answered in evaIuating a method of treatment. During the period under review there were no deaths in any way attributabIe to the use of internal fixation. There was one case of spreading infection necessitating amputation. This case wiI1 be discussed in detail later..Therewere minor disasters (Table I) Iike broken pIates and refractures but none that jeopardized life or Iimb. It is justifiabIe, therefore, to consider the method worthy of further anaIysis. One of the principal arguments against the use of interna fixation is that it introduces or promotes infection. There are enough recorded cases of infection foIIowing plating to make this
V<,I
Stimson--Internal
LXXIV, NO. F
Fixation
AwericilnJo~trwrl(115~ra:rr.v
“0
I
no idle criticism. But the metal, if properly sterilized, does not in itseIf introduce bacteria nor does it provide a medium for their growth. If, however, it is improperly applied so that motion occurs and erosion of bone around the screws takes place, bacteria will muhiply in the areas of necrosis so formed. The result is at best a low grade Iocalized osteomyehtis, at worst a spreading infection. But the fault lies not with the metal but with the surgeon. It took us a Iong time to learn that an adequate length of plate and one or more transfixion screws to stop torsion strain were necessary and the two nonunions were a result of our ignorance. Transhxion screws were not used in our series until late in 1938. The amount of meta used, if rigidly applied with even distribution of strain upon the screws, does not increase nor predispose to infection. (Fig. 2.) TABLE I FRACTURES-FEMUR AND TIBIA-65 TOTALCOMPOUND 1932-4r-30 ‘942-35
Deaths--4 Children not included-6 Deaths-3 Children not included-z Cases anaIysed-zo ‘932-4’ Internal fixation-r6 ’ 942 Cases analysed-3o InternaI fixation-2 1 Pin fixation-9
I Disasters.
None
I
I
I
2
0
0
I __-._ Amputations.. Non-union. Broken plates.. Refractures. Sequestrectomy
---
I:
’ 942
Internal Fixation
Internal Fixation
-
T
1932-41
None
___
; I
0
0
2 6
o 2
-.___ 1942
‘5
i Rigidity is, therefore, the first principIe underlying the use of internal fixation in compound fractures. Piates of adequate length, screws through both cortices pIaced at right angIes to the pIate and inserted through drill holes of the correct diameter, and transfixion screws across the fracture line, all are essential features of fixation. If there is Ioss of bone
FIG. 3. Compound wound healed except area showing exposed plate; no infection.
for small
substance or marked comminution, other methods of treatment of the fracture should be seriously considered. If rigidity has been obtained, the need for external splmting has been reduced to a minimum and maintenance of function of the adjacent joints can be accomplished with the concomittant improvement of circulation and muscle action. Wound heahng in these cases is much more rapid than if circulatory stasis and edema persist. The initial treatment of the compound wound in all the cases analysed was essentially the same. Surgical debridement and copious lavage with water or saline was done in each case. Separate instruments were used for the plating and gloves and gowns were changed. From 1932 through 1941 a11 wounds were left open with sutures pIaced but not tied. Most of them were packed with Vaseline gauze. The
702
American
Journal
of Surgery
Stimson-InternaI
sutures were tied, usualIy without anesthetic, in from four to ten days, in no case compIetely closing the skin edges. Healing was uniformly sIow, pinch grafts being necessary in a majority of the cases. In the 1942 series, because of the nature of the study, some of the wounds were closed initiaIIy. The resuIts are tabulated in TabIe II. Where rigid fixation was not obtained and where pIaster encasement were required, the healing was deIayed. TABLE II WOUND HEALING-1942 INITIAL CLOSURE InternaI Fixation I (0) healed at 21 days I (S) healed at 21 days I (S) healed at 25 days I (0) healed at 9 days, broke down 7 weeks I (0) healed at 8% months months I (S) healed at 9 I (S) not heaIed 3 years Pins I (S) healed 2% months months I (S) healed 3 I (S) healed 3% months months I (S) heaIed 4 I (S) healed 4% months 0 = No chemotherapy S = SuIfaniIamide in wound and orally
In a number of cases the wounds, though not cIinicalIy infected, did not hea compIeteIy unti1 the hardware was removed. (Fig. 3.) Because of the position of the compound wound pIates and screws were pIaced on the bone surface presenting to avoid excess exposure. Such plates are used as temporary splints and remova after the fracture has united is not considered a faiIure of the method. Chemotherapy in the Iight of present experience is not discussed because it was not used. Undoubtedly peniciIIin and other antibiotics make the surgeon sIeep better at night but repIace neither careful surgery nor mechanica principles. The case mentioned earIier in which amputation was necessary had an undkbrided and undrained area of damaged tissue in the posterior compartment of the leg and had the fascia1 layers sutured over the plate. Five days Iater the wound was wideIy opened and the necrotic muscIe excised. Gas-forming organisms were found in the excised tissues. In spite of wide excision the mixed infection was not controIIed and amputation was performed six weeks Iater. This result was due to inadequate d&bridement and tight closure. The presence of
Fixation
NOYEM,J~H, ,<,1-
the meta did not jeopardize the management of the infection but actuaIIy made it easier. The foIIow-up resuIts of five years or more are shown in TabIe III. In order to incIude some of the experience gained in the war the writer (thanks to the courtesy of coIIeagues in Great Britain) has been abIe to obtain Iate results on fourteen war injuries of femur and tibia that had some form of interna fixation. The operations were perTABLE III RESULTS ‘932-1942 T
Interna Fixation
4-4-4 3-4-4 4-3-4 3-3-4 3-3-3
10
9 2 9
2 2 2
Death due to other causes.. Amputations. Lost...........................
i-
-
In recording foltow-up figures the findings are listed according to anatomic, functional and economic results: 4 = roe%, 3 = 75 to 99%.
formed at intervaIs varying from three days to six weeks after wounding, usuaIIy through a separate incision. AI1 wounds were Ieft open for five days then sutured under an anesthetic. There were no deaths, no amputations, no spreading infections and no non-unions. Of the nine compound fractured femurs four were stiII in the army in 1947. The other five were employed at fuI1 time jobs but two had Iimited knee motion. These two had been in pIaster spicas for some months. AI1 wounds were soIidIy healed. The five men with compound fractures of the tibia were a11empIoyed but two had limitation of knee motion. Four of the fourteen had received systemic penicillin but almost a11 had had calcium peniciIIin suIfathiazole powder in the wounds. AIthough these figures are too smaI1 to warrant sweeping generalizations, after anaIysis of the cases used for this paper the writer is of the firm conviction that certain compound fractures of the Iower extremity should be plated. The criteria essentia1 for satisfactory results are correct surgica1 treatment of the
VIM. LXXIV,
wound
Stimson-Internal
No. 5
which
should
include
no initia1
skin
closure but adequate suture under anesthetic at five days and rigid mechanical fixation of the fracture. In conclusion, the impressions gathered over the past eighteen years have been strengthened b? this study. Compound fractures of the shafts ot femur and tibia, suitably selected and properly plated, are best treated by internal fixation. DISCUSSION
HENRY C. MARBLE (Boston, Mass.): I want to say that I consider this a privilege and an honor. This is the first paper that has ever been presented to this Society by a lady member and this is the first lady member. I read her paper and I was reminded then onIy of the first time that this matter was proposed in my surgical experience. Dr. O’NeiII Sherman, of Pittsburgh, gave a paper not unlike this before a part of the American College of Surgeons, and I believe it was in Montreal. Dr. Sherman finished his paper and the audience arose aImost to a man and what happened to Dr. Sherman was very much like what happened to the merchant of Venice. They tore his raiment, they spit on his garline, and when he was through, with one or two notable exceptions, poor Dr. Sherman’s paper was torn to bits. Two or three decades have brought about a wondrous change, and now Dr. Stimson comes and reiterates what Dr. Sherman then said and we sit here quietly and bIandIy in our seats and agree. Of course, one cannot but agree with what she has said. There are several factors which we have learned in these years. The first factor is how to do a proper, careful, accurate debridement. I might add that Dr. Stimson did not teI1 you but she probably does it-nameIy, that portions of the dbbrided tissue may to advantage be put into test tubes and subjected to the bacteriologist’s wiles to see if they are benign or if they are maIignant. It is a great comfort to have the bacteriologist tell you the day after you have sewn up such a fracture that as far as he can see, there are no cIostridia1 organisms and not too many streptococci in the wound, aIthough parentheticaIIy I have had gas-forming organisms in wounds in which there was no clincial evidence whatsoever. However, that is good for peace of mind. We have also added to our armamentarium certain other drugs which Dr. Stimson says make her sIeep better. Peace of mind for a surgeon is a grand thing. Off the record, sulfa drugs do not give me peace of mind, and giving a11 of my patients penicillin does not help my peace of mind either. I Firmly believe that a careful, thorough, painstaking
Fixation
American
Journnl
of Surgrry
“03
carefuIIy controlled by bacteriodkbridement, Iogic test, wiI1 give you a11 the peace of mind you need. If the bacteriologist shows you that there are organisms in there that require attention, then we have the sulfa drugs and we also have peniciIIin. Added to that, we then must fix the fracture, as she has toId you, and we must close the wound. 1 want to add that in closing the tibia1 wounds, which I think are difficult, the old expedient, which Dr. Fred Cotton taught me, of making lateral incisions far to the side of the leg so that the tibia1 wound over the pIate can be compIeteIy closed, is useful and helpful and these lateral incisions can then or Iater be closed by skin graft. OSCAR P. HAnlnroN, JR. (St. Louis, Mo.): It is a privilege to discuss Dr. Stimson’s paper. It was my privilege to see some of her excellent work in Italy. When the American Army turned down Major Barbara Stimson, with a11 of her knowIedge of bone and joint surgery, it was a British gain, because she certainty contributed a great deal to the management of soldiers of the British Army who were bone and joint casuaIties. I might say that, without disrespect to our British aIIies, she certainly rocked them on their heeIs in the earIy days because she wanted to put metal on bone in compound fractures. That was heresy. When she came to North Africa but after she had moved to ItaIy and carried on there, others of the British MedicaI Corps were doing it, too. She carried her point and her concepts wcrc we11 received when she was through. Of course, the use of hardware in compound fractures really requires consideration in two phases. ReIativeIy speaking, its use in fractures soon after injury has been accepted. I say “rclatively speaking.” There are still some who do not or wouId not use it, but there are many others who aIways or frequently do. 1 wouId like to point out that in her use of the metal in compound battle fractures, Dr. Stimson was placing this meta in compound wounds several days, perhaps several weeks, after wounding. I know that she thought the idea1 time was five days after wounding, but the majority of the internal fixation were done from tive to ten days after wounding. I believe we can draw an anaIogy to comparable fractures seen in civiIian life. We receive them from distant places or we may have them under our care from the beginning. Unreduced fractures with open wounds, Iivc to ten days after injury-that is the problem. Now, Dr. Stimson stated it frankly, that the problem of the use of metal presents itseIf in this way: Does it produce infection? I would like to present again for your consideration the concept that wound sepsis results from the septic decomposition of dead tissue, including blood clot in dead space. ParticuIarIy is this true in the presence an effective antibacterial agent to protect Iiving
704
American Journal of Surgery
Stimson--Internal
tissue from invasive infection of organisms recognized as stiIl present in the retained devitalized tissue and in the open wound; so that if a wound can be rid of devitalized tissue by a meticulous dgbridement, of which Dr. Marble spoke, and the surgery is good enough to put on the metal without creating additiona devitalized tissue and to eliminate residual dead space, how is the meta going to predispose to sepsis. It does not if this concept is accepted. I wouId like to speak briefly about the use of meta in septic wounds. Often, the rigid internal fixation of a fracture may be an important factor in overcoming a septic compound fracture. A septic compound fracture presents two probIems: one, contro1 of sepsis and wound heaIing; the other, maintenance of reduction of the fracture projected toward healing in as near an anatomic position as possibIe. Now, if one accepts the concept which I outlined, the use of meta is not going to proIong that sepsis
Fixation
NOYEMBBH,,941
and, as Dr. Stimson said, by holding the fragments stiI1, continuing trauma and subsequent devitalized tissue is minimized. I aIso wouId Iike to point out that dead space about the unreduced fracture is eIiminated. BARBARA B. STIWSON (cIosing): I want to thank the discussers for their courteous handIing of the paper. I agree entireIy with Dr. MarbIe that skin closure is essential as soon as it is safe. We found that in five days, most of the very bad wounds couId be cIosed with not much tension. We have used the Iateral reIeasing incisions with a great dea1 of interest and help, because I agree with him that it is essentia1 to cover the tibia, if possibIe. Of course, I agree with Dr. Hampton. We have seen a number of septic compound fractures that progressed very satisfactoriIy with the use of interna fixation. We have pIated them at a month and a month and a half, in the presence of pus, and the bones unite and the sepsis is controIIed.