- Email: [email protected]
VI.—MANIPULATIVE TREATMENT
96. ’ fracture. This is rather more than the gap in one of the cases just mentioned where operation was limb resting on the outer splint. In a few cases recommended. I do not think operation should be belonging to Type D the Cline’s splint was discarded done here, and in this case of mine the end-result was in favour of a Thomas bed splint with Sinclair perfect. Although I agree that a good reduction of foot-piece. One surgeon prefers the use of moulded the deformity is essential, it is not necessary to secure plaster-of-Paris to the Cline’s splint. A special word is necessary for the three cases who FiG. 20, A. FiG. 20, B. had primary operations. of the heel are prevented. 5. Massage be used early without risk of displacement, the
displacement can
The first of these was a torsion fracture of the Pott’s variety with an oblique fracture immediately above the external malleolus in which it was found impossible by splints alone to maintain correction (Figs. 19, A and B). Here a long screw nail was introduced to bind the malleolus to the tibia above the level of the joint after full correction had been obtained. This nail was removed under local anaesthesia a fortnight ater. The second case was a comminuted fracture, which after several attempts at re-position had failed was treated by wires encircling separately the tibia and the fibula. The third case was the compound fracture already referred to. As Mr. Platt has said, " This is not, strictly speaking, a fracture of the type which I have dealt with and therefore the fact that it was operated on can hardly be used as an argument against conservative as compared with operative methods."
The conclusions arrived at from a consideration of the 60 consecutive cases are a, follows : 1. The results of conservative treatment combined with operation in I specially selected cases would seem to offer an efficient I method for indirect violence fractures at the anklein the series of 60 consecutive cases 91-6 per cent. being at work. 2. That the period of incapacity in all the cases, extending as it does to 20 weeks in a simple fracture of the external malleolus to double this period in some of the other fractures, seems to be unduly prolonged. 3. With a few exceptions the chances of the patient returning to work after fracture in the neighbourhood of the ankle-joint is comparatively good. 4. Fractures involving the ankle-joint are seldom compound. If fractures in this region be compound it is evidence in favour of a direct violence fracture. 5. Disability following fractures in this region is due to bad alignment of the fragments, to synostosis of the bones, or to arthritis in the joint. 6. Patients over 50, and especially those over 60, have a more prolonged period of incapacity and much less chance of returning to work at all than younger patients. 7. The prognosis in cases of men drawing workmen’s compensation and in injuries due to motor accidents seems to be less favourable than in fractures of other sorts, the date of the industrial labourer’s return to work being often decided by his shop steward or his branch secretary and not by his medical adviser.
I Ankle fracture with gross
displacement.
After manipulative reduction.
the most absolute precision in order to get complete return of function. Fig. 21, A shows the nearest approach to what I understand by a " Dupuytren fracture " seen in my department in seven years, and yet, although the displacement is so gross, the reduction (Fig. 21, B) shows good apposition, though not perfect, and the end-result was in every way excellent. I believe that a very useful aid in difficult compound fractures above the ankle where the tibial diaphysis FIG.
21,
A.
FIG.
21, B.
VI.—MANIPULATIVE TREATMENT. BY R.
OLLERENSHAW, M.D. MANCH., F.R.C.S. ENG.,
ORTHOPÆDIC SURGEON, SALFORD ROYAL HOSPITAL, AND ROYAL MANCHESTER CHILDREN’S HOSPITAL.
ON the practical aspect of this question I would like to say that I have no bias either in favour of open operation as opposed to more conservative means of treatment, or against it. I am strongly of opinion that operation should be reserved for those cases where satisfactory apposition and maintenance of that apposition cannot be achieved by manipulation and the usual splints or plaster. In the fracture clinic of my orthopaedic department at Salford Royal Hospital I have had admitted to my wards during the past six months 43 cases of fracture of the long bones. There have been 11 operations only during that period. Five of these were cases sent to me second-hand "-mal-union or non-union of fractures dating back three months to two vears, so that only six primary open operations were done, and I find that with each succeeding year I do fewer primary open operations on fractures. The following are two cases of the worst type of ankle fracture which show completely satisfactory reduction by manipulation. The first (Fig. 20, A) was a very severe type of Pott’s fracture and after reduction (Fig. 20, B) there is still a small gap between the edges of the fibular "
Ankle fracture with gross dis-
placement (Dupuytren type).
Same after manipulative reduction.
is projecting through the skin is to reduce the fracture and to maintain its position by plating the fibula. . Through a small incision over the fibula a plate is fixed holding the fibula and controlling the lateral displacement perfectly. After healing of the wound has occurred and the fracture has become steadyfour weeks later-the plate is removed under local anaesthesia. It has served its turn, and I believe that most plates used so close to the skin as this give trouble eventually.
displacement can
The first of these was a torsion fracture of the Pott’s variety with an oblique fracture immediately above the external malleolus in which it was found impossible by splints alone to maintain correction (Figs. 19, A and B). Here a long screw nail was introduced to bind the malleolus to the tibia above the level of the joint after full correction had been obtained. This nail was removed under local anaesthesia a fortnight ater. The second case was a comminuted fracture, which after several attempts at re-position had failed was treated by wires encircling separately the tibia and the fibula. The third case was the compound fracture already referred to. As Mr. Platt has said, " This is not, strictly speaking, a fracture of the type which I have dealt with and therefore the fact that it was operated on can hardly be used as an argument against conservative as compared with operative methods."
The conclusions arrived at from a consideration of the 60 consecutive cases are a, follows : 1. The results of conservative treatment combined with operation in I specially selected cases would seem to offer an efficient I method for indirect violence fractures at the anklein the series of 60 consecutive cases 91-6 per cent. being at work. 2. That the period of incapacity in all the cases, extending as it does to 20 weeks in a simple fracture of the external malleolus to double this period in some of the other fractures, seems to be unduly prolonged. 3. With a few exceptions the chances of the patient returning to work after fracture in the neighbourhood of the ankle-joint is comparatively good. 4. Fractures involving the ankle-joint are seldom compound. If fractures in this region be compound it is evidence in favour of a direct violence fracture. 5. Disability following fractures in this region is due to bad alignment of the fragments, to synostosis of the bones, or to arthritis in the joint. 6. Patients over 50, and especially those over 60, have a more prolonged period of incapacity and much less chance of returning to work at all than younger patients. 7. The prognosis in cases of men drawing workmen’s compensation and in injuries due to motor accidents seems to be less favourable than in fractures of other sorts, the date of the industrial labourer’s return to work being often decided by his shop steward or his branch secretary and not by his medical adviser.
I Ankle fracture with gross
displacement.
After manipulative reduction.
the most absolute precision in order to get complete return of function. Fig. 21, A shows the nearest approach to what I understand by a " Dupuytren fracture " seen in my department in seven years, and yet, although the displacement is so gross, the reduction (Fig. 21, B) shows good apposition, though not perfect, and the end-result was in every way excellent. I believe that a very useful aid in difficult compound fractures above the ankle where the tibial diaphysis FIG.
21,
A.
FIG.
21, B.
VI.—MANIPULATIVE TREATMENT. BY R.
OLLERENSHAW, M.D. MANCH., F.R.C.S. ENG.,
ORTHOPÆDIC SURGEON, SALFORD ROYAL HOSPITAL, AND ROYAL MANCHESTER CHILDREN’S HOSPITAL.
ON the practical aspect of this question I would like to say that I have no bias either in favour of open operation as opposed to more conservative means of treatment, or against it. I am strongly of opinion that operation should be reserved for those cases where satisfactory apposition and maintenance of that apposition cannot be achieved by manipulation and the usual splints or plaster. In the fracture clinic of my orthopaedic department at Salford Royal Hospital I have had admitted to my wards during the past six months 43 cases of fracture of the long bones. There have been 11 operations only during that period. Five of these were cases sent to me second-hand "-mal-union or non-union of fractures dating back three months to two vears, so that only six primary open operations were done, and I find that with each succeeding year I do fewer primary open operations on fractures. The following are two cases of the worst type of ankle fracture which show completely satisfactory reduction by manipulation. The first (Fig. 20, A) was a very severe type of Pott’s fracture and after reduction (Fig. 20, B) there is still a small gap between the edges of the fibular "
Ankle fracture with gross dis-
placement (Dupuytren type).
Same after manipulative reduction.
is projecting through the skin is to reduce the fracture and to maintain its position by plating the fibula. . Through a small incision over the fibula a plate is fixed holding the fibula and controlling the lateral displacement perfectly. After healing of the wound has occurred and the fracture has become steadyfour weeks later-the plate is removed under local anaesthesia. It has served its turn, and I believe that most plates used so close to the skin as this give trouble eventually.