TREATMENT OF
Dr. \V. YV. Council, surgeon for the
Copper River & Northwestern rail
way, contributes the following inter
esting paper to the Alaska Medical
Association Quarterly Bulletin on the
general treatment of fractures:
It is not the purpose of this paper
to advocate any special method for
the treatment of all fractures, but to
try and give you some of the methods
with which 1 have had the most suc
cess.
The amount of discussion and con
troversy since Lane first advocated
the open method continues unabated,
and the end is not in sight. Some ad
vocate open operations for all frac
tures, and others the closed method
for practically all.
I shall not take up the relative mer
its of the different materials used as
grafts and splints, nor will I discuss
the pros and cons of the supposed
bone forming cells and tissues, but
will confine myself to the diagnosis
and the mechanics of reduction and
immobilization of fractures, the long
bones principally of the lower extremi
ties.
There are two results which the
bone-setter must strive for: First, a
good functional result, and second, a
good anatomical result. Old Dame
Nature is a wonder worker when it
comes to bone repair, and I have seen
many a case where a good functional
result had been obtained, but if a ski
agraph of same was shown to a jury
sitting on a personal injury suit they
would award all that was asked for.
Of patients admitted to the hospital
here for treatment from 1909 to 1916
(2,240 in number) 123, or 5 1-2 per
cent have been suits for personal in
jury against the different companies or
corporations patronizing the hospital
here, practically 100 per cent were
fracture cases. The burden of a large
number of fracture cases will fall up
on the doctor accepting contract work
in Alaska, and will continue for years
to come, or as long as Alaska is in
the development stage. Inasmuch as
this is the case, he must be well
equipped for such work. If a develop
ment company or corporation furnish
es the equipment, the amount saved
by the proper treatment of even one
case might furnish all the equipment
necessary.
By equipment I mean, first of all, a
good X-ray outfit, and second, the pro
per instruments, such as chisels, saws,
drills, plates, screws, splints, etc. The
doctor himself must have a good equip
ment, i. e., a thorough knowledge of
anatomy mechanical skill and a per-!
feet surgical technique coupled with
sound judgment. These are essential
lUlUgD,
Wlien a fracture is suspected a ski
agraph should always he taken where
possible. I have seen quite a number
of cases show a fracture where none
could be determined by palpation or
manipulation and the nature of the
injury determined. If it is a simple
transverse fracture and there is no
great amount of contusion or swelling,
the patient should be anesthetized to
complete relaxation, and the limb ma
nipulated until the ends are in appo
sition, which can be determined by
gently pushing the distal ends toward
the body. When the ends seem to be
in good apposition the patient is al
lowed to partially regain conscious
ness. Muscular contraction will then
aid in keeping the ends in apposition
while the cast or splints are applied.
As an immobilization apparatus plaster
paris in proper hands has no rival. It
is inexpensive, can be quickly applied
and as any splint or immobilization
apparatus, to be effective, must ex
tend beyond the joints next above and
below the seat of fracture, no other
form of splint can be made to fit as
snugly and be so comfortable for the
patient. A skiagraph is now taken
through the cast and result of the
work determined. If you have gotten
a three-quarter anatomical alignment
of the fragments you can be assured
of a good result. A picture should be
made each week up to three weeks to
determine if there has been any later
movements of the fragmnts.
This method is not applicable to
fractures in the lower nor the upper
third of the femur. So much for sim
ple transverse fractures.
If your plate shows an oblique or
spiral fracture and you have compe
tent assistance, and the condition of
your patient is good, an open opera
tion and fixation is the method of
choice. Here, to assure success, the
asepsis must be perfect. The entire
limb is gone over with benzine and by
tincture of iodine, which is allowed
to thoroughly dry. I then remove the
surplus iodine over the surface to
be incised with alcohol or ether. The
limb and patient are covered with ster
ile gauze, towels or sheets. Two knives
must be used in making your incision.
The knife used to make the skin in
cision is discarded to avoid the pos
sibility of carrying germs from the
skin into parts beneath, and the skin
margin isolated by the use of clamps
and sterile gauze. Make your incis
ion down to the seat of fracture long
enough to give good working room.
Strive for complete hermostasis, as
this will facilitate your work of fix
ation. The application of an Esmarch
and tourniquet before beginning an
operation will groatly aid in keeping
the field dry. If there are any small
fragments or splinters remove them,
together with all clots. Manipulate
fragments to position, clamp and fix
with Lane plate and screws. If you
are in doubt about one being suffi
cient, put on another. The bone frag
ments must only be handled with In
struments where possible. The wound
is now closed, care taken to fill in all
dead space and a cast applied. Move
the limb as litjle as possible after the
plates are made fast. The wound Is
dressed through a window In cast. I
say, "use plates,” because for the sur
geon doing only an occasional opera
tion of this nature, it is the simplest,
easiest and quickest method, and
where they are deeply buried they are
not apt to give trouble. If they are
near the surface (tibia, for instance),
they will probably have to be removed
at a second operation.
There are other methods of merit,
especially the use of autogenous
splints or grafts, but the cutting of
these, unless one has a motor saw, is
a very tedious proces, making a long
drawn-out operation, causing more
shock to the patient, and in the end
securing no better results.
If conditions are unfavorable for an
operation, then some method of ex
tension must be resorted to.
In my series of cases there has been
nineteen cases of fracture of the fe
moral shaft. I used the Buck exten
sion method on my first cases of ob
lique fracture, and although I got firm
union in all but one case, I always got
some shortening, from 1-4 inch to 1-2
inch. I therefore concluded that the
Buck method is inadequate and should
I have occasion to use extension aga(n
1 shall use the method advocated by
Steinman. That is, by driving a nail
through the lower segment, if a frac
ture of the femur, just above condyle,
and if of tibia and fibula, through the
oscalcis, and making traction on each
end of this by wire loops connected
with ropes which run through a pulley
made fast to the bed.
It was my pleasure in January of
the present year to see a number of
cases being treated by this method in
the Cook county hospital, and I shall
take pleasure in trying to describe it
here.
and maintained. When a complete re
duction and partial union has taken
place the nail Is removed. This will
be found comparatively easy, as some
pressure necrosis will have taken
place and slightly increased the size
of the nail hole. A cast should be ap
plied and windows cut over the en
trance and exit of the nail to observe
if there Is any later infection. In se
lecting the site for the nail care must
be taken not to encroach too closely
upon the joint nor the synovial sack.
Probably 3-4 or 1 Inch from the joint
would be a safe margin.
I will not, at this time, go very
thoroughly into fractures near joints
nor fractures Into Joints, but would
tike to add a few words upon fractures
near joints where motion is liable to
be limited after the healing of such
fracture.
Take the elbow for example. Our
old text books tell us to put a limb
up with the forearm flexed across the
chest at right angle of inextenslon.
In some of my earlier cases I found
that when I did this I sometimes had
a forearm that could not be flexed
any further. I then adopted the me
thod of putting same up in extreme
flexion. I found that by doing this
1 got a freer motion after union had
taken place and the limit of extension
increased more rapidly than did the
limit of flexion In the old method of
a right angle fixation. In all cases of
fractures near joints where it is not
wise to use plates, 1 fix the limb In
the extreme position which was the
hardest to obtain after a union of the
limb treated by the old text book me
thods. This method is particularly
adaptable to fractures involving the
neck of the humurus, which should be
fixed in extreme abduction, to frac
tures of the ulna and radius near the
elbow joint, and to fractures of the
carpal bones, especially the scaphoid.
Here 1 have always found that it was
difficult to obtain extension after re
pair had taken place. I now, in frac
tures of the carpal bones, fix the hand
In hyper extension. After union has
taken place It is found comparatively
easy to regain flexion as the flexor
muscles of the forearm are very much
more powerful than the extensors, and
can be brought into play and used as
an aid to increase flexion. In all frac
tures into joints or near enough to in
fluence motion, passive motion should
be instituted about the fifteenth day.
In conclusion, I wish to say to you
who have had the patience to read this
little article through to the end, that
too much care and watchfulness can
not be given to any case of fracture,
no matter how small or how common.
A case well handled may save you
some very embarrassing moments
later on, and every case well treated
brings to the doctor the same satis
faction that any good workman feels
over a well finished task.
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H- ■ GROWTH I
rted to the Territorial Banking Board. Under I
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Superintendent Cordova Agon*
An ordinary pointed wire nail about
six inches long is used. This can be
placed in position with the patient
fully anesthetized, or by the use of a
local anesthetic with little pain to the
patient. The site of the nail is select
ed, taking care to keep away from the
medulary canal if possible; if a long
bone, preferably near the epiphysis.
The site and exit of Introduction are
sterilized by the benzine-iodine me
thod, and a small stab incision made
down to the bone. The nail is then
inserted and driven through, holding
a block of wood or some heavy body
covered with sterile gauze or towels
against the opposite side of the limb.
When the skin is pushed out on the
opposite side by the nail a small incis
ion is made here and the nail pushed
through. The wound at the entrance
and exit of the nail is then sealed with
collodion and covered with a sterile
gauze dressing, and a copper wire
about two feet long with a loop at each
end of the wire is placed over the nail
ends and held in position with a rob
ler bandage. To this is made fast
a rope which runs through a pulley at
the foot of the bed. This eliminates all
stress upon joints and soft parts. This
allows as much weight as is necessary
to reduce and maintain extension un
til the bones are partially united. Ro
tation of the limb can be controlled
by placing weight on either end of the
nail. This nail is left in situ for about
eighteen or twenty days, numerous
X-rays being taken to determine if
enough weights are being used and if
the fragments are In proper position,
for compound fractures with infection,
this is by far the best method I have
ever seen in use. It maintains the
fragments in proper position and al
lows all the space about the fractures
for dressing and treatment.
The difficulty with the Buck exten
sion method was that In fractures of
the femur, not enough weights could
be applied to maintain extension and
the plaster always came off in a short
time, which necessitated putting on
new ones, and also caused the patient
a great deal of discomfiture by the
tension on the joints and skin.
By the nail extension method, the
tension is made upon the bones direct,
and as such is the case, the correct
amount of weights can be determined