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VOL. III.

CHICAGO, SEPTEMRER 8, 1896.

CONTENTS OF THIS NUMBER.

ORIGINAL ARTICLES:

PAGE.

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No. S.

ONE FALLACY REGARDING UNUNITED FRACTURES, WITH REPORT OF CASES.*

By E. R. LEWIS, A. M., M. D., KANSAS CITY, Mo.

One year ago, at our annual meeting in Chicago, I had the pleasure of presenting a paper on the subject, "Ununited Fractures; Development and Repair of Bone." Since that time I have seen three cases of ununited fractures, that is, ununited in the ordinary acceptation of the term, as laid down by our best authorities on the subject-who say that after six months, a broken bone which has not been repaired by bone will not be capable of so doing-and is an ununited fracture and will continue so without surgical interference, and this is the point I wish to correct, and verify by my own experience in three cases seen since our last meeting. One of the three cases occurred in my own practice, and was under treatment at our last annual meeting, but not sufficiently advanced at that time to be discussed in the paper presented then. My patient was a male, 41 years of age, foreman of a crew at our live stock yards. While loading a New York stock train, one of the animals became unruly, and in attempting to force the animal into the car, it fell between the car and the platform, catching the patient's right leg between the edge of the heavy oak platform and the animal's body and not only fracturing the bones, but comminuting them, cutting the vessels and thereby producing an enormous subcutaneous hemorrhage. When I arrived at the yards and examined the patient, who was stretched out on the floor of the pen. I did not think it possible to get him home without the sharp fragments of bone making our injury a compound comminuted fracture,

*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May 1, 1896.

but the police patrol wagon attaches proved quite skillful in the handling of the patient and he was laid upon his bed a mile away with the cutaneous tissue still intact, though exceedingly thin at more than one point, and enormously strutted with the homorrhage, which seemed to be still going on.

The idea of evacuating the blood was debated, but I feared to convert my injury into a compound one, so applied temporary splints for the first week, after which time I used a plaster cast, leaving it on for six weeks. At the end of that time I found no union. I again applied the plaster, after using some friction of the ends of the bones, leaving it on more than three months from the time of the original injury, and at the expiration of this long time found no union. After the removal of the first cast and the application of the second, my patient was up and around on crutches all of the time. I removed the second cast in the fourth month, and although the patient was around all the time, I used only light splints about the point of the non-union during the day, removing them at night, and finally leaving them off altogether as the limb got stronger and stronger under the daily use of massage. In fact, after the removal of the permanent splints, I had the patient submit himself to an expert masseuer almost daily for several months, before bony union occurred, which was about the last of the seventh, or the first of the eighth month; and now, after fourteen months from the date of injury, he is attending to his work in the live stock yards as before. Having a great desire to see what condition the bones were in, I availed myself of the great courtesy of Professor Lucien I. Blake of the University of Kansas to submit my patient to the Roentgen rays for the purpose of making a skiagraph of the leg. After the plate had been developed, I was delighted to be able to see continuous bony repair in both tibia and fibula.

The second case I saw for the last time during the year, proving that bone will repair itself with bone after six months, occurred in the practice of a member of the National Association of Railway Surgeons, the chief surgeon of the Kansas City, Ft. Scott & Memphis Railroad. The patient was injured in Arkansas in 1889 and was treated in the company's hospital in Kansas City during the year

ending July, 1890. I saw this man with Dr. N. J. Pettijohn, the chief surgeon of the road, during the time he was in our town, and from the very extensive injury, did not at one time think the limb could be saved, even with a false joint, but as to the fallibility of my judgment, I leave you to judge after reading the history of the case, as kindly furnished me from the hospital records by order of the chief surgeon. The record showed the following, viz.:

"Charles W. Barton, fireman, aged 35, was injured September 24, 1889, by an engine leaving track and his right leg being caught in the debris, crushing the tibia and fibula at the junction of the middle and upper thirds, producing a compound comminuted fracture of the tibia, with a section of two inches of the fibula entirely removed. All of the anterior skin, muscles and vessels were crushed and extensively lacerated over the seat of injury. On the day after the injury the patient was brought to the General hospital at Kansas City, all of the loose fragments of bone removed, the ends of the tibia and fibula approximated and wired and the lacerated muscles adjusted with buried sutures, the limb dressed and placed in a side splint for six weeks, after which it was put in a permanent plaster of Paris splint, so arranged that the necessary dressings could be applied without interfering with the process of repair. (The wire sloughed out.)"

This patient remained in the hospital about ten months, being discharged July 17, 1890, without solid bony union, there being slight motion at the seat of injury. He was furnished with a shoe and lateral braces, which gave support to the limb, with instructions to use it as much as possible on crutches. Three months after leaving the hospital there was a solid bony union, and the limb is now as strong as the other, with the exception of two inches shortening. Thus it will be seen that after eleven or twelve months, this patient was rewarded by most complete bony union.

Our third case occurred in the practice of our fellow member, Dr. A. O. Williams of Ottumwa, Ia., and I here embody his report of the case, in the following letter, dated April 18, 1896, viz.:

Ottumwa, Ia., April 18, 1896. Dr. E. R. Lewis, Kansas City, Mo. Dear Doctor:-I consider that I owe you

an apology for not informing you long ago about my case of ununited fracture, insomuch as you took such an interest in the case and furnished such valuable suggestions. I am happy to say that the patient is now well and at work. I send you a history of the case. I shall surely be in St. Louis and shall be pleased to confer with you further.

Yours respectfully,

A. O. Williams.

The following is Dr. William's report: "Wm. McKinney, aged 30, habits good, no constitutional or hereditary ailments and in good health, was struck, February 8, 1895, by an iron which was half of a hook used by the wrecking crew to pull cars out of the ditch. An engine was pulling on the rope, the hook broke, flew back, struck McKinney on the tibia at the union of the middle with the lower third, producing a compound comminuted fracture of the tibia and fibula. The fragments were adjusted two hours after the accident. Temporary splints were used for seven days, when the leg was encased in a plaster of Paris bandage. Seven weeks from the day of the fracture there was no union. The external wounds healed without supurattion. At the end of 60 days there was union. The limb was again encased in plaster and the patient allowed to go around on crutches. The fracture was examined every few days. There was little progress toward union from one examination to another. Four months after fracture the leg was bandaged with a rubber band just below the knee joint, in order to obstruct return circulation. The ligation was kept up continuously for four weeks. Six months after the accident the patient was sent to D. E. R. Lewis of Kansas City, Mo., who recommended massage, which was followed persistently. The union rapidly became firmer, until nine months after the accident no motion was perceptible."

From the above it will be seen that Dr. Williams' patient was nine months without complete bony union. Taking the three cases, we have the earliest union in the eighth month, and the latest union after the twelfth month. In my patient there was no constitutional condition, such as tuberculosis or syphilis, to delay union, and so far as I have been able to judge, neither of these conditions complicated either of the other cases. I will not now enter

into a discussion of the development and repair of bone, for in my Chicago paper I covered that ground so far as possible from my study and personal experience. For the most approved methods of operating upon ununited fractures, I refer to an exhaustive article by one of our members, Prof. N. Senn of Chicago in the Annals of Surgery for August, 1893.

DISGUSSION OF DR LEWIS' PAPER.

President Murphy: This is one of the most interesting topics that can come before the association, and I would like to have every member take an active part in the discussion.

Dr. Milton Jay, Chicago: The subject of ununited fractures is certainly one of great importance to railway surgeons. What is generally meant by ununited fracture is not that we have no deposit between the fractured fragments, or that we have no plastic lymph or fibrinous deposit in the periosteum. Notwithstanding the very interesting paper of Dr. Lewis, it is yet a question, if at the end of six months no bony lymph or fibrous deposit has taken place in the periosteum, whether we get bony union without boring the ends of the bone. We sometimes see delayed union where the periosteum, which makes the provisional callus, or which forms a band around the ends of the fragments of the bone, will admit of considerable motion between the fractured fragments. The definitive callus, by the circulation from the bony structures, performs a slight function in the union of bone anyhow. If Dr. Lewis could have seen between the ends of the bone, if he could have seen the condition of the periosteum, which lines the bone, and could have seen no deposit or any intention on part of nature to perform any kind of union, then I still doubt whether at the end of six months he would have union. This provisional callus on the outside is slow, particularly where there has been a compound fracture. However slow it may be, it continues where the plastic lymph is thrown out, so that slight pressure may cause constant irritation, increase the deposit of lymph, and the union of the fragments does not take place, but at the end of six months there was a deposit in the periosteum of provisional callus, which was afterwards absorved, yet it permitted of some kind of motion. If the motion was lateral, the entire thickness of the bones, he never would have had union unless he had sawed off or laid

bare the ends of the bone. The point I wish to make is that if at the end of six months there was no intention of nature towards bony union, I still doubt whether he would have bony union.

Dr. Crook: My excuse for trespassing upon the time of the Association is merely to report a case along the line of Dr. Lewis' paper. When I was an assistant surgeon to the Sacramento (California) Hospital, early in the spring of 1895, an Italian, 34 years old, presented himself with severe ankylosis of the knee-joint. After he had been in the hospital for a week or two and was properly prepared, I operated on him and broke up the ankylosis. In addition there was malposition of the femur, overlapping of the bone, and a shortening of the leg of three inches. He could not bear any weight on the leg. With Dr. White, superintendent of the institution, and assisted by the physicians in the hospital, I operated and removed two and a half inches of the femur. The ends were brought together and sutured with silver wire. The leg was then invested with plaster of Paris with a window on one side for drainage. The plaster cast was allowed to remain nine weeks, at the end of which time it was removed, but union had not taken place. We were very much discouraged. We waited for a week and the man complained of severe pain in the right side. An analysis of the urine was made and it was found to contain pus. A diagnosis of pyonephrosis was made, and a nephrectomy performed. The old wound in the leg was afterwards reopened, the wires taken out, the ends of the bone put together again, and the man was well at the end of five months.

Dr. S. S. Thorn, Toledo: I have had some experience with cases of delayed union. My observation is, that the most fruitful cause of delayed union is malnutrition. I took this ground once before in this Association. It is starvation. A little over a year ago I was in favor of anchoring such bones, but I have seen failures from efforts at wiring the fragments and have suggested to surgeons trying the plan advocated by Mr. Owen, of Liverpool, that is, to maintain fixation of the joints beyond the seat of fracture. In these cases, the ankle and the knee. This fixation is maintained by a trough of plaster of Paris, and the method was presented at our meeting in Chi

cago last year. Let your dressings be loose. That is another important point. After all the necessary preparations are made, turn as far as you can the ends of the bones, in this way make flexion, and pummel them well with the hammer, just as a man does when he is percussing, then put your thumb back into the cast loosely, maintain fixation of the joint, then let it alone. I did this in one case, and at the end of twenty-one days the patient came back and did not like it, at which time I removed the dressing, told the patient that he had better try this treatment for twenty-one days longer, which he did, and there were evidences of successful union. This process of pounding the tissues over the ends of the bones in this way has served me very successfully five or six times within the past five years. I have not wired bones for at least five years. Unless the most perfect precautions are taken, the operation is apt to be followed by unpleasant conditions. In one case an amputation was the only successful termination.

Dr. W. S. Hoy: I regret that I did not get here earlier so as to hear the excellent paper of Dr. Lewis. I understand the subject for discussion is ununited fractures. Dr. Thorn has forcibly struck the keynote of the causes of ununited fractures, and that is anemia of the parts. Very frequently the surgeon, when called to treat a fracture, places a bandage around the limb so tightly that the circulation is partially cut off, and as a result he has nonunion of bone. But the question is, how are we to obtain union in ununited fractures? Dr. Thorn does not believe in wiring the fragments. I do not believe in it. I believe friction does a great deal more than wiring will do. I have in three cases obtained good union, and a useful limb without any marked shortening. My method of treatment of compound fracture is simply to put on a light dressing. I believe the surgeon to-day makes a mistake when he puts on any fracture a cumbersome dressing. I think the more light, the more airy and simple the dressing is in all cases of fracture, the better will be the results in the end. It is a good rule, in the treatment of fractures, to confine the joints above and below the seat of fracture. I believe in immobility of the parts, and believe that rest is the great principle underlying the treatment of fractures in which there is delayed union. Perhaps some of you have

never tried decalcified bone, taken either from the bone of the ox or cow, slipping it over the fragments. I recall a case in which eight months had elapsed, and yet there was nonunion. The physician in charge suggested that we cut down upon the bone and wire the fragments. He went to a dentist, who drilled six holes, three in each end of the bone. This was a fracture of the tibia. He then applied a plate made from a battered silver watch case, This patient, after eleven months, made a perfect recovery, union of the fragments being perfect. After the screws had become loose in their sockets in this case, the plate was removed and we found perfect union of the fragments, with healing of the external wound.

Dr. P. Daugherty: A few questions have occurred to me since this discussion has been going on. First, as to the causes of delayed union in ununited fractures. One cause has not been spoken of, and that is muscular tissue getting between the ends of the fractured bone. So long as that remains there we are not going to have union. There is a possibility that in the course of time this muscular tissue may become absorbed or disappear and that we will get union without any further trouble. There is one way by which we can nearly always tell whether we have a condition of that kind or not. If we take hold of the bone, force the ends of the fragments together, and we get crepitation we may be sure that there is nothing interposed between the fragments. If we get no crepitation we may be certain that something is interposed between them. Syphilitic, tubercular and anemic subjects from any cauşe are liable to delay union in cases of fracture.

As to the dressing of fractures, we have had suggested and recommended various dressings from time to time. Some thirty years ago I devised a method which I have used ever since. I was called to the southeastern part of Illinois, fifteen miles in the country, to see a man who had a fracture of the leg. This was in the days of the fracture box. There was no lumber, no saw. There did not seem to be anything about the place, not even a ham

I looked around, saw a piece of board box on a shelf. I had the woman tear up a sheet and make some starch, as though she were going to starch clothes. I took the old board box, out of which I made a splint reaching from the knee to a little below the bottom

of the foot, enveloping it on each side of the leg, leaving a space in the back and in front. I ran it into my starch until it was perfectly stiff. I then took my cotton batting, made a roller bandage, starching each layer as I went on. When the strach was dry I had a perfectly firm, very light, yet perfectly fitting splint. Three days thereafter the man was up on crutches. The swelling in the leg had materially diminished and the bandage became loose. I split it down in front and opened it, and just as often as it became loose I would tighten it. From that day I have never used any other splint. Plaster of Paris is good, and a great many use it-in fact, nearly everybody uses it now, but I would caution you to look out for one thing, and that is, not to get your bandage too tight. If it is too tight you will have an anemic limb, and that of itself will delay union.

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Dr. McCrae: It seems to me a great deal of valuable time is being wasted in discussing the treatment of fractures, when further down on the program we have the subject of treatment of compound fractures. Dr. Lewis' paper does not treat of compound fractures, but ununited fractures. That is the idea which he wishes to convey. The members who have so far discussed the paper have been speaking on the treatment of compound fractures. We are not on that subject.

In the case Dr. Lewis mentioned, I hardly think it was one of non-union. It was not bony union, but he did have, as the first speaker said, the presence of a provisional callus. It is only cases where there is absolutely no provisional callus that we may call ununited fractures, and after six months, if union has not taken place, I doubt, with the first speaker, whether it ever will take place.

Dr. Howard: I would like to ask a question. I have a case of three years' standing in which the radius was thoroughly ossified for some time, but in trying to use friction eight months after the injury, I snapped off an inch and a half of the radius. There never has been provisional callus from the beginning, and I told the man there never would be union. I wish to know if it would not be good policy to remove as much of the bone as is diseased and try to treat it anew?

Dr. G. A. Nash-I think we are pretty well agreed as to the changes which take place in

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