THE HISTORY OF MANAGEMENT OF OPEN FRACTURES
JAMES HARKNESS, M.D.
Throughout history open fracture has been greatly feared due to the high incidence of infection leading to death. Until the beginning of the twentieth century the most dependable way avoiding such an unhappy result was to carry out early amputation. Hippocrates summed it up by saying”...not to reduce it is to incur the reproach of ignorance; to reduce it is to increase the chance of death.” However, he did, in spite of his misgivings, give instructions as to the reduction fractures with protruding bones by the use of a mochlieus, an iron lever flattened at one end, to shoe-horn the bones back into the limb, and treat the wound by a pitch and cerate dressing.
Ambroise Pare’ in 1561 was crossing the Seine on a ferry when his fractious horse kicked him. He had his colleague Richard Hubert treat the resulting open fracture but gave him the following instructions “If the wound were too small, he should enlarge it with a razor, so as more easily to replace the bones in their natural position; and that he should carefully explore the wound with his fingers rather than any instrument (the sense of touch affording the greatest certainty) in order to remove such fragments, and bits of bone as might be completely detached; pressing out and evacuating also the blood which is abundantly effused about the wound”.
Another great surgeon, Percival Pott, fell off his horse in Southwark and sustained an open fracture of the tibia. He had the presence of mind to instruct some porters to take a door off its hinges and transport him on this litter to a surgeon. Several surgeons agreed that amputation would be the best course and Pott concurred. The leg was saved, however by the timely intervention of William Nourse, to whom Pott had been apprenticed, who dressed and immobilized the leg with a happy result. During his convalescence, Pott wrote “Some General Remarks on Fractures and Dislocations” (1768) in a period of two weeks. Surely antoxample of industry that others should follow.
Trauma management has always been advanced by the experience gained by surgeons during wartime. Napoleon had a superb surgeon-general, Baron Larrey, who organized “Flying Ambulances” to pick up wounded soldiers and transport them with the minimum delay after wounding to field hospitals. During this period the concept of “debridement” was introduced, perhaps by Desault or one of the other French surgeons. Debridement literally means the unbridling of a horse and has nothing to do with removal of debris. It consists of enlarging a wound so that the depths can be explored and to provide free drainage by incising fascia and removing damaged tissue. This has continued to be the most important single measure in the management of open fracture until the present day.
The Civil War produced a plethora of open fractures. Perhaps the most used text-books followed in the management of fractures where Malgaigne’s “Traite’ des Fractures et des Luxation” (1847) and James Symes’, “Principles and Practical Surgery for Field and Hospital” which espoused the principles of debridement. F.H. Hamilton, Professor of Military Surgery and Hygiene at Belleview Hospital Medical College and Long Island College Hospital, wrote in his, “A Treatise on Military Surgery and Hygiene” (1863) “gunshot fractures of the upper extremity don’t demand amputation and those of the lower extremity generally do so”. He had discouraging words about open fractures of the head and neck of femur—“They generally die not matter whether you excise, amputate or treat as a fracture without the knife”. He had seen no resections of the shaft of the femur which did not terminate fatally. His advice regarding the reduction of open fractures with protruding fractures was – 1) Apply extension and counter extension 2) Place finger in the wound and stretch the skin over the sharp point or use a spatula made from a piece of shingle, and 3) Enlarge the wound only as a last resort. To save a limb with a gunshot fracture, he advised the removal of all loose pieces of bone and foreign bodies, and that any portion of integument, fascia or muscles entangled in a wound which prevent a thorough exploration or the free drainage of blood or matter must be divided. Hamilton also advised against the early closure of wounds in open fractures – a sterling principle that had to be relearned by each generation of surgeons in subsequent wars.
Contrary to popular conception, there was very little hand-to-hand fighting with saber and bayonet in the Civil War. The introduction of conoidal bullets and rifling increased the range and accuracy of rifles and pistols so that the large majority of wounds were gunshot wounds, and the associated fractures were severe. Fifty percent of gunshot fractures were amputated with a 26% mortality and three out of every four surgical procedures performed were amputations.
Hospital gangrene or phagedaemic gangrene was rife both in military and civilian practice, and commonly followed open fracture. A moist, gray slough appeared in the wound surrounded by an area of erythema, and progressed inexorably, and rapidly throughout the extremity. Only amputation, carried out before the process reached the root of the limb, could save the ampient. It is likely that these were infections by synergistic organisms and akin to what we now call necrotizing fasciitis.
Joseph Lister, the prize pupil and son-in-law of James Syme acceded to the Chair of Surgery at the University of Glasgow on his mentor’s recommendation. While there he was introduced to the work of Pasteur by his friend Thomas Anderson, the professor of chemistry. He also was aware that the effluent of the gas works in Carlisle had disinfected the sewage system there. Anderson gave him a sample of creosote and Lister found that carbolic acid derived there from killed bacteria.
Alexis Carrell, an innovative, imaginative surgical genius who perfected arterial suture, and who pioneered organ transplantation, tissue culture, virology and extracorporeal circulation did his great work at the Rockefeller Institute after being recruited by Simon Flexner.
In 1914 Carrell was visiting his house in France when World War I erupted and was immediately conscripted into the French Army as a field surgeon. Since he was having a problem with infected open fractures, he wanted an antiseptic solution that would not destroy tissue. He asked Simon Flexner to find such a material and was put in touch with Dakin; a young chemist who suggested the use of freshly prepared sodium hypochlorite solution combined with boric acid. Wounds were debrided but not closed and this solution was instilled in the wounds every two hours. Daily bacterial cultures and counts were made and the wounds closed when the cultures where sterile.
Carrell’s technique was so successful that the U.S. Army adopted the technique and had a school in New York to teach the method to U.S. military surgeons.
Not everyone was enthused by the Carrell-Dakin treatment of wounds. Sir Almroth E. Wright carried out a series of laboratory exercises on wound infections and stated: “I have not come across any satisfactory clinical or bacteriologic evidence of the utilitary of antiseptics as employed in infected wounds. The antiseptic treatment of infected wounds is of quite doubtful utility.”
Sir Almroth advocated opening up the wound to provide free drainage, washing the wounds out with therapeutic fluids, immobilization of the extremity, ablation of the heavily infected and infiltrated wall and floors of the wound, and secondary suture after the infection was overcome.
Indeed, the hypochlorite treatment of wounds required many man-hours to provide the fresh hypochlorite solution and carry out the treatment. The skin was easily irritated by the hypochlorite so that it had to be protected by vasoline and it was critical to have exactly the proper concentration of hypochlorite since less than 0.45 percent was ineffective and more than 0.5 percent was too irritating. The wounds needed to be somewhat basin shaped to keep the solution in contact with all parts of the wound, and the constant wetness precluded the use of plaster-of-paris casts to immobilize the fracture. Furthermore, secondary infections of the wounds were common.
Perhaps the most outspoken critic of the Carrell-Dakin treatment was a young American orthopaedist, Dr. Winnett Orr, who was a member of a small group of orthopaedic surgeons, led by Joel Goldthwaite that worked with the Royal Army Medical Corp prior to the United States entry into the Great War. Winnett Orr perfected his own method of treatment that incorporated thorough debridement, packing of the wound with gauze to provide free drainage, and prolonged immobilization in plaster. This method was highly successful and later he employed it in civilian practice for the treatment of chronic osteomyelitic. This method was also used with great success by Trueta in the Spanish Civil War. Trueta treated 1073 open fractures with only 6 deaths, two following amputation and four of unrelated causes. There were 91 poor results and 4 cases requiring amputation. Changing of casts was largely predicated by the foul odors produced by this method, so that casts were changed about every fifteen days during the summer and every thirty days during the winter. Absolute indications for removing the casts were edema, inability to move fingers or toes, unremitting pain, and lassitude.
Dr. William S. Baer, another young American orthopaedist in World War I, treated two soldiers who had been lying on the battlefield for seven days without attention, who had open fractures of the femur and wounds of the scrotum and abdomen. Much to his surprise, their wounds were in pristine state, clean and uninfected. This happy condition was due to the fact that the wounds had become infested with maggots, the larvae of blowfly, which had debrided their wounds without damaging viable tissue. The observation that maggot infestation cleaned out wounds had been noted by French surgeons during Napoleon’s campaign in Egypt and indeed, had been noted in antiquity. However, Baer was not content merely to make this observation but started a maggot farm to treat wounds on a larger scale. Further investigation revealed that the maggots defecated potentially lethal pathogens so that he devised a process of producing sterile maggots that he used with great success subsequently at Johns-Hopkins Hospital in the treatment of chronic osteomyelitic and infected wounds. Unhappily, esthetic considerations made this therapy unacceptable to many patients so that this very useful method is rarely, if ever, used at the present time.
During World War II the painful lessons of the need for adequate debridement with free drainage and secondary closure of clean wounds had to be relearned, but as the war progressed the management of these wounds improved with experience to that Mather Cleveland and John A. Grove were able to report a 93 percent success in the management of open fractures. The use of Sulphonamides in open wounds did not prevent infection and this treatment in North Africa, sensitized the skin to sunlight. The introduction of penicillin, on the other hand, prevented invasive infections and reduced the incidence of gas gangrene although it did not preclude completely wounds becoming infected.
The management of open fractures by internal fixation was anathema until recent times although William Sherman treated fractures of the femur by plating in World War I. When he did so in 1939, he left the wound open and rather surprisingly removed the plates and screws at six weeks. Immobilization of fractures by transfixion pins incorporated in plaster-of-paris casts produced unmitigated disasters in World War II and was discontinued by the U.S. Army on this account.
The use of external fixators has been in and out of vogue for more than a hundreds years but the re-introduction of the Hoffman apparatus improved by Vidal and Ardrey sparked new interest in this method of fixation that allowed free access to wounds while providing excellent stability of even comminuted fractures. More recently the AO group (European trademark for Association for Osteosynthetik, known in the U.S. as Association for the study of internal fixation) has shown that rigid fixation of open fractures militates against infection and McNeur during the Vietnam conflict had excellent results when open fractures were adequately plated. More recently still, the introduction of interlocking intramedullary nails has provided very stable fixation of open fractures and may well, in the future, be the procedure of choice. No method of internal fixation however, will allow wounds in edematous extremities to be closed under tension so that such wounds are better left open and closed at a later date when the edema has subsided. In cases where massive soft tissue destruction has occurred, however, it is impossible to restore the soft tissue envelope surrounding the bone by delayed primary closure. Marco Godina, who made an international reputation by salvaging infected non-unions treated by compression plating, was able to reconstitute this soft tissue envelope by using free tissue transfer i.e., by vascularized latissimus dorsi grafts. He has shown that early application of such grafts in the first forty-eight hours after wounding is highly successful and has salvaged many limbs that otherwise would have been amputated.
Slowly and painfully a rational approach to the management of open fractures has evolved which consists of early and thorough debridement of wounds, the avoidance of soft tissue closure under tension, the stabilization of fractures by internal or external fixation, the use of appropriate antibiotic prophylaxis and where indicated, the application of free tissue transfers, has made this formerly lethal injury one that is manageable in most cases.