In this chapter we are only concerned with the treatment of fractures of the shafts of the radius and ulna in their middle thirds. There are many difficulties in treating the radius and ulna by closed manipulation; closed methods can give excellent results, but the element of luck is rather prominent, and for this reason I am in favour of operative treatment. Some of the difficulties which damp enthusiasm for closed reduction are illustrated in the following sequence of catastrophes:

1. An excellent reduction may be secured by skilful manipulation.

2. The patient may suffer severe pain, with swollen fingers, because a closefitting plaster is obviously necessary; this causes the surgeon considerable anxiety, and may necessitate splitting of the plaster, thus causing further suffering to the patient unless a second anaesthetic is used.

3. When the swelling subsides there is a strong possibility of the initial reduction collapsing.

4. A second manipulation (sometimes the third anaesthetic) may therefore be necessary after fourteen to twenty-one days.

5. This may be followed by further pain and further swelling of the fingers.

6. An excellent reduction obtained initially is rarely ever retrieved by the second manipulation.

7. Delayed union of one or other bone may occur.

8. Limited pronation and supination may result after four to six months of plaster fixation.

9. External deformity may be so great as to be visible even to the patient.

10. […]

How often we see plaster of Paris applied merely because X-ray examination has revealed a small crack or undisplaced fracture! On many such occasions the surgeon would probably have treated a case without plaster had he used his clinical sense alone; he would then have been treating the injury according to his estimate of the damage inflicted on the soft parts. It is a platitude to say that soft-part injuries can be more serious than mere cracks in bone. One of the commonest instances in which the clinical assessment of an injury by soft-part damage is more important than the radiological is seen in severe ankle sprains where simple X-ray reveals ‘no bone injury.’ If an ankle presents very gross swelling, with extensive ecchymosis and solid induration due to the tension of the swelling, it is highly likely that there has been a rupture of the tibiofibular syndesmosis or of the external lateral ligament, and late displacement of the talus or recurrent subluxation of the ankle will occur if too early function without plaster is permitted. On the other hand, patients are frequently prevented from returning to work by plasters which are not essential but which are forced on them by surgeons who think only in terms of routine procedures and do not adjust their method to the demands of the individual problem.

It frequently happens that a surgeon is obliged to X-ray limbs for the medicolegal implication of an injury; but the result of this examination need not make him change his clinical judgment too lightly (p. 85, Fractures of the Scaphoid).

Descriptions of operative technique are to be found in most modern textbooks of fracture treatment, and often in great detail; by comparison the details of manipulative technique are usually indicated in only the vaguest of general outlines. This is not surprising if manipulative treatment is regarded as an art rather than as a science, because an art is essentially something which defies description and is therefore to be learned only by practice and apprenticeship.

In this chapter an attempt is made to reveal the scientific basis of manipulative methods. Unless the teacher of manipulative technique is able to create a mental picture of a manipulation, the student may waste months of experience and much valuable material before he eventually discovers what others may long have known but have failed to communicate. These mental pictures should not be decried by an experienced operator if the interpretations here offered seem to him open to question; the student must adapt these pictures to suit impressions gained from his own practical experience and they will thus form a useful basis on which to build.

The Soft Tissues associated with a Fracture

When the student inspects the radiograph of a badly displaced fracture, such as that of a Pott's fracture of the ankle, he may well despair at the thought of manipulative reduction. Manual reduction of a case such as that illustrated in Fig. 38 would appear not unlike the assembling of a jig-saw puzzle in the dark. The solution of the difficulty emerges, and the precision of reduction is realised, only when the supreme importance of the soft tissues is appreciated.

The bad results of open reduction and internal fixation of fractures are most commonly seen in fractures of the shaft of the tibia. There are several reasons for this: the tibia is the commonest major long bone to be fractured; it is very commonly a compound fracture; it is a fracture which is easily exposed and therefore tempts inexperienced operators; it is a subcutaneous fracture and after plating is especially prone to defective wound healing accompanied by what in some quarters is euphemistically termed ‘drainage’

We have still a long way to go before the best method of treating a fracture of the shaft of the tibia can be stated with finality. I feel sure that a closed method will eventually prevail, but we need mechanical aids to improve our control of the bone fragments. It is possible time will show that an intramedullary rod, introduced through the tibial tubercle, without exposing the fracture site, will be enough to enhance alignment as an adjuvant to closed methods. Used in this simple way the intramedullary rod will not be responsible for immobilisation; it will merely control alignment and prevent slipping of the reduced fracture.

Most surgeons who practise internal fixation of tibial fractures do so with the idea that accurate coaptation of the fragments, combined with rigid fixation, enhances the ability of the fracture to unite. I have attempted to show in Chapter I that this mechanical approach to fracture healing is out of touch with biological reality.

It is a fortunate thing that excellent functional results usually follow the common Colles' fracture, because disappointing anatomical results occasionally develop even in the most skilful hands. Though in general it is fair to class this injury as a minor fracture, this is not always the case, because the group includes a substantial number of comminuted fractures which would demand elaborate mechanical treatment if perfect anatomical restoration were to be the most important aspect of the problem.

From the student's point of view it is confusing that this common fracture is satisfactorily treated by a method which transgresses two of the basic principles of fracture treatment because, as will be shown later, the dorsal plaster slab is mechanically unsound as a method of fixation, and the position of flexion of the wrist is contrary to the general rule of splintage in the optimal position for function. Here, however, is an example of a method which is sanctioned by results and by convenience rather than theory, and these are very important practical matters in a busy clinic.

ANATOMY OF THE FRACTURE

The triple displacement of a Colles' fracture, i.e., dorsal shift, dorsal tilt, and radial shift of the distal fragment, constitutes the classical ‘dinner-fork’ deformity known to every student. Less obvious, but more important as regards treatment, are the ruptured soft parts which accompany this displacement.

In this third edition I have persisted in my attempt to write a book on the conservative treatment of fractures which at one and the same time would be a vade-mecum for the junior man and an interesting treatise for the experienced surgeon. It might be considered that these two objectives are incompatible, and that it would have been better to have written a simple textbook for the junior and to have reserved my ponderings on the nature of fracture repair for a separate monograph. In the training of young surgeons I believe that the attempt to foster the habit of making clinical observations and questioning accepted beliefs ought to start from the earliest moment. There is still a great deal of fundamental information concerning the healing of fractures waiting to be deduced, by the process of logic and close reasoning, from clinical facts collected in the operating theatre and out-patient department.

There is a tendency to imagine that serious research nowadays can only come out of a laboratory, and that contributions from the pure act of thinking on clinical facts ended with the great clinicians of the past. The old clinicians had their faculties for observation by sight and touch heightened by the absence of X-rays and laboratory tests. But though the clinical acumen of the old observers was greater than ours, it was frequently offset by a strain of credulity, which is apparent in a different form among clinicians to-day.

It is over thirty years since Arbuthnot Lane published his Operative Treatment of Fractures; but we still cannot compare conservative and operative principles from the viewpoint of basic science because the fundamental nature of fracture repair still eludes us. The best we can do is to compare the results of clinical practice; but there are so many variables (comminution, sepsis, mechanical details of the operation, blood supply, level of fracture, different observers, etc.) that a series of one or two hundred cases, which is a large series for any one operator, is soon reduced to statistical insignificance. Attempts to control the conditions of the fracture by using experimental animals have yielded nothing of importance compared with what we have learned ‘the hard way’ by developing operative techniques on the human subject.

The followers of Lane and Sherman believed that the failures of internal fixation would ultimately be eliminated by improved technique. We now know that internal splints are exposed to truly enormous forces and are subject to the phenomenon of failure by fatigue. Improvements in the design of plates and screws have reduced, but not eliminated, the mechanical failures which were common when techniques derived from the woodworker were used. The change to using electrolytically inert metals has only slightly diminished our problems, though there is no excuse for returning to the brass screws and reactive steel plates with which Lane himself achieved sufficient success to establish the method.

The precision with which it is possible to reduce a Pott's fracture by manipulation becomes a source of pleasure once the surgeon understands the mechanics of this reduction. My own satisfaction is increased when I recall the uncertainty of my own early attempts to reduce this fracture-dislocation and how I was once dependent on the X-ray as on a ‘lucky dip.’

The problem in treating a Pott's fracture is not so much how to reduce the fracture but how to make sure that it will stay reduced. I shall endeavour to indicate when I think it is dangerous to persist with closed reduction and when operative aid should be invoked.

Operative treatment of the Pott's fracture is not a procedure to be encouraged as a routine, because there are special complications of operative treatment quite as serious as the defects of closed treatment. In the ordinary Pott's fracture the functional and anatomical results of a skilful closed reduction should be perfect. Even if a small posterior marginal fragment remains displaced, the ankle possesses a latitude for recovery of function which is often astonishing. The open reduction of this fracture-dislocation can be a matter of considerable technical difficulty; to secure adequate exposure in the cramped space available may impair the blood supply of a detached fragment. If for any reason open reduction should be attempted, nothing less than a ‘hair-line’ restoration should be regarded as justifying it; incomplete reduction after open operation must be regarded as an error of judgment. If open reduction is considered imperative, then the minimum of metallic ‘hardware’ should be used.

The reduction of a supracondylar fracture of the humerus can become a comparatively simple feat if it is undertaken without delay and if the surgeon who has the first opportunity of treating it has a clear mental picture of its mechanism. The first reduction is the one most likely to succeed; after subsequent attempts the elbow becomes so indurated that the swelling may obstruct even the most expert manipulator.

ANATOMY OF THE FRACTURE

In the supracondylar fracture of the humerus the fracture line passes more or less transversely through the metaphysis at a variable distance from the epiphyseal line. When the fracture line is extremely close to the epiphyseal line it sometimes appears in the X-ray almost as an epiphyseal separation, but in every case a thin shell of the diaphysis is adherent to the distal fragment.

There are three elements in the displacement of the distal fragment of the supracondylar fracture: (i) posterior displacement, (2) lateral (or medial) displacement, and (3) rotary displacement.

In the manipulative reduction to be described, the rotary deformity will more or less correct itself under the influence of the tense fascial structures in the course of the preliminary phase of reduction by traction. An error of 10 degrees of rotation will not affect the functional or cosmetic result, though it will give rise to interesting appearances in the radiograph which need special comment (see below).

Opinions vary considerably on the frequency of late symptoms following unsatisfactory reductions of a Bennett's fracture. Casualty officers do not usually find it an easy fracture to reduce, and because it is also quite a common injury, one can presume that numerous cases must be treated inexpertly every year; but even so, the number of cases presenting themselves with symptoms of traumatic arthritis is remarkably few. However, this is no reason why a high standard of manipulative reduction should not be expected. The reduction of this fracture presents no great mechanical difficulty but it demands from the surgeon a fine sense of touch, and for this reason the injury could well be used as a ‘passing-out’ test for the student of closed reduction.

ANATOMY OF THE FRACTURE

As its alternative name implies, the ‘stave’ fracture is often sustained in a bout of fisticuffs. An ill-delivered blow transmits force in the line of the thumb while in flexion, thereby shearing off the anterior part of the base of the metacarpal, and so allowing the bone to escape from the joint in a dorsal direction. The volar ligament of the carpo-metacarpal joint remains intact and this is responsible for holding the wedge-shaped fragment of the metacarpal in its normal relation with the articular surface of the trapezium. The essential deformity of this injury is one of angulation with the concave aspect on the volar side; the intact soft tissues which are to act as the ‘hinge’ for the reduction are thus to be found on the volar aspect of the base of the metacarpal.

Perfect anatomical restoration and perfect freedom of joint movement can be obtained simultaneously only by internal fixation. It is possible to argue that most of the difficulties of closed fracture treatment can be traced to the prevention of joint stiffness. Closed methods can offer anatomical restoration only if the start of joint movement is delayed. It is the significance of delay in starting joint movement which is the crucial point in understanding closed methods.

The ultimate recovery of full joint function after a fracture depends on many factors and not only on early exercise. This is suggested by the fact that the end results of conservative treatment, after a slow start, can often be surprisingly good, while those of operative methods, after a very promising start, can sometimes be disappointing. It is therefore obvious that we must review the factors which govern the recovery of joint movement following a fracture, so far as we know them.

In studying the stiffness of a joint following a fracture of an associated bone the greatest danger to the furtherance of knowledge is the too facile acceptance of simple mechanistic explanations. It is probable that the processes concerned with the recovery of joint function are of great biological complexity. Too often there is a tendency to think of stiff joints in terms of stiff engine-bearings or of rusty door-hinges and, with this childlike concept, to devise apparatus to loosen the stiffness by repeated mechanical movements.