The History of Fracture Treatment (2024)

Early Fracture Surgery

Wire Fixation

It is generally believed that the earliest technique of internal fixation of fractures was that of ligature or wire suture and, according to Malgaigne, the first mention of the ligature dates back to the early 1770s. A. M. Icart, surgeon of the Hôtel Dieu at Castres, claimed to have seen it used with success by Lapujode and Sicre, surgeons of Toulouse. This observation came to light when, in 1775, M. Pujol accused Icart of bringing about the death of a young man with an open fracture of the humerus in whom Icart was alleged to have performed bone ligature using brass wire. In his defense, Icart cited the experience of the Toulouse surgeons in the earlier part of the decade, although denying that he himself had personally used this technique in the case in dispute. In a scholarly discussion of Pujol versus Icart, Evans has called into question whether this type of operation was any more than the subject of surgical theory at that time, but Icart’s contention was widely accepted by so many French observers in the 19th century that it is highly probable that bone ligature was performed at least by Lapujode (if not Sicre) around 1770.

On July 31, 1827, Dr. Kearny Rodgers of New York is recorded as having performed bone suture. He resected a pseudarthrosis of the humerus and, finding the bone ends to be most unstable, drilled a hole in each and passed a silver wire through to retain coaption of the bone fragments. The ends of the wire were drawn out through a cannula that remained in the wound. Although on the 16th day the cannula fell from the wound with the entire wire loop, the bones remained in their proper position and union was said to have occurred by 69 days after the operation. The patient was not allowed to leave his bed for 2 months after the operation!

In the introduction to his Traité de l’Immobilisation Directe des Fragments Osseux dans les Fractures (the first book ever published on internal fixation), Bérenger Féraud recounted that, at the beginning of his medical career when he was an intern at the Hôtel Dieu Saint Esprit at Toulon in 1851, he was involved in the treatment of an unfortunate workman who had sustained a closed, comminuted fracture of the lower leg in falling down a staircase. Initial splintage was followed by a period of infection and suppuration, requiring several drainage procedures; eventually, after many long weeks, amputation was decided on. At the last moment, the poor patient begged to be spared the loss of his leg, so Dr. Long, Bérenger Féraud’s chief, exposed the bone ends, freshened them, and held them together with three lead wire ligatures (cerclage) “as one would reunite the ends of a broken stick, and to our great astonishment then guided the patient to perfect cure without limp or shortening of the member, which for so long had appeared to be irrevocably lost.” The patient survived, and the lead wires were removed 3 weeks later; the fracture united, and the workman left the hospital 105 days after his accident and resumed work 6 months after the operation. Bérenger Féraud went on to say:

I assisted at the operation and I bandaged with my own hands the injured for many long weeks. Can anyone understand how this extraordinary cure struck me? The strange means of producing and maintaining solid coaptation of the bony fragments by encircling them with a metallic ligature fascinated me as during my childhood I had heard tales of this technique being performed by Arab surgeons and, until then, had considered this to be a mere product of a barbaric empiricism. … In my childhood, in 1844 and 1845, I heard an old tebib renowned in the environs of Cherchell, in Algeria, for his erudition and his experience, recount to my father who, a surgeon impassioned with our art, avidly questioned native practitioners of French Africa, in order to sort out, from their experiences and their therapeutic means, the scientific principles, which had been passed down to them from their ancestors, amidst some of the ordinary practices of a more or less coarse empiricism. I tell you, I heard him say that in certain cases of gunshot wounds, or when a fracture had failed to unite, the ancient masters advised opening the fracture site with a cutting instrument, ligating the fragments one to another with lead or iron wire … and only to remove the wire once the fracture was consolidated.

It therefore seems that there is some anecdotal evidence to suggest that such techniques had been used in the early part of the 19th century or even before. Bérenger Féraud himself cited the example of Lapujode and Sicre mentioned earlier. Commeiras reported native Tahitian practitioners to be skilled in the open fixation of fractures using lengths of reed.

Screw Fixation

The use of screws in bone probably started around the late 1840s. Certainly in 1850, the French surgeons Cucuel and Rigaud described two cases in which screws were used in the management of fractures. In the first case, a man of 64 sustained a depressed fracture of the superior part of his sternum, into which a screw was then inserted to permit traction to be applied to elevate the depressed sternal fragment into an improved position. In the second case, a distracted fracture of the olecranon, Rigaud inserted a screw into the ulna and into the displaced olecranon, reduced the fragments, and wired the two screws together (vissage de rappel), thereafter leaving the arm entirely free of splintage and obtaining satisfactory union of the fracture. Rigaud also described a similar procedure for the patella. In his extraordinarily detailed and comprehensive treatise on direct immobilization of bony fragments, Bérenger Féraud made no mention of interfragmentary screw fixation, which was probably first practiced by Lambotte (see following section).

Plate Fixation

The first account of plate fixation of bone was probably the 1886 report by Hansmann of Hamburg entitled “A new method of fixation of the fragments of complicated fractures.” He illustrated a malleable plate, applied to the bone to span the fracture site, the end of the plate being bent through a right angle so as to project through the skin. The plate was then attached to each fragment by one or more special screws, which were constructed with long shanks that projected through the skin for ease of removal ( Fig. 1-13 ). He recorded that the apparatus was removed approximately 4 to 8 weeks after insertion and described its use in 15 fresh fractures, 4 pseudarthroses, and 1 reconstruction of the humerus after removal of an enchondroma.

George Guthrie discussed the current state of direct fixation of fractures in 1903 and quoted Estes as having described a nickel steel plate that he had been using to maintain coaption in compound fractures for many years. This plate, perforated with six holes, was laid across the fracture, and holes were drilled into the bone to correspond to those of the plate. The plate was fixed to the bone by ivory pegs, which protruded from the wound. Removal was accomplished 3 or 4 weeks later by breaking off the pegs and withdrawing the plate through a small incision. Guthrie reported that in a recent letter Dr. Estes had said, “The little plate has given me great satisfaction and has been quite successful in St. Luke’s Hospital.” Guthrie also quoted Steinbach as reporting four cases of fractured tibia in which he had used a silver plate by this method and obtained good results. He removed the plate using local anesthesia. Silver was greatly favored at this time as an implant metal, as it was believed to possess antiseptic properties. Interestingly, in this article, Guthrie referred to the use of rubber gloves during surgery, seemingly antedating the reputed first use of gloves by Halstead.

The man who coined the term osteosynthesis was Albin Lambotte (1866 to 1955), although Bérenger Féraud referred to the restoration of bone continuity by ligature or bone suture as synthèsisation. It is believed, however, that by osteosynthesis Lambotte meant stable bone fixation rather than simply suture. Lambotte is generally regarded as the father of modern internal fixation, and in his foreword to a book commemorating the works of Lambotte, Dr. Elst briefly discussed the early attempts in the 19th century at surgical stabilization of bone and then continued, “Thus at the end of the last century, the idea was floating among surgeons. As always in the field of scientific progress, comes the right man in the right place, a genial mind who collects the items spread here and there, melts them into a solid block and forges the whole together. So did Albin Lambotte in Belgium, a pioneer of osteosynthesis.”

Lambotte ( Fig. 1-14 ), the son of a professor of comparative anatomy, biology, and chemistry at the University of Brussels, was taught almost exclusively by his brother Elie, a brilliant young surgeon, who sadly died prematurely. Albin had worked under the direction of his brother at the Schaerbeek Hospital in the suburbs of Brussels and then in 1890 became assistant surgeon at the Stuyvenberg Hospital in Antwerp, rapidly progressing to become the head of the surgical department. From 1900, he tackled the surgical treatment of fractures with great enthusiasm and much innovation. He manufactured most of his early instruments and implants in his own workshop, developing not only plates and screws for rigid bone fixation in a variety of materials but also an external fixation device similar in principle to the ones in use today. He met with much intellectual opposition, but his excellent results were persuasive. In 1908, he reported 35 patients who had made a complete recovery after plate fixation of the femur. His classical book on the surgical treatment of fractures was published in 1913. His legendary surgical skill was the product not only of a keen intellect but also of his extraordinary manual dexterity, which was also channeled into his great interest in music. He became a skilled violinist, but this was not enough for him, and he subsequently trained as a lute maker. He, in fact, made 182 violins and his name is listed in Vanne’s Dictionnaire Universel des Luthiers. Elst related the following anecdote as an indication of Lambotte’s manual skills:

One day Lambotte was in Paris staying at the Hôtel Louvois, at that time, and even nowadays, the Belgian headquarters in Paris. One morning he was on his way to the Avenue de l’Opéra, accompanied by a young colleague who was the one who told me the story. As he made his way through the old narrow streets, lined with windows and workshops belonging to every type of craftsman, Lambotte would enter one or two, admiring each one’s dexterity and set of tools and discussing their methods like an expert. All of a sudden he stopped short, gazing with marvel at the instruments of a shoemaker. The idea of a new type of forceps had struck him. Suddenly inspired, he strode quickly towards the famous manufacturer of surgical instruments, the Collin factory, neighbouring the area that he was in. With great gestures and explanations, he tried to describe the instrument he desired. It seemed as if nobody could understand him, and not being able to endure it any longer he took off his jacket and rolled up his sleeves. Before a flabbergasted audience, he began to forge, file, hammer, strike, model and so finish off the piece of iron. They were all stunned with admiration and one of them came up to him and said “I have been here for forty two years sir, and never have I seen anybody work like you.” Lambotte went away deeply moved, confiding in his companion “That is the highest prize I have ever received. It moves me as much as all the academic titles.”

As if these qualities were not enough, he is also recorded as being an extremely hard-working and kind man, noted for his devotion to his patients; a patron of the arts; and a great surgical teacher. Indeed, before World War I, the brothers Charles and William Mayo would take turns coming and spending several weeks in Antwerp. It is said that as soon as they disembarked, they devoted all their time in Europe to Lambotte and left only when their work in Rochester called them back. As an indication of the esteem in which he was held, among the many international figures attending his jubilee celebration in Antwerp in 1935 were René Leriche, Fred Albee, Ernest Hey Groves, and Vittorio Putti. The Lambotte instrumentarium remained in regular use until the 1950s ( Fig. 1-15 ).

The History of Fracture Treatment (2024)

Early Fracture Surgery

Wire Fixation

Screw Fixation

Plate Fixation

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