nerve can be lifted out from between the fragments, should that condition exist. We thus lessen the chances of deformity, non-union, neuralgia, atrophy, necrosis, and ankylosis. When the fragments have been adjusted they can be absolutely retained as you left them, tissue, muscle, nerves, and periosteum can be sutured. Pain is also relieved if due to extravasated blood, or inflammatory exudate. Incision even lessens the danger of gangrene, and the pain during the course of treatment is lessened, owing to practical immobilization, repair of the break and restoration of functions taking place more rapidly than under ordinary methods of treatment.

nerves.

Displacement of fragments and imperfect immobilization are the prime factors in causing exuberant callus and thereby impairing functional results with accompanying pain. Displacements of detached fragments in compound comminuted fractures are often not recognized, much less corrected, without intervention by exploratory incision. In oblique fractures, compound as well as simple, the interposition of soft tissues takes place more commonly than is generally supposed, and not infrequently is the cause of non-union. Overriding of fragments is frequently productive of harmful pressure upon important vessels and Direct treatment of fractures in well selected cases does not add to, but rather diminishes the danger of traumatic infection, provided the operation is done with the necessary care and thorough antiseptic precautions. It certainly seems that the time is at hand when fractures presenting the indication for direct fixation should be treated upon the same principles as wounds of the soft parts, to wit: To bring into apposition and hold in contact by direct temporary mechanical measures, the different anatomic constituents of the wound until the process of repair is completed. As soon as this method of treatment is perfected and more generally adopted, we shall hear less frequently of the many unsatisfactory remote results of these injuries, such as delayed union and pseudoarthrosis, paralysis, impaired health from long confinement in bed, excessive shortening, angular deformity, displacement, rotation by and permanent injury to adjacent joints from long continued extension.

Now as to the kind of suture selected it will depend somewhat on the particular case, all kinds having been used, for instance silk, silkworm gut, ivory or bone pegs, metallic screws and pegs, or wire. Silver wire in my estimation is decidedly the best, as it is non-irritating, and soon encapsulated by the tissues. Whatever is used must be firm, unyielding, and remain as left by the operator at the time of application. The antiseptic qualities of silver wire places it in the first rank, it being able to resist the greatest tension, retaining perfect immobilization and preventing shortening in oblique fractures. I may also add that bone is very tolerant to silver wire, and if the wound remains aseptic, permanent encapsulation of this suture is the rule, not one of my cases but healed by first intention. I cannot but condemn catgut, it will invariably give more or less, particularly if any tension exists. In the case in which I tried it perfect apposition could not be maintained, the knot would slip and the suture yield, so I was compelled to re-operate and use silver wire. Should an appropriate case present itself I would not hesitate to use ivory, bone, or metal pegs, or screws, yet I

believe cases are very rare indeed where they are to be preferred to silver wire.

In badly comminuted fractures, the loose fragments may be temporarily removed, disinfected in a warm 21⁄2 per cent solution of carbolic acid, or 1,000 bichlorid, then rinsed in warm salt solution, and replaced after the wound has been thoroughly disinfected, not detached and thrown away as formerly recommended. Even in cases of nonunion the edges can be freshened, and wired with excellent results. Should a gap appear and removal of much bone be necessary, fill in the gap with decalcified bone chips, or healthy bone at your disposal, cover with periosteum and connective tissue, sewed separately, and put limb up in plaster cast.

Very recently there is a fresh impetus to the use of silver wire in operative surgery, and if you will pardon me I will digress a little. Schede was the first to champion the use of silver wire, closing abdominal incisions with a view to preventing a subsequent hernia; his suture embraces the entire thickness of the abdominal parietes exclusive of the skin. He has practiced this method for many years, and has never seen a ventral hernia occur after any of his abdominal operations, where the wound could be thus closed. To Willy Meyer of New York, belongs the credit of the most happy results in closing and positively curing excessively large ventral hernias with atrophied walls or loose cicatrices and in consequence of previous surgical intervention by the implantation of a silver filigree wire, using in one instance a pad 4 by 634 inches. Until very recently this was used only where the aperture was of enormous dimensions, and no results could be expected by other methods. I may add, however, it is being done by a few surgeons in all questionable cases, regardless of size. Think of the cases that have been operated upon repeatedly without relief, some even refused further operation, fearing negative results. Phelps of New York has been working in this line since 1892, and he advocates the discarding of all absorbable suture material, even chromicized catgut, and kangaroo tendon.

There is no doubt that the field of usefulness for silver wire will be widened as we gain farther experience. What may we not expect in the future? Anesthesia is always necessary for diagnosis and proper adjustment, and it will certainly take but a very few minutes longer to wire, so that I believe it is our duty to ourselves and those we represent to be careful, cautious and accurate, remembering the results we obtain play an important part in the matter of settlement, and redound to our credit. Do not think that I advocate this procedure in all cases of fractures and under ordinary circumstances, as such would be ill-advised, but where the surroundings are favorable, with thorough aseptic work, there need be no hesitation and we may expect better results.

Case 1-O. M. C., male, age 22, laborer. Admitted to Mercy Hospital I a. m. August 7, 1902. Inner surface of elbow burned, as well as other burns on body; the joint badly swollen, black and blue; comminuted fracture of the ulna 11⁄2 inches below the olecranon, extending into the elbow joint, and the fragment split in two pieces; tissues badly lacerated and ecchymosis very marked. Operated August 8, joint opened, blood clots removed, parts thor

oughly cleansed, fragments of bone wired, tissues sutured, wound closed. Unfortunately one of his burns was in close proximity requiring frequent dressings, splints adjusted, wound healed by first intention, burn not so rapidly, but did well; gentle passive motion was used, increased with each subsequent dressing. Discharged September 9, with extension to within 2 inches of normal; had him return to Des Moines from his home once a week for two weeks, at which time I discharged him with the most perfect results.

Case 2-E: D., male, age 27, laborer. Admitted to Mercy Hospital 1 p. m. August 7, 1902. Comminuted fracture of the clavicle in three places, one section in minute particles driven in different directions into the surrounding soft tissues; quite large ecchymosis; parts badly contused. Operated August 8th, exploratory incision, clotted blood and a very few spicula of bone removed (such as could not be used in adjusting the shape and contour of clavicle proper); wound properly cleansed and closed. Arm and shoulder supported by the usual method for such fractures known as Velpeau bandage; wound dressed every three or four days, or when dressing became loose and needed readjustment.

Healed by first intention, the contour and the usual prominence of the clavicle perfect; had it not been for the slight scar no one could have told which one had been broken. Discharged September 17, 1902.

Case 3-J. M., male, age 32, laborer. Admitted to Mercy Hospital I a. m. August 7, 1902. Compound comminuted fracture of the clavicle in four fragments, ecchymosis marked, parts contused in addition to other injuries. Operated August 9, removed dirt and debris, adjusted fractured bone, wired, cleansed under thorough antiseptic precautions, and closed wound, primary union. Arm and shoulder supported properly, dressing when necessary, recovery complete, and results perfect.

The three cases are sufficient, I think, to prove the advisability of such procedure and show results not obtainable under former modes of operating.

There was one case not mentioned in which I used catgut and was compelled to reoperate and use silver wire, as it proved a failure, tension too great, could not retain adjustment or satisfactory coaptation. This leg was so thoroughly mangled and tissue necrosed that septic conditions arose, compelling amputation later on.

In the case histories I mention only the part referring to the fractures, omitting the numerous other existing conditions.

FRACTURES IN THE NEWBORN.-Wilson details the etiology and diagnosis of various fractures in the newborn. In general, there are certain positive signs which should lead to the diagnosis of fracture. Among these are the infant's cry indicative of pain, disability as to motion, dimpling of the overlaying tissues, swelling of the soft parts and undue mobility. The evidence of displacement revealed by the radiograph is, of course, conclusive. On the other hand, the degree of displacement and the differentiation of fracture from dislocation is sometimes obscured by the presence of fat in overgrown children.— Philadelphia Med. Jour.

THE TREATMENT OF DELAYED UNION AND
UNUNITED FRACTURE.*

BY EMORY LANPHEAR, M. D., PH. D., ST. LOUIS, MO., CHIEF
SURGEON OF THE WOMAN'S HOSPITAL OF

THE STATE OF MISSOURI,

Some recent experiences have led me to believe that ununited fracture is of more frequent occurrence than we have been taught to be the case. Notably, the number of cases seen, the frequency with which the question is asked: "How do you treat delayed union?" and the fact that the X-ray reveals the presence of such a condition when fracture near a joint has resulted in functional helplessness. Adding to this the further truth that recent text-books on surgery give but scanty mention of the subject, and in very unsatisfactory terms, a reasonable excuse for this paper is furnished.

DEFINITION.

Two expressions are used rather loosely relative to non-union of bones: Delayed union and ununited fracture. These two are so intimately associated that it is impossible to discuss them separately save as to therapeutic measures.

As a broad rule it may be said that a case should be classed merely as one of "delayed union" when there is pain on passive motion and little or no voluntary muscular movement of the extremity-in which condition persistence of absolute rest in good position should be adopted. But if there is no pain at the site of the false joint, and if voluntary movement of muscles about the joint is practiced by the patient, the case should be regarded as "ununited fracture" and subjected to operative treatment.

The distinction is, therefore, one of condition, and not of time. Indeed the question, "When does a case cease to be delayed union and become ununited fracture?" is one which cannot be answered in days, or even weeks or months. Union of bone depends upon so many thingsthe character of treatment employed, the disposition of the patient, environment, and somewhat upon the general health of the individual, very much upon the location of the injury and whether a closed or open wound-that even a distinction by the clinical signs mentioned, plus a reasonable time for healing of the particular bone affected, may deceive even the most experienced surgeon in the matter of prognosis. For this reason the surgeon should not be in too much of a hurry to operate in closed fractures; by absolute fixation very much may be accomplished, sometimes long after non-operative treatment would seem hopeless.

Illustrative Case.-In a patient of 45 with fracture of the femur at the surgical neck, examined more than three months after injury, there was such free movement that prominent surgeons declared the man would be a cripple for life if he did not submit to operation. The ill-fitting,

inadequately supporting plaster of Paris cast was abandoned (it is a very objectionable dressing for fracture of the femur, at best) and a long Taylor splint applied, with a pad over the trochanter held in place by a wide belt around the pelvis; this gave truly perfect immobili

*Read at the sixteenth annual meeting I. A. R. S., Indianapolis, June 17-18-19, 1903.

1

zation of the joint and fracture (and the knee as well-
an important item). In eight weeks union was complete.

CAUSES.

The chief causes of non-union are:

(1) Imperfect apposition of fragments. The presence of muscle, ligament, synovial membrane, splinter of bone, periosteum or even huge clots of blood between the ends of the bone, as well as the overriding of fragments, prevent early (or even any) bony union.

(2) Improper dressings.-Splints wrongly or loosely applied, so that motion of the ends of the bone occur, are almost sure to bring slow or imperfect union or even nonunion.

(3) Too early movement.-Either by removal of dressings for passive motion or active use or by the adoption of the ambulatory treatment in fractures of the lower extremity vicious or imperfect union. may result.

(4) Infection. In compound fractures the presence of germs prevents early or perfect union. Even though active suppuration may not appear, small quantities of pyogenic cocci may hinder bony union, especially if free drainage has not been provided. Many cases of "typhoid fever," "continued malarial fever" and even "pneumonia," said to follow fracture, are but septicemia of mild degree, as may be easily demonstrated by recourse. to the Widal test, examination of blood for plasmodium and the sputum for the pneumococcus respectively.

(5) Lack of blood supply.-By reason of too tight bandaging, or by injury to the blood vessels at the time of accident (as when there has been great contusion), nutrition of the injured parts may be so seriously interfered with as to result in failure of the bone to unite.

(6) Constitutional Conditions. . Certain general causes, as syphilis, tuberculosis, rickets, pregnancy, diabetes, scorbutus and phosphaturia, as well as some acute febrile diseases, tend to prolong the process of bony repair, and may-in rare instances-cause final non-union.

PATHOLOGY.

When union is merely postponed for a few weeks beyond the regular period for that particular break, the only local condition found is an excess (rarely an almost total absence) of the so-called provisional callus.

Later on, when by reason of interposition of foreign. substances, etc., the condition has become one of "pseudarthrosis"-typically found in ununited fractures of the humerus, tibia and femur, occurring in the order named as to frequency-upon exposure by free incision, one of two conditions will be found:

(a) The fragments may be loosely joined by solid bands of fibrous tissue often inclosing small nodules of bone the ends of the fragments being in fair condition; or

(b) Within the fibrous bands there may be a cavity containing a fluid resembling the synovial fluid, but containing osteophytes-the ends of the bones sometimes being smooth and hardened, sometimes even covered by a cartilage-like surface (practically a new joint), and sometimes one end almost wholly unchanged, while the other is expanded into a cup-shaped cavity surrounding the first, as if nature were attempting to form a ball-andsocket joint. Rarely, when there has been infection, a

rarefying osteomyelitis will have left its characteristic changes.

Obviously the treatment must vary according to the condition found.

TREATMENT OF DELAYED UNION.

The treatment of delayed union may be tersely expressed as:

(a) Securing perfect immobilization; and

(b) Improving the general health.

The first must be accomplished even at a sacrifice of the latter; but in most fractures save of the femur it is possible to secure perfect fixation and yet allow the patient to be out of doors.

Local measures, like (a) hammering the region of the fracture daily, (b) massage, (c) electricity and (d) blistering, have had strenuous advocates. They are to be condemned. Either surgical quietude of the affected parts will secure desired results or it will not; if it prove unsuccessful operative treatment must be instituted the same as in pseudarthrosis.

As to time for operative intervention: It is not unwise to wait at least six months in absolute fixation, with occasional passive motion of joints above and below the point of injury-these joints always being fixed in the proper treatment of delayed union.

TREATMENT OF UNUNITED FRACTURES.

For the relief of "false joint" many plans of treatment have been suggested.

1. Injection of Irritating Fluids. The injection of various irritating fluids has been tried, with the idea of setting up a plastic exudate which would increase the amount of callus. If interference with the circulation were the only condition present something might be hoped from this, but when one recalls the pathology its futility is apparent.

2. Acupuncture. By the insertion of needles between the ends of the fragments it has been hoped to stimulate the formation of strong bony callus-Brainard's drills being but a modification of this plan. In delayed union dependent upon some constitutional trouble, and not on local conditions, this treatment is sometimes effective; but when the trouble has gone on to true ununited fracture it is useless.

3. Setons. Introduction of setons was advocated by the older surgeons. I know of no one who would practice this treatment to-day.

4. Electrolysis. Great things have been promised from electrical treatment, but it has proven a dismal failure in these cases.

5. Subcutaneous Section of Callus.-The use of a knife or chisel introduced though the skin at a considerable distance from the site of fracture has had some strong commendation, and where vicious union or superabundance of callus are the chief object of attack may be advisable; but in a general way this method of treatment, like the previous ones, is to be condemned.

6. Rubbing.-Violent rubbing together of the ends of the bone has been practiced by many great surgeons, especially when the trouble has not existed very long. If followed by complete fixation for weeks, including the joints above and below the point of fracture, it may be successfully tried in many early cases; and may be em

ployed in iate cases where operation is denied-but with guarded prognosis.

7. Apparatus.—In late cases when operation is declined, and with patients in whom a bad result has followed operative measures, recourse must be had to fixation apparatus. The ingenuity of a good instrument maker, coupled with the knowledge of a practical surgeon, may give a useful arm or leg that would, without their aid, be an incumbrance. Nothing definite can be said relative to plans, as each individual case must be carefully studied and its particular indications met.

8. Operation. When we come to the consideration of the operative treatment the importance of clearly understanding the pathology becomes at once apparent: That which is appropriate for a fibrous union is wholly inadequate in a false joint with one fragment the site of extensive rarefying osteomyelitis.

The advisability of operating is a question which requires much judgment and some study to answer. The location of the injury has much bearing upon the subject, as has also the general condition of the patient and his surroundings; to attempt operative treatment upon an ill nourished patient in a farm house with an ununited fracture of the leg, for example, would be scarcely less than criminal. Indeed typical "wiring" of such a fracture is a formidable undertaking in even the best hospitals; it should be remembered that there is a 20 per cent mortality in wiring the femur. I, myself, have had two fatal cases; one of the femur and one of the tibia; and have had a considerable number of amputations where operation (by myself and others) had failed. Operations upon the upper extremity are not so apt to be followed by disastrous results, yet even here the uncertainties are such as to make one pause. At best it is always well to plainly state the possibility of failure, and let the patient decide whether or not he will take the chances. (a) Pegging. The use of ivory pegs had an enthusiastic advocate in my late lamented friend and teacher, Dr. Christian Fenger, of Chicago; and there are many who yet use the pegs after drilling the bone in such way that the pegs will hold the ends in apposition. They are especially recommended in cases where there is a strong tendency to the overriding of the fragments in an oblique fracture, even after the callus is cut away and the muscles freely divided. Personally I have never employed them and do not advise their use.

(b) Nailing. The use of wire nails instead of ivory pegs has been highly praised by some authorities. I have introduced them a few times, and have had excellent results; but I am now convinced that the same ends might have been attained without the dangers accompanying their use. I have therefore abandoned this plan of treatment, even in cases where there is very little destruction of bone-tissue.

(c) Wiring.-The operation which has been most popular during the past few years consists of (1) cutting down upon the site of injury with a long, free incision; (2) removal of the callus and interfragmentary substance with chisel and bone-scoop; (3) fashioning the ends of the bone, by chisel, gouge or saw, so that good, healthy v surfaces can be brought together; (4) drilling the ends. of the bone in two places on each fragment; (5) intro

duction of a heavy silver wire through the openings; (6) replacement of the fragments to point nearest the natural position; (7) uniting the ends of the loop of wire, cutting the ends short, and hammering down the twist beneath the periosteum; (8) loosely closing the tissues with drainage to the depths of the wound, and (9)—watching with fear and trembling the outcome of the case. I must confess to a number of dismal failures, as well as some gratifying results. Rarely I have had to cut down and remove the wire long after its introduction.

Candidly I do not believe the wire does much good; certainly where its employment seems indicated chromicized catgut will hold equally well for the required length of time, and is eventually absorbed instead of remaining as a foreign body; however unirritating silver wire may be, it is still a foreign body which must either be thrown out or encysted-each a tedious process. In certain recent cases, then, where there is not much loss of good bone, and in instances of great overriding (as in the femur) suturing the bones with either wire or catgut must at present be regarded indispensable to some surgeons.

(d) Periosteal Suturing.-In most ununited fractures, however, this drilling of bone and direct joining of fragments may be abandoned. If the callus be carefully cut away without great injury to the periosteum, if all substances between the ends be thoroughly removed, and if the freshened fragments be brought into close contact and held in correct position by an intelligent assistant, the periosteum and fascia may be stitched around the break in such way as to give good permanent apposition, if reinforced by appropriate splints—the wound then being closed by suture, with deep drainage, and treated as any other compound fracture.

(e) Packing.-In some late cases, where there has been much absorption of bony tissue with formation of a "joint," neither wiring nor suturing has given satisfactory results in my work. In such cases I have adopted the same plan of treatment found to be advisable in instances where necrosis has followed the use of silver wire. It is the same treatment I advise in non-union of compound fractures, presently to be described-namely, cleaning out the wound and packing with gauze.

Illustrative Case: A man of 28, strong and active, fractured his patella. It was "set" by his usual attendant; result, a two-inch ligamentous union without use of leg. Fibrous tissue was removed and fragments wired by a neighboring surgeon. Necrosis followed. On admission. to hospital he had a useless leg and a rotten patella. It was curetted, and remnants held in place by careful suturing of periosteum and surrounding fibrous tissue, the cavity being filled with iodoform gauze. Slowly the bone reformed by the process of granulation, and in fourteen weeks perfect healing was secured. He now walks with scarcely a limp.

NON-UNION IN OPEN FRACTURE

The principal cause of non-union in open fractures is infection-suppuration. It may not be marked. It may also be present in closed fractures. Fever of alarming character may never be present from the septic infection. Yet deeply within the tissues most interested in the formation of bony union, there is just enough of the pus