THE OPEN METHOD OF TREATING FRACTURES.*

BY F. N. G. STARR, M.B. (TOR.),

Associate Professor of Clinical Surgery, University of Toronto.

Mr. President and Gentlemen,-Upon more than one occasion I have been consulted by patients with a deformed extremity resulting from a fracture that has either not been properly reduced, or that has not been kept in position after reduction, or that has been in the neighborhood of a joint, and though perfect reduction and union have been secured, yet deformity of the limb has resulted owing to stiffening of the joint.

It seems to me that, when there is difficulty in reduction, or when there is failure to keep the broken fragments approximated, or when the fracture is in close proximity to a joint so that the associated inflammation may lead to ankylosis of that joint, or in fractures of both bones of the forearm where ankylosis of the radius and ulna may occur, the safer course to pursue is to cut down at once upon the fracture and unite the fragments by artificial means. In this way, the length of the convalescence is shortened, subsequent operations-if one succeeds in his asepsis -are avoided and one is able to begin, with safety, passive motion. of the implicated joint at a much earlier period.

Of course in fractures near a joint where the bones are superficial this is not as essential, as for example in Colles's fracture, for here one may begin passive motion in a week by carefully steadying the broken fragments between the fingers and thumb, and thus secure an ideal result.

In connection with these remarks I desire to record a few cases in the treatment of which I have adopted the open method.

The first case that I shall mention was in a boy, aged 8 years, who, by falling from a six-foot fence, knocked off the external condyle of the right humerus. The line of fracture extended from the right external supra-condyloid ridge downward and inward through the radial head of the humerus. After some manipulation under chloroform, I thought I succeeded in reducing the fracture, and applied a temporary splint. At the end of five days, when I removed this splint to apply an Aikins, I found the fragment again in its faulty position, with its pointed end threatening to come through the skin. Dr. Peters saw the case with me, and again under chloroform we tried to secure reduction, but failing, decided to cut down upon the fracture. Accordingly, under proper antiseptic precautions, an incision was made over the

* Read at meeting of the Canadian Medical Association, London, August, 1903.

posterior and outer aspect of the external condyle, and the fracture exposed. Imagine our surprise at finding the fragment completely rotated upon itself so that the articular surface looked upward and forward. It was with the greatest difficulty, too, that this was brought into its proper position. Apposition of the fragments was finally secured by grasping the condyle with forceps, and using a strong periosteal elevator as a fulcrum. The fragment was then wired in place, the wound closed without drainage, and an Aikins' splint applied. Union by first intention was secured, and at the end of eight days passive motion was commenced, and carried out daily for two weeks, when the splint was removed altogether, and the child encouraged to use his arm. He was given a small pail to carry about, and from day to day additional weight was added so as to secure a good carrying angle at as early a date as possible. The result was very good indeed, for in six weeks he was again riding his wheel and playing ball with the other boys.

The second case, in a female aged 45, was one of fracture of the surgical neck of the humerus, with dislocation of the head, occurring in the practice of Dr. W. A. Sangster, of Stouffville, some eight weeks before. The doctor, after several unsuccessful attempts to reduce the dislocation, very properly brought the broken ends together, and put the limb up in this position, hoping to secure union, and then having the humerus as a lever, he hoped to be able to reduce the dislocation. I am reporting this case, not because it can, strictly speaking, be called a recent case, but to show the advantages of the open method over the usual methods laid down in some text-books. Under an anaesthetic, I endeavored to reduce the dislocation by Kocber's method, hoping for failure lest success might mean a rupture of some of the axillary contents. My hopes were realized in that, at the first attempt at manipulation, the recently united fracture at once gave way-in fact, very little attempt at union had occurred although the fragments were in perfect apposition. With Mr. Cameron's assistance, I cut down by means of an anterior incision, commencing just external to the coracoid process, and carrying the incision downward for about three inches, dividing the skin and fascia. The fibres of the deltoid were then torn apart, and the fracture exposed, while the dislocated head rested under the coracoid. Even now all attempts at reduction of the dislocation failed, consequently it was decided to excise the head. After stripping up the periosteum, and then detaching the muscular insertions, the head was removed without much difficulty. The ragged edges of the upper end of the lower fragment were snipped off, a drainage tube inserted, the wound closed, and an Aikins' splint applied. At the end of thirty-six hours the drainage tube was removed, but for four or five days

a considerable amount of bloody synovial fluid continued to drain away. At the end of ten days, the wound was entirely healed, and before three weeks passive motion was commenced. The patient left the General Hospital at the end of five weeks, and was then able, with some assistance, to put her hand to her forehead, and to carry a small weight in her hand without discomfort. Up to this period there had been no shortening. The last I heard of the patient is that she has a useful arm, and is able to do her housework. (Figs. 1 and 2.)

The third case that I shall mention is a somewhat complicated one, which occurred in the practice of Dr. Richard Raikes, of

Midland, with whom I saw the case upon the day of the injury. A lad, of 19 years, fell from a lumber yard truck, alighting upon his shoulder. Under an anesthetic, what I first took to be a dislocation of the head of the humerus was easily reduced, and as easily recurred. A mass was then discovered under the clavicle, but no amount of manipulation would move this. Thinking we had to deal with another case of fracture with dislocation of the head, I thought the best treatment would be to cut down upon the part, reduce the dislocation, if possible, and wire. Consequently, by means of the anterior incision, as already described, I exposed the site of injury. Upon exploring with the finger, I found the lump under the clavicle to be a knob of callus on its under sur

face, resulting, as I afterward discovered, from a fracture of that bone two years previously. I then turned out the upper end of the lower fragment of the humerus, and found it rounded and burnished. Upon making this discovery, we felt satisfied that we had to deal with a dislocation of a false joint, which would account for the difficulty experienced in keeping the limb in place, when reduction had first been tried. Upon feeling for the

Representing lines of fracture in lower end of humerus in Case 4.

head it was found in the glenoid cavity. By grasping it with a pair of forceps, one was able to satisfy himself of its mobility. Its under aspect was hollowed out, making a socket for the new head. This socket was scraped out to freshen the surface, and from the upper end of the lower fragment a thin shaving was snipped off. The outer surface of each fragment, as far forward, and also as far backward, as possible, was then drilled, and two heavy silver wire sutures inserted, which, when tightened and