fracture of the femur

TRANSACTIONS OF

THE NEW YORK t3 NEW ASSOCIATION OF RAILWAY

ENGLAND SURGEONS

Thirty-Sixth Annual Meeting, New York, October 23, 1926

FRACTURE OF THE FEMUR* JAMES MORLEY HITZROT, M.D., F.A.C.S.

NEW YORK CITY

F RACTURE of the femur is a surgica1 emergency and the immediate treatment shouId be confined to the

splinting of the bone in the axis of the Iimb with suflicient traction to overcome secondary displacements. For this purpose no apparatus is quite as satisfactory as the Thomas spIint, which shouId be avaiIabIe wherever thigh fractures are apt to occur and the method of its appIication shouId be suffIcientIy we11 known to make its use practicaIIy universa1. Misdirected attempts at reduction at the site of the accident onIy produce further IocaI injury and shock to the patient. In my opinion, no femur fracture shouId receive any except emergency treatment at the site of the accident, and the subsequent treatment shouId be carried out by a properIy quahfied surgeon in the proper surroundings and with the proper armamentarium, which, reduced to simpIe terms, means at a hospita1. I cannot see any vaIid objection to the transporta- tion of an individua1 with a fractured femur once the proper emergency spIint has been appIied and except in rare instances a hospita1 is aIways accessibIe.

I. From birth to tweIve years. 2. From fifteen years to forty years. 3. From forty-five years up. In the first group, from birth to tweIve

years, the commonest type is fracture of the shaft. The resuIts in this group are good if the axis of the Iimb is reestabIished and, if the gross overriding and IateraI dis- pIacement are corrected, growth wiI1 take care of the shortening and correct it in the majority of the cases, as demonstrated in the series by Burdick and Siris. ManipuIa- tion and traction usuaIIy s&ice and open reduction is reserved for those cases in which the interposition of the soft parts or periosteum prevents bony contact between the fragments. Direct fixation after reduction need be used onIy if the fragments cannot be maintained in position by any other method.

In any discussion of fracture of the femur the age incidence is of great importance. The important age groups wiI1 vary, but it has been my practice to make three age groups :

In this age group the cases of epiphysea1 separations at the hip and at the knee require compIete anatomica reduction, which shouId be obtained by that method appIicabIe to the given case; and unIess thus obtained reduction by open operation is necessary. There is a definite exception to this statement in the epiphysea1 separations in infants and very young chiIdren, in that many of the epiphysea1 separations, aIthough uncorrected, show the formation of a new shaft with normaI

* Read at the thirty-sixth annua1 meeting of the New York and New EngIand Association of RaiIway Sur- geons, New York, October, 23, 1926.

28

New Series VOL. II, No. I Hitzrot-Femur Fractures American Journal of Surgery 29

deveIopment of the bone after a suitabie interva1. It is a moot question to decide in which cases this happy outcome wiII take place.

In the second group, from fifteen years to forty years, a great variety of Iesions may be found. The commonest are those of the shaft and the character of the Iine of fracture is variabIe, that is, transverse,

method. It requires ski11 and training and a proper understanding of the resuIt to be accompIished before it can be inteIIi- gentIy used. The impression extant, that if tongs or a pin are appIied and traction is obtained by this means on the femur, “the deed is done ” has Ied and wiI1 Iead to unsatisfactory resuIts. To be used properIy skeIeta1 traction shouId correct the over-

FIG. I. Transverse fracture of the shaft of the femur. Reduced by manipuIation under an anesthetic within two hours after the injury. IncompIete reduction. CompIete functional return without shortening. Period of disability, seven months.

obIique, spira1 and cornminuted Iines of fracture occur with varying degrees of frequency in any given series.

In this group manipulation under an anesthetic wiII succeed in producing a satisfactory reduction onIy in very rare instances, viz., in the transverse fractures in individuaIs with weak muscles when the reduction is done within two hours after the injury.

FIG. 2. ObIique fracture, mid-shaft of femur. Skin traction by the Stimson method in Hodgen’s spIint. IncompIete correction in the IateraI plane. Com- pIete functiona return without shortening. Period of disabiIity, eIeven months.

riding, bring the ends of the bone into apposition and bring the axis of the femur into the correct weight-bearing Iine for the individua1. CompIete anatomica repIacement is seIdom obtained.

Traction: Adhesive or skin traction is appIicabIe to onIy a smaI1 group of seIected cases in which the dispIacement is very slight, which can be corrected and in which the correction can be maintained by such traction.

Emphasis shouId be Iaid upon the fact that the femur is not a straight bone. It has a curve pecuIiar to the given individua1 and to obtain a satisfactory Iate resuIt the curve pecuIiar to that individua1 must be restored. The appIication of the tongs or pin is the Ieast important of the steps in the treatment by skeIeta1 traction. The supervision of that traction and the restoration of the weight-bearing axis by abduction of the Ieg, flexion of the hip or knee or bd 0 y, counterpressure or countertraction on the fragments are essentia1; if the end- resuIt is to be a good one.

SkeIetaI traction by means of the pin or It is in this group that most of our diffI- by tongs is perhaps the most satisfactory culties arise since it is in this group that method at present in use; it is not a simpIe the Iarger portion of individuaIs with

30 American Journal of Surgery Hitzrot-Femur Fractures

powerfu1 muscIe groups are found. Here aIso are found the cases in the most active period of industria1 Iife with the greatest need for return to their fuI1 earning capacity.

That that return is not at present being accompIished is UnfortunateIy the case. In g6 cases of fracture of the shaft of the femur treated by skeIeta1 tractiontin the metropolitan district of New York City reviewed by me to estabIish the amount of

joints due to fauIty posture. It is no Ionger satisfactory to consider disabiIity and shortening a necessary outcome of fracture of the shaft of the femur. It is not aIways possibIe to obtain a11 that we strive for, but that does not offset the necessity for doing a11 that can be done to produce the best possibIe resuIt; and a perfect func- tiona1 resuIt with a return to fuI1 earning capacity shouId be our goa1.

FIG. 3. LatemI view of oblique fracture of mid-shaft of femur. Treated by tongs traction. IncompIete correction. CompIete functiona return. Period of disabiIity, six months. The case was a compound fracture, and the skin wound was excised and cIosed. Primary repair of the superficia1 wound.

disabiIity, onIy four had compIeteIy satisfactory resuIts, whiIe the remainder had to be given industria1 ratings from 60 per cent to IOO per cent disabiIity of the Ieg and in one case with a fracture of both Iegs a tota bodiIy disabiIity had to be aIIowed because of the resuIt.

The disabiIity may invoIve the knee, the thigh muscIes and the foot, with Iimp due to shortening and secondary changes in the

FIG. 4. Left: Transverse dentate fracture of the middle third of the femur. MuscIe penetration by the sharp prongs on the lower fragment. Treated by open operation. Right: ResuIt of the operation with six-screw Sherman pIate. Period of disability, six months. CompIete functiona resuIt. PIate has been in position since February, 1915, without causing symptoms.

AnguIation or dispIacement at the site of fracture has been one of the many diffl- cuIties in traction by tongs even under care- fu1 supervision. Doctor N. W. CornelI, my Associate on the Fracture Service at the New York HospitaI (CorneII Division), has evoIved a method which combines skeIeta1 traction with pIaster fixation and which so far has met the above diffIcuIties.

New Srries Var. II. No. 1 Hitzrot---Femur Fractures American JournaI of Surgery 31

A description of his method is to be pubhshed.

With regard to the open operation and the use of stee1 pIates in fracture of the femur, wiseIy used in seIected cases, it is of the greatest value especiaIIy in that group of cases most diffIcuIt to correct because of the powerfu1 muscIes, the interposition of soft parts, etc. Operation is seIdom

FIG. 5. Fracture of the mid-shaft of the femur. Treated by tongs traction, showing one of the failures of tongs traction spoken of in paper. The IateraI view shows very marked angular deformity of the shaft with the apex backward. There is also a IateraI angular deformity with the apex inward.

required in individuaIs under twenty and shouId rareIy be used in those over forty Fears oId. It is not a method to be used by the occasiona surgeon who is not properIy equipped and it is a nice point to decide which surgeon has that equipment. That there are men so fitted that they use stee1 pIates and the open reduction with great satisfaction cannot be disputed, and Sher- man’s cIinic in Pittsburgh is a good exampIe. To the surgeon who has any doubt about the matter the onIy admonition which can be given is: don’t use the method; use any other method, because safety first is better than regret after.

The time of the operation is aIso of the greatest importance. There is a marked difference between operations done before the tweIfth day and those done after

fifteen or twenty days. The early operations disturb the norma bone formation but IittIe, whereas Iater operations inter- fere with the norma sequence of bone repair and the pIates cause troubIe. This disturbance in the norma sequence of events in bone repair is emphasized by Hey Groves as one of the chief factors in non-union, deIayed union and, in my opinion, in infections and secondary muscle changes, with Iimitation of motion in the knee joint, so often reported.

The bone pIate has a distinct place in the treatment of fracture of the shaft of the femur and I have used the pIate in g8 cases with one death and two infections that necessitated the remova of the piate. AI1 three cases were improperly seIected and I wouId not now operate m simiIar types. In the remainder there were no non- unions, no stiff knees, no pIates removed and, except for the muscIe atrophy in the line of the scar, no changes in function or in the anatomy worthy of note. Ninety per cent of the cases were returned to their previous occupation without disability.

After forty, operation shouId be considered onIy when the operation wiI1 give a result that wiI1 compensate for the greater risk connected with the operation; and in the oIder peopIe that method of treatment shouId be seIected which wiI1 fit the needs of the case, that is, the treatment should consider the patient as a whoIe and not the femur aIone.

From forty-five years upward fractures of the femur tend to invoIve a different area and in the oIder patients the most common Iesion occurs at the neck of the femur. Here aIso are found a group of sub- trochanteric fractures which offer dif%cuIt probIems for soIution.

The abduction method of Whitman with the application of the pIaster spIint has given resu1t.s so much better than the other methods that except in rare instances it is the method of eIection for fractures at the neck of the femur.

Repair of the fractures in cases invoIving the narrow part of the neck with a satis-


factory extremity may be expected in 50 to 60 per cent of the cases. My own figures are 66 per cent. In fractures through the base of the neck invoIving the trochanters repair and the functiona resuIt are aIways good.

In the rarer cases of shaft fractures the treatment seIected must be adapted to the individua1 patient and the patient as a whoIe studied to determine how much can safeIy be done. After fifty some dis- abiIity is bound to occur in a11 cases and it is far more important, for this group, to save the Iife of the individua1 than toobtain a perfect anatomica and functiona resuIt.

Diabetics, nephritics, cardiac and arterio- scIerotic patients present a muItitude of probIems -to be considered in treating fractured femurs. Hence, before resorting to any treatment the whoIe of the patient must be studied and that treatment pur- sued which wiI1 fit the individua1 case most SatisfactoriIy.

GentIeness and the avoidance of further injury are, as Darrach has stated, of the utmost importance in eIderIy individuaIs.

The reading of this paper was foIIowed by the exhibition of 52 Iantern sIides, in&ding iIIustrations of Dr. CorneIl’s method of com- bining skeIeta1 traction with pIaster of Paris fixation.

Discussion

DR. ARMITAGE WHITMAN (New York): It is a very difXcuIt task to discuss a paper in which one finds practicaIIy nothing to discuss. Dr. Hitzrot has skimmed the cream off his subject so briefIy, so admirably, that there are very few things I find myseIf prepared to say. I notice a shght note of defiance in his tone as he mentions his appIication of the Lane pIate and his empIoyment of the open reduction of fractures. He evidentIy expected to be vioIentIy disagreed with on this point. I think, myseIf, in properIy seIected cases and in the hands of competent operators this operation is one of the most nearIy indispensabIe that we have.

I was aIso pIeased to hear him say that skeIeta1 traction for fracture of the femur is dif%cuIt and comphcated and requires skiIfuII maneuver and shouId aIso be Ieft onIy to the hands of those competent to appIy it.

From the orthopedic aspect, which I suppose I am expected to dweI1 on, there is onIy one thing I have to say, and that is, I heard him mention getting his patients with fracture of the femur, in which he used pIates, up in ambuIatory splints at the end of three weeks. I think this is very commendabIe, very boId. I shouId hardIy dare do such a thing myseIf. Of course we must reaIize, I think, that the treatment of fracture of the femur does vary according to the surroundings of the patient, the cIass of the patient, the patient’s physica condition and the abiIities of the man who is appIying the treatment.

This is now very much the age of standardization. The American CoIIege of Surgeons is busiIy engaged, through its various committees, in estabIishing standard treatment for a11 types of fractures. I think it is a very commendabIe effort, but I do not beIieve it is ever going to work, and I shouId imagine in associations such as this, that is of raiIway surgeons deaI- ing with traumatic cases, that various surroundings wouId find themseIves particuIarIy opposed to this standardization.

A treatment that may be successfu1 in a specia1 fracture ward, for exampIe, of a Iarge hospita1 wiI1 be absoIuteIy inappIicabIe in a smaI1 one, where the surgeon cannot give the case his daiIy persona1 attention.

We have, therefore, at our command three methods of treatment, that is by traction in suspension, by pIaster of Paris and by open operation. AI1 these methods are good in certain hands and in certain cases. They have their advantages and they have their disadvantages.

Traction in suspension is comfortabIe for the patient. It aIIows motion in the joints of the fractured Iimb. In skiIfu1 hands it is a most exceIIent treatment for aImost any type of fracture. On the other hand, I know of no treatment in unskiIfu1 hands which is SO diffrcuIt of application and so unsuccessfu1 in its resuIts. IncidentaIIy, it is entireIy at the mercy of anyone who comes in contact with the patient, or at the mercy of the patient himseIf. He may sIide around in bed, disarrange his weights, puI1 his ropes off the puIIeys, and, in generaI, render the treatment entireIy futiIe. It is undoubtedIy, as I say, in speciaI wards in Iarge hospitaIs a most vaIuabIe method of treatment.

Second is the pIaster of Paris treatment, which, unti1 the Great War, was the method aImost universaIIy empIoyed. There again,

New Series VOL. II, NO. I Hitzrot-Femur Fractures American Journal of Surgery 33

plaster of Paris properIy apphed is comfortabIe. The patient is absoIuteIy under the supervision of the person who has applied the cast and, in the majority of cases, the fracture having been once reduced and pIaster of Paris apphed, the thing is finished. You are comfortable in your own mind for about two months, at Ieast.

On the other hand, pIaster of Paris not properIy appiied is the most uncomfortabIe dressing that couId possibIy be devised, and very dangerous, as it exposes the patient to the risk of bed sores, and I have seen patients pract.icaIIy kiIIed by its application.

The third method of treatment, that is of open reduction and the appIication of Lane plates, in skiIIed hands, has most beautifu1 resuIts. In unskiIIed hands its resuIts are tragic.

What I mean by a11 this is that I hope before I die to see peopIe who are treating fractures of the femur, or fractures anywhere, skiIIed in these three methods of treatment, and that each case wiI1 be judged according to its own merits, according to the surroundings in which one finds it necessary to treat the patient, and according to the particular individua1 ski11 of the man who has the case in his charge. There- fore, I hope in the future that the treatment of fracture of the femur wiI1 be the treatment not of standardization but the treatment of election.

DR. EDWARD WALLACE LEE (RandoIph, N. Y.) : Treatment of the fracture of the femur is a tremendous question. From what I see going on now and from what I have seen in the past, it has not yet to my mind reached any- thing like a satisfactory status.

During the War fractures were handIed in a great many instances in what I thought was a ridiculous manner. Everything was done to get a satisfactory roentgen-ray picture, and I have seen fractures put up and taken down a dozen times in an effort to accompIish this. Of course, a roentgen-ray picture is absolutely necessary; but before we had the roentgen ray we did not get good functional resuhs in fractures, and since its advent there has been so much disturbance in trying to get an aIignment corresponding to what the picture demands as a good result that the patient is often worn out, union is deIayec1 and there are unsatisfactory resuIts, just because the extremity was manipuIated day in and day out in order to get a perfect picture.

There are severa indications that are demanded in a fracture. In the first pIace, proper adjustment, proper aIignment. If you

can get that, and then estabIish traction, and something to hoId the bone in aIignment, you have accompIished a11 that is necessary. There has been too much fussing with fractures. DR. BAKER (Rochester): I wouId Iike to ask

Dr. Hitzrot in his open reductions what type of preparation he uses, particuIarIy as to the Iength of preparation, the type of skin preparation, etc.

There is one thought that I have in regard to the cases that are beginning to show circuIatory decompensation. I have been having some very happy resuIts in the use of pIaster by turning the patient first on one side and then on the other side, tipping the bed up at the foot, and IastIy turning the patient directIy over on the face, to eIiminate as nearIy as possibIe the risk of hypostatic concIitions of the chest. Indeed by this method I have been fortunate in not having any signs of the stasis.

DR. WILLIAM B. COLEY (New York): Dr. Hitzrot brought out one of the most important points of a11 when he said that in most cases, particuIarIy with middIe aged and eIderIy peopIe, the treatment of the patient comes first and the treatment of the fracture comes second. He aIso emphasized very truIy, I beIieve, the importance of seIecting a method in accordance with the experience of the man who is going to appIy that method, which is particuIarIy true with the question of pIates. There is a very great difference of opinion as to the vaIue of pIates in the treatment of fractures.

Two years ago at the meeting of the Ameri- can CoIIege of Surgeons, HamiIton RusselI, the Ieading surgeon of Melbourne, Australia, toId me that he never used the plate in his practice, and believed it very unwise to do so. On the other hand, Sherman of Pittsburgh, as Dr. Hitzrot has said, has very briIIiant results with the Lane pIate. I think those who are not famiIiar with the operation, not quaIified to carry out the proper technique, had better Ieave it in the hands of someone who is quaIified.

I have one end-resuIt that might be worth caIIing to your attention. It was in a case where plates were used. A soft tumor of the humerus started about a year later at the site of the piate, and was probabiy caused by the constant irritation of the pIate. There is one method which I think might be used with fruitfu1 resuIts: instead of putting in foreign bodies of bone pIates, spIints, or screws, we accompIish equaIIy good resuIts by putting


the bones in perfect apposition and hoIding them in pIace by heavy kangaroo tendon. I had one occasion in which this method was tried, after severa attempts were made at reducing the fracture of the neck of the humerus in which the upper end of the fragment was in the axiha, and three or four weeks Iater there was a very firm union, and I had a perfect anatomica and functiona resuIt.

I am incIined to agree with Dr. Whitman that the perfect and compIete standardization of practice is not the ideaI, at Ieast, for raiIway surgery, and we must reIy more upon the eIec- tion method, .seIecting the methods that are best for the individua1 case in regard to both the anatomica condition and the age of the patient; and I do not beIieve that the perfect standardization of practice wiI1 ever become entireIy practica1, even if it may be theoreti- caIIy ideaI.

DR. O’NEILL: I was struck by something that Dr. Whitman said about the possibiIity of getting motion in an open suspension. I have had a number of cases where the tissues about the wound were very much traumatized, and I felt that I wouId Iike to wait before getting a permanent fixation for some restoration of those tissues, and in that waiting I have known that my fixation has been disturbed severa times, sometimes by the patient and sometimes by outside infhrences, and the point I wouId Iike to raise is for how Iong a period may I wait with a feeIing that the bones when they are put in that position wiI1 reunite?

DR. B. T. TILTON (New York): I am a strong advocate of traction by the use of the cahpers, with reservations. I beIieve that peopIe who have not tried this method do not reaIize that it has in it certain very serious dangers of infection, and even of death, and for that reason the insertion of the caIiper shouId be Iooked upon as a major operation, in my opinion, and shouId never be done in the ward but always in the operating room under the most carefu1 technique. Furthermore, it shouId not be done in every case, especiahy if there is any wound which couId possibIy be contaminated in the vicinity of the surgeon’s cahpers and aIso when there is any fracture in the vicinity of the joint. I think there is grave danger of infection of the joint if one puts caIipers in where the joint is aIready invaded by the Iine of fracture, but, if we pick our cases, I think that practicaIIy go per cent of them are suitabIe for this treatment. I beIieve we have here the most

idea1 method for the treatment by traction. As Dr. Hitzrot said, in the cases in which we use the skin traction there are seIdom anatomicahy perfect resuIts. We were satisfied with the haIf-inch to one-inch shortening in aImost every case, but, since we have introduced traction by the caIipers we can get in many cases (I wiI1 not say in IOO per cent, but in a very Iarge per cent of cases), we can get anatomicaIIy perfect resuIts without any shortening whatever and with very good aIignment, but, of course, the cases must be very carefuIIy watched to accompIish this. If we find a person intract- abIe, if he does not cooperate, if he takes off his traction, etc., of course, we have to change our method; but otherwise there is no reason why, with a daiIy looking over of the case, daiIy revision of the traction, we shouId not get in practicaIIy every case a good resuIt.

I read a paper in CIeveIand two years ago (Dr. CoIey may remember it) before the New York CentraI RaiIroad Surgeons’ Association, in which I showed a good many cases of traction by this method. An orthopedic surgeon of Chicago who preceded me had virtuaIIy said in his paper that the method of choice in practicaIIy a11 cases shouId be operative; and his cIaim was that there was no way of getting anatomica resuIts except by open operation and the insertion of pIates. One of the discussers waxed very enthusiastic and said, yes, he agreed with that speaker and he wouId even go further; he wouId say that 95 per cent of a11 fractures of the femur shouId be treated by open operation. He said that was the onIy way that an end-to-end resuIt wouId be obtained. Then I exhibited my pictures, which showed in about a dozen cases an absoIute end-to-end approximation and perfect aIignment with this by caIipers; and a very favorabIe resuIt was obtained in bringing down this enthusiasm for the open operation, which I think was a very important thing. Dr. CoIey at that time in the discussion emphasized the fact that it was very dangerous for a meeting of railway surgeons to say that the open operation was a method of choice, because, if you are going to operate openIy, you have got to have the technique of an absoIuteIy perfect operating room.

DR. HITZROT: First as to the method and the standardization of methods in the treatment of fractures. It is not so much the method that is used as it is the way in which that method is used. A good method badIy carried out cannot produce a good resuIt, whereas a

New Series VOL. II, No 1 Hitzrot-Femur Fractures American Journal of Surgery 35

poor method we11 carried out may produce a very satisfactory result.

Dr. Whitman and I might find many points of disagreement such as the use of circular pIaster spIints, but the orthopedic surgeons are marveIs with pIaster and unti1 the genera1 surgeon becomes as proficient in its use it is wise for us not to condemn it too hastiIy. I notice that Dr. BIake states in one of his pubIications that when he expects to use pIaster after an operation he has an orthopedic surgeon appIy it for him.

In reference to standardization: if we can standardize the human ideas upon such things as politics, reIigion and prohibition perhaps we may standardize the treatment of fractures. m’e can agree on what the resuIts shouId be, but the method for obtaining that resuIt wiI1 have many variations,

The question of the choice of any method of treatment must depend upon the equipment of the man. My oId chief, Dr. Stimson, had some very definite ideas about fractures and when I had something new or something radica1 in the handling of fractures it had to run the gauntIet of his criticism. When I couId convince him, I was sure that the method had something to commend it. One can standardize the handling of fractures by pIacing the care of such cases in the hands of men equipped to take care of them. By that I mean by the so-caIIed “fracture service” in a hospita1. By this method the resuIt can be improved as it wiI1 draw together a group of men interested in fracture probIems as it has done at the New York HospitaI.

One of the gentIemen said that correcting the axis of the Iimb was a11 that was essentia1. In the weight-bearing bones shortening may and often does produce poor late results. In 1912 I pubIished some resuIts in cases of fracture. Since then I have been abIe to foIIow about 25 cases of fracture of the femur, reported in that paper, in which there was shortening of more than one-haIf inch and which at the earIy period showed a very satisfactory functiona resuIt. hlany of these cases now have some disturbance in the knee or hip which has graduaIIy deveIopec1 with use. The disability has been reIativeIy greater in those cases in which there has been a divergence from the normal axis of the Iimb together with the shortening.

1Vhat was said about too much fussing with fractures is quite true. In one case that I saw

recentIy, a fracture of both bones of the fore- arm, eIeven attempts at reduction were tried in three days and the arm was in terrible shape due to the increased injury produced by such manipuIations.

In fracture of the femur our procedure is as foIIows: An immediate examination of the Ieg to determine, first, that there is a fracture; second, its location; third, the amount of reaction in the soft parts. If the sweIIing is marked, a Thomas spIint with traction is appIied and a roentgenogram made. If the sweIIing is not marked and if the roentgen-ray picture can be made immediateIy, we spIint the extremity in a Thomas splint and wait for the roentgen-ray film which heIps to visuaIize the fracture. If a roentgen-ray apparatus is not avaiIabIe, we make a detaiIed examination under an anesthetic, and institute treatment with an attempt to correct the axis and Iength of the bone by manipuIation or by caIiper traction, etc. With the roentgen ray we can elim- inate cases in which the Iine of fracture wouId make impossibIe any reduction by manipuIation. One manipuIation is a11 that shouId be necessary for, if the first one faiIs, the second one is not very IikeIy to succeed. The further procedures are discussed in the paper.

Concerning the preparation of the patient before operation : If possibIe the Iimb is shaved, washed with a cream composed of equa1 parts of Iime and soda to be removed by steriIe water, and the area is wiped with aIcoho1 and ether on the day before the operation. On the day of the operation the ether and aIcoho1 preparation is repeated and the operative area is wiped with 5 per cent thymo1 in aIcoho1 in the operating room. Tinker and Sutton in their examination of the skin disinfected in this way find it steriIe. Just what virtue the thymo1 has in the immediate process is a question, but it keeps the dressings sweet and prevents the decomposition of the bIood with the fou1 smeI1 so often met in these operations a few days after the operation.

With regard to the use of pIaster of Paris and the movement of the patient: In cases with decompensation of the heart, pIaster may be a vaIuabIe dressing to aIIow changes in posture. Acute diIatation of the stomach is one of the annoying CompIications in these cases and unless this is recognized earIy and treated energetically by the stomach tube, the patients do very badIy and I have Iost two or three cases which might have been saved had the condition


been recognized earIy. The diffIcuIty Iies in the recognition of a diIated stomach through the Iarge plaster spIint.

Dr. CoIey raised a point as to the constant irritation of the pIate. I can onIy say that in the cases I have shown here by Iantern sIides a11 of the pIates have been in tweIve years or more. Whether they are causing irritation or not I do not know, but they show no signs of irritation in the roentgen-ray pIates and the patients have no symptoms. I beiieve you can put steel in a bone just exactIy as you can put stee1 in a tree. I mean I think it is an anaIogous thing. I am doing some experiments on trees with these foreign bodies, and I am trying to study what happens to them.

With regard to the remova of the pIates: I have been fortunate enough to have seen some cases in which I have taken out pIates after tweIve or fourteen years. They are not cases of my own and I wouId like very much to have one of my own to take out, but these happened to be cases of the other man. The pIate was al1 right, not causing any troubIe, or sign of irritation roentgenographicaIIy, but some pain in the region of the fracture. No irritation was found in the bone that the microscopist couId determine, but there were some deposits of suIphide of iron in the tissues around the bone, and that was aI1. That is a11 I can say with regard to pIates. I do not know what to say regarding the use of the kangaroo tendon. It may be of interest when I say that I have taken knots of kangaroo tendon out of bone that have been in there a year and six months. AII this is a question of the absorbabiIity or non- absorbabiIity of these various things. I think we have wasted our time discussing that question too much. During the period in which the introduced substance is of any use whether it be absorbabIe or non-absorbabIe, it is a foreign body; and as to whether it is absorbabIe afterward, if nature is going to take care of it, she wiI1 take care of a non-absorbabIe as we11 as an absorbabIe body, if there is no infection; and personaIIy, I do not fee1 that in the majority of cases kangaroo tendon answers the question.

Now, that is Iike everything else; it is again a question of choice of method. I have just recentIy operated on a fracture of the tibia in which I used kangaroo tendon to fasten it, because it seemed the best method for that particuIar case.

A MEMBER: How about a metal band, the Parham band?

DR. HITZROT: We have quite a IittIe to Iearn about the Parham band. I think it disturbs the circuIation. I think it has a pIace, a very distinct pIace in the treatment, and I have used it about twenty times now, especiaIIy in fractures in the humerus and fractures of the radius. In a fracture of the tibia it gave a very bad resuIt.

Regarding the question of the patient’s cooperation in traction, there are many points: Motion at the Iine of fracture during traction is supposed to be prevented by the weight producing the traction. There is an essential feature in traction which has been emphasized by every man that has used it, and that is, one must put on enough weight to puII down the Iower fragment quickIy. Do not put on weight graduaIIy; one of the things we hear is to put on a IittIe weight, then a IittIe more weight and a IittIe more weight. That is absoIuteIy wrong. If you are going to use 60 pounds put 60 pounds on right off, do not put on 25 pounds today, IO pounds tomorrow and so on. As soon as you get the bone down you wiI1 need onIy a smaI1 amount to hoId it in position, so if you use sufficient weight during the time when the patient is very restIess, the weight itself wiII keep him from disturbing the fracture Iine by muscIe puI1, unless he is an unusuaIIy powerfu1 man.

With,traction, you wiI1 be successfu1 if your patient wiIl cooperate, but you wiI1 not be successfu1 if he is going to sIide down and get the traction apparatus puIIing against the foot of the bed, because you can not Iengthen the bed sufFicientIy to keep the traction working, and if he is going to disengage the puIIeys, or do as one patient of ours did, cut a11 the ropes that were suspending the apparatus. What is the use of trying to use traction unIess you have cooperation on the part of the patient?

With regard to the question of infection with the tongs, I think that is not as important a question as it wouId seem to be. Infection about these wounds, if you do not get pressure of the tongs or the pin on the skin is not apt to occur. In my experience one of the reasons that infection occurs is faiIure to puII the skin up and then make the incision, so when the traction comes on the tongs pressure does not occur at the Iower angIe of the skin wound. In a11 the cases I have seen where it was said there had been an infection at the wound, this was due to the fact that there had been pressure

New Series VOL. II, No. I Hitzrot-Femur Fractures American Journal ofSurgery 37

on the skin by the tongs at the Iower angIe of whether with open operation or not? the wound. That point was made by Pearson, DR. HITZROT: I do not know, but I do not who was the advocate of tong traction during think so. the war. DR. LEE: In what cIass of cases was acute

A ~IEMBER: Have you ever seen any osteo- diIatation of the stomach after these fractures porosis? most IikeIy to take pIace? Did they have

DR. HITZROT: OnIy in one case in which stomach disturbance before, or is vasomotor there was infection at the same time. Dr. disturbance created by this dilatation of the CornelI is at present working on that par&Jar stomach? question. DR. HITZROT: I can onIy say that it occurs

A MEMBER: Does that increase the amount in a11 types of cases apparently, with no of new bone that is thrown out around the particuIar preceding gastric disturbance. The fracture during heaIing? decompensation and other cases have some

DR. HITZROT: I do not think so. I did not gastric disturbance due to their broken com- have time or I wouId have shown you plates at pensation. But in one case just recently, with twelve-year intervaIs, and a11 you would notice tong traction, in a man who had nothing at ali is the normal repair process you would find in wrong with his stomach diIatation occurred. any bone; an amount of thickening just Iike a DR. BAKER: In aI1 these cases I put the pIumber’s “wipe joint”; the meduIIary canal is pIaster on over the abdomen, and a window reestablished, and there is not any more than is cut as soon as the pIaster is dry, so that a norma thickening in the cortex of the bone; the abdomen or the stomach region is the caIIus has undergone the secondary change. entireIy uncovered and acute diIatation of the

A MEILIBER: Is there any difference in the stomach is very quickIy discovered in the quality of the new bone that is thrown out, beginning.

fracture of the femur

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