Immobilizing the fracture: nonsurgical fracture treatment
From plaster of Paris to sand-filled boxes to sophisticated braces: helping fractures heal on their own.
For countless generations, “bone setters” and later, the more sophisticated practitioners of the medical art, adhered to the belief that immobilization was essential for the uneventful healing of fractures. One can speculate that this belief took root upon the observation that pain was reduced when injured limbs were immobilized, and that once immobilized, they healed.
History tells us of the many methods used by our ancestors in managing fractures, such as wooden sticks fastened around the fractured limb, the placement of the injured extremity in a box filled with sand, and later, the wrapping of the newly invented bandages of plaster of Paris. All these methods shared the objective of immobilizing the fractured fragments as much as possible.
Improvements in anesthesia in the early part of the 20th century and the later discovery of antibiotics made the surgical treatment of fractures a practical reality. The surgical approach appeared to crystallize the dream of anatomical reduction of fractures. The promise that surgery would eliminate the need for immobilization of joints adjacent to the fracture made the new therapeutic modality even more attractive. A parallel loss of interest in nonsurgical treatments was a logical consequence.
Acceptance of rigid immobilization
One can also suspect that physicians who believed that immobilization was good for fracture healing must have concluded that rigid immobilization was even better. This goal was thought to have been achieved when the technique of rigid fixation and interfragmentary compression was popularized by the Arbeitsgemeinschaft Osteosynthesefragen (AO) in the late 1950s. The original concept of rigid fixation had been advocated earlier by Danis, a Flemish surgeon.
A similar philosophy regarding the benefit of fracture immobilization had developed among those who were treating fractures by non-surgical means. The principle that joints above and below a fracture must be immobilized became almost universally accepted. Exceptions to the prevailing practice never achieved wide recognition. Delbet, a French surgeon, described a method of treatment of tibial fractures using a “gaiter” firmly applied over the extremity, extending from below the knee to below the ankle. Lucas-Championniere, also a French surgeon, attempted to popularize the concept of massage to the injured limb. His success in disseminating his ideas was limited.
The aftermath of World War I brought about the virtually universal acceptance of the precept that the highest degree of immobilization of fractures was mandatory. Sir Robert Jones, from England, had earlier made the pronouncement that “fractures must be immobilized continuously and uninterruptedly until union is complete.” He was, indeed, reinforcing the teaching of his uncle, Hugh Owen Thomas who is considered the founder of modern orthopedics in the United Kingdom.
Leading the rebellion
A rebellion against the premises advanced by Sir Robert Jones seems to have been led by George Perkins, another Briton who advocated skeletal traction of fractured tibias, while encouraging active and passive motion of the knee joint. His method was practiced in Great Britain but failed to receive wide acceptance in Europe and America.
In Central Europe, just preceding the onset of the World War II, Bohler, from Austria successfully popularized the use of “skin-tight” plaster of Paris casts and the parallel active use of the injured extremities. His teachings reached America primarily through his disciple, Ernest Dehne, an Austrian who had emigrated to the United States. As a member of the armed forces, he successfully popularized Bohler’s system. Bohler’s casts adhered, nonetheless, to the traditional belief that immobilization above and below a fracture was necessary.
One of the fractures that had been traditionally managed with casts that included the adjacent joints was that of the humeral diaphysis. Spica casts immobilized the elbow and shoulder joints. The “hanging cast,” popularized in the 1950s for the treatment of this fracture, demonstrated that immobilization of the two joints was not necessary for uneventful healing.
A new cast is born
Inspired by the effectiveness of the patella tendon bearing prosthesis (PTB) used by below-the-knee amputees, a cast was designed for the treatment of diaphyseal tibial fractures in the 1960s. The cast was conceived on the assumption that weightbearing stresses could be effectively transmitted from the floor to the patellar tendon and tibial flares, and in that manner prevent shortening of the fractured extremity.
Within a short time, it became obvious that the success of the new cast was not based on the anticipated transfer of stresses proximally but by the support of the soft tissues surrounding the fractured bone. This realization permitted the provision of freedom of motion, not only to the knee but to the ankle joint as well. The below -the-knee functional brace replaced the below-the-knee, PTB cast.
Clinical and laboratory studies eventually demonstrated that, especially in body segments with two bones connected by an interosseous membrane, the initial shortening experienced in closed fractures remains essentially unchanged, and the role of the brace is significantly limited to providing angular stability through a hydraulic- like mechanism. Similarly, it was documented that the motion between the fractured fragments, produced by the active use of the extremity, has a beneficial osteogenic effect.
Functional fracture bracing benefits
Functional fracture bracing was extended to the management of other fractures with different degrees of success. Femoral fracture bracing failed to demonstrate a consistent rate of success, since angular deformities were seen with great frequency when the brace was used in the care of fractures above the distal third of the bone. Forearm fracture bracing also never gained popularity, probably because of technical difficulties encountered in the application of the brace and the simplicity of plate fixation. Braces for fractures of the humerus, ulna and distal radius, also developed in the 1960s and 1970s, brought about a high success rate.
Fracture bracing further supported the often-neglected observation that angulation of a few degrees and mild shortening are not complications but inconsequential deviations from the normal.
A review of the literature has revealed that stabilizing devices for fractures resembling modern braces had been used in the past. In England, Gooch described one such device in 1776. Smith, in 1855, in Philadelphia, described “prostheses” for the treatment of nonunions. His appliances resemble modern braces. It is, however, a giant leap of the imagination to conclude that their designs, rationale, underlying philosophy and use were the same as those of contemporary functional fracture braces.
As progress is made in the field of surgical treatment of fractures, comparable advancements are taking place in the nonoperative care of long bone fractures. “Gold standards” in fracture treatment do not belong, at this time, exclusively to one single methodology.
The 20th century closed with a record of major advances in the care of fractures. Unfortunately, the universal crisis in the delivery of health care, mainly produced by the high cost of advanced technology, has precluded the extension of such benefits to several in regions of the world where many are unable to afford its implementation. It remains a challenge and responsibility to future generations to address this issue in earnest, and to find practical and humane solutions.
Augusto Sarmiento, MD, is director of the Arthritis and Joint Replacement Institute in Coral Gables, Fla.