No. 4720.

FEBRUARY 14, 1914.

Hunterian LectureON THE

EXPERIMENTAL PRINCIPLES OF THEOPERATIVE TREATMENT OF FRACTURESAND THEIR CLINICAL APPLICATION.

Delivered before the Royal College of Surgeons of Englandon Feb. 6th, 1914,

BY ERNEST W. HEY GROVES, M.S. LOND.,F.R.C.S. ENG.,

HUNTERIAN PROFESSOR OF THE COLLEGE; SURGEON TO THE BRISTOLGENERAL HOSPITAL.

MR. PRESIDENT, LADIES AND GENTLEMEN,-It isfirst my pleasant duty to thank you, Sir, and theCouncil of the College for the high honour youhave done me in allowing me for one proudmoment to occupy the chair of the great Hunter,and in the second place to offer my sincere

gratitude to those many surgeons from this countryand abroad who have, in so generously respondingto my request, furnished the material for theexhibition which accompanies this lecture, and tothe Museum Committee for allowing me to arrangethe exhibits in the atrium of the museum. The

problems connected with the treatment of brokenbones are very many and complex, and recentsurgical teaching has tended to multiply and

complicate these problems rather than to solvethem.

THE PROBLEMS IN QUESTION.A quarter of a century ago the matter was com-

paratively simple. The broken bone had to be4

set "-i.e., its jagged ends replaced in apposition ;and when this had been done the limb was to be

placed on a splint for a period varying from a fewweeks to three months; then the patient was dis-missed, sometimes with a good limb and sometimeswith a maimed one. Vicious union, delayed union,and non-union were processes which might occurto mar the result, but no one thought of blamingthe treatment for this, provided that the orthodox"setting and splinting " had been carried out. Itwas just bad luck, and there was nothing more tobe said.Now all this sweet simplicity has changed. Work-

men’s Compensation Acts have directed attentionto the terrible financial loss produced by maimedlimbs, and have forced us to ask, Is this prevent-able, and if so, why not prevented ?To three great men belongs the credit of

awakening the profession to a knowledge of thetruth about fractures, and each has established anew method of dealing with them. Two of these,

I

alas, have died within the last twelve months, buthappily one’ remains with us to-day as a dauntlesspioneer in this and other fields of surgery.Bardenheuer has shown that infinitely better

results can be obtained by steady traction than by" setting and splinting." Lucas-Championniere hasdemonstrated the almost magical capacity of a

certain kind of massage to abolish pain and reducedisplacement, and he has proved beyond contentionthe evil effects of prolonged immobilisation. Lanehas contended that broken bones must be fixed byoperation, or else they will remain displaced andthe function of the limb will be damaged. And, aboveall, the X rays have come to demolish all our formeroptimism about

"

setting " broken bones, so that we

now know that, except in partial and subperiostealfractures, the accurate setting of a bone in a

position in which it will remain is a myth, andtherefore the whole foundation of the old treatment

I is destroyed.,

We have now to choose between immobilisationwith disregard to all but gross deformity, con-

tinuous extension, massage with mobilisation, andopen operation. We have to decide to what extentthese represent rival systems or merely cooperativeprinciples which must be applied according tocircumstances.Whilst leaders like Bardenheuer, Lucas-

Championniere, Lane, and Lambotte have eachdeveloped their own particular methods to a greatdegree of perfection, the profession as a whole hasmaintained a conservative and sceptical attitude,and continues for the most part to trust to splints,or plaster, and to luck in the treatment of fractures.The value of extension and of massage has beenwidely acknowledged, but the time and trouble

necessary for the mastery of the methods and theirexecution have prevented their being carried outwith anything like the thoroughness of their

original advocates.But it is with regard to the scope, methods, and

results of the operative treatment that there hasarisen the greatest difference of opinion. Skiagramsare produced to show the perfect results of opera-tions, others to show the perfect results of othermethods, and, again, others to show the imperfec-tions of this method or that. The clinical evidenceis so confusing because it deals with fractures of allkinds and all ages, with surgeons who may or maynot have special interest in the subject, and withmethods of every possible variety. The very term

operative treatment " is so vague that it maymean anything, from the mere twisting of a bit ofwire round the bones by one who has never donesuch a thing before to the elaborate application ofa carefully planned apparatus by an experiencedmaster of craft.

It is rather remarkable that though there havebeen many experimental researches on the

subject of fractures and their healing, almost allof these have had relation to the origin andformation of callus ; and none, as far as I

know, have been carried out to test the prin-ciples of the operative treatment. Experimentson animals cannot tell us much about non-operativetreatment of fractures, because such treatmentleads to so much deformity that in veterinarypractice an animal with a bad fracture is nottreated, but killed. But they can give us informa-tion about the operative fixation of bones, which isto be obtained from no other source, and as a sideissue this study will provide, for any who care totake it up, a perfectly efficient method of treatingthe broken bones of animals, so as to save for use-fulness and breeding many a valuable horse or dog.

Quite apart from experiments on living animalsfor the study of vital repair and the restoration offunction, there is another experimental method forthe study of the technique and the acquirement ofdexterity in the various methods-viz., the opera-tions upon the dead body. Operative repair offractures is a matter of manual practice and

dexterity. It is in one sense the work of a car-

penter, which can never be properly carried outwithout the education and training of a carpenter.If everyone who practised these operations had apreliminary six months in a carpenter’s shop, andthen performed on a sufficient number of broken

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436

bones on dead people to ensure technical skill, weshould see and hear far less than we now do ofoperative failures.For the past three years I have been pursuing

these two lines of investigation, mending fractureswhich I have made in the bones of living animalsand dead men. For my present purpose I proposeto show typical examples of the experimental work,so as to give the basis of the various principles inthe operative treatment of fractures, referring thoseinterested in the matter, to a recent publication fora full account of my work on animals.

RESULTS OF OPERATIVE FIXATION IN ANIMALS.Most of my animal experiments have been on

cats, a few only being on rabbits, using chiefiy thetibia and sometimes the femur. No attempt atexternal splinting was made, the animals beingallowed to use the limb according to their owninstinct.

On Insecu1’e Fixation.

One of the greatest surprises that my experimentsafforded me was the demonstration of what a rela-

tively strong fixation was necessary to keep theends of a broken bone in good apposition until theyhad firmly grown together. The tibia of a cat isabout 1/4 inch thick, and its medullary cavitymeasures about 1/8 inch. If this bone is dividedand then a solid bone peg inserted into the marrow

cavity, although this is one-half the original thick-ness of the bone, it was invariably broken, and thesame thing occurred in the femur, where the pegused was 5/32 inch thick. This fracture of the pegdid not occur at once, the muscles remaining some-what inert for a few days after the traumatism ofthe operation, but at about 5 to 7 days after, whenthe animal first began to use its limb. The fixationmust leave the bone as strong as it was before thefracture, or there will be a risk of its speedybreakage.The use of short plates fixed by small screws,

which hold only by their bite of the dense bone,gives similar results. In such cases I have neverseen a fracture of the plate, but the screws becomeloosened from one or both ends of the bone. (Fig. 1.)Bone is a living tissue, and as such it softens andyields before local pressure. The words of SirWilliam Macewen are pertinent in this connexion.He says: " A pin driven into the diaphysis, so thatit is firmly caught, will in the course of a few daysbecome loose, owing to the softening which themechanical stimulation has set up in its periphery.The greater the pressure the greater the area ofsoftening." 2 Obviously the same thing applies totightly driven screws.

This fact is of great importance when we haveregard to the prevalence of screwing methods inmodern bone surgery. A screw which presses uponthe bone will rapidly loosen its hold; the rapiditywith which it becomes loose will be in direct

proportion to the pressure which is exerted uponit. This loosening of screws which fix plates tobones may be minimised in two ways, either byusing a large number of screws, so that the pressureupon any one is small, or by keeping the limbrigidly splinted so that muscular traction isreduced to a minimum. By either of these devicesthe plate may hold in place until vital union hasoccurred, but it is clear that such a result will berather a happy accident than a certain effect.

1 British Journal of Surgery, vol. i., No. 3, p. 438.2 Growth of Bone, p. 21.

The objection may be raised against myexperi-mental methods that the plates were so short thatthey cannot be compared with those used inhuman surgery. But in the first place the questionof size is a relative one. The plates were aboutone-fifth the length of the bone, which would beequivalent to a 3-inch plate used for the humantibia or femur. The screws were one-eighth of thethickness of the shaft, which would give screws

1/8 or 3/16 inch thick for the human leg bones.And, secondly, the inefficient principle of themethod, depending as it does upon the fact thatevery tightly driven screw becomes loose by reasonof its own pressure upon the bone, will not bealtered by any increase in the size or number ofscrews, though by this means its ill effects may beaverted.Whatever may be the cause of the insecurity of

fixation, the results are extremely bad-i.e., everypossible variety of mal-union or non-union, withthe frequent addition of septic complications. An

operative fixation of a fracture, which gives wayearly, leaves the bone in a very much worse condi-tion than it was before the operation. And thisfor at least four reasons : (1) that in the course ofthe operation the periosteum and muscular sheathof the bone have been separated from it to someextent, and therefore the preventive of displace-ment is lost; (2) there has been some interferencewith the minute vascular supply of the bone ends ;(3) there is a loose foreign body left in the tissues;and (4) there is an external wound through whichsepsis is very likely to enter.

On Incomplete Fixation., There are some methods which are perfectlyefficient as regards the strength of the union theyproduce, but they allow from the outset some

slight movement between the bone ends.The most important among these is the applica-

tion of encircling wire under certain conditions. Ihave not studied this systematically by experi-ment, because the use of wire having been so-

largely abandoned in human surgery there did notseem to be much practical use in the research.But I have often used it in addition to such thingsas gelatin or decalcified pegs. These pegs are

very quickly broken or absorbed, and the obliquelydivided bone, left surrounded by several turns ofwire in very much the same way as fractures usedto be treated by

"

wiring." Such a union is alwaysbad. The bones cannot slip altogether apart, but,the divided ends are constantly chafing against thewire. This chafing occurs just at the very placefrom which the principal agent of repair, theexternal callus, originates. The early stage ofcallus consists of soft granulation tissue, and thiswill be destroyed by the rubbing wire just as fastas it is formed. Hence I always found in myexperiments that the most certain means of pre-venting or delaying bone union will be by the loose

encirclement of the broken ends by wire.Another method which allows slight mobility ofthe fragments without displacement is that of

intramedullary pegs. These can only be slippedinto the bone ends if they fit rather loosely. Theresult on the healing of the bone in this case is thetendency to the production of some amount ofcallus excess. This will occur especially in thecase of single bones, such as the femur or humerus,where the peg does nothing to prevent rotation ofthe fragments. (Fig. 2.) I have never seen any harmas regards the function of the limb arise from this

437

callus excess either in animals or human beingsbut it is not a desirable condition, especially as onEhas no means of controlling it. But, neverthelessthe uniformly good results, the facility of its

application, and the small incision through whiclit can be applied, make the method one of greatvalue, which I shall speak of again when dealingwith human fractures.

On Mechanically Efficient Fixation.In the course of upwards of 100 experiments

upon animals the fact which has impressed itselj

upon my mind more than anything else is the

importance of mechanical efficiency of fixation. Abroken bone is a part of an ever-moving piece ojmachinery, of which the surrounding muscles forman integral portion. Even if voluntary movementbe abolished by external splints there is always thestrong tonic contraction of the muscles to bereckoned with.

It is like mending the broken shaft of the pro-peller of a steamer. For a short time the engine isat rest. but the broken shaft in that time must beso fixed together as to withstand all the throbbingof the engine and the beating of the seas until theship can reach her harbour. So with an operationon a broken bone under the aneasthetic the ever-pulling muscles are quiet, and during that moment,if the surgeon is to do any good, he must so fixtogether the bone that it can withstand any strainlikely to be put upon it until natural repair hastaken place. Of course, this analogy must not bepushed too far, for the bone will heal if left. tonature, while the steam engine will not. Butnature has her own method, and if the bone iscompletely broken the ends become displaced andthe limb shortened, so that the muscles are thrownout of gear, and the condition of stable equilibriumor rest demanded for reparative processes is thusattained, but often at the ultimate expense of thelength and form of the limb.

If a long plate be applied to a bone, and fixed bypins or screws which go through its whole thick-ness and are not held by a mere frictional grip, butby a relatively broad flange or nut, then there isprovided a mechanically efficient union, and suchunion has in my experiments given uniformly goodresults. (Fig 3.) Generally I employed what aretechnically termed split or cotter pins, fixing a steelplate about one-third of the length of the bone. Ihave also used double plates, on opposite sides of thebone, joined through its thickness either by cotterpins or by bolts and nuts. Ten such experimentswithout a single failure have convinced me thatthe principle is correct, and it only remains tomaster the technical difficulties of its application.Firm, strong bone union occurs without any

callus excess, showing that absolute fixation of thefragments is no hindrance to vital repair. Theanimals use the leg freely from a week to a fort-night after the operation, showing that no splintsand no after-treatment are necessary to secure a

functionally perfect result.

The Problem of Sepsis.From the earliest days of the operative treatment

of fractures the problem of sepsis has largelydominated the question. At first it seemed to beHying in the face of Providence to convert a closedinto an open fracture. And then it became a

common experience, and possibly is so to thepresent day, for the post-operative course to becomplicated by the occurrence of a septic sinus,which only closed when the metal substances used

, for the operation had been removed. Hence the} dictum that asepsis is the first and chief necessity, for fracture operations. That asepsis is the first; necessity no one would deny, but asepsis during theL operation by no means ensures that no septic com-tplications shall afterwards arise. First let me give my experimental evidence of

this before I attempt to explain it. In a long seriesof cases where the bones were not firmly or properly

, fixed (short plates and screws or pegs which broke

: or were absorbed) there was a very high proportion, of sepsis, amounting to about 60 per cent. In an’

equally long series where the bones were firmlyunited there was not a single septic case.Now such a result in the hands of the same operator, and under the same conditions, must: prove that there is something else than a fault of: aseptic operating. And this other or post-operative’

factor is not far to seek. When the bone is unitedin such a way that disunion occurs, the fragments

, moved by the muscles cause a great outpouring of

: lymph, and the foreign bodies lying loose in the: tissues produce the same result. This fluid quickly

oozes out from the recent wound, and along thesinus thus formed, sepsis quickly finds its way from

the skin to the deep tissues, where there is everyencouragement for its development. Exactly thesame thing happens in human surgery. A wobblyunion of the fragments or loose screws, especiallyif these lie just beneath the skin, cause a discharge,which becomes septic. This is one or two weeksafter the operation, and it is the result and not thecause of the faulty fixation.

The Question of Delayed Union.This is another point of great importance.

Is there any evidence that operative treatment

per se causes this ? Experimentally as well as

clinically I think there is. Clearly one can onlydeal with this point in cases uncomplicated byany other untoward event. In the two methodswhich have given uniformly good anatomicaland functional results-viz., those with the longplates and transfixing pins and the steel intra-medullary pegs-I have had one instance of delayedunion in each series.

I do not think it is due to mere immobility, other-wise it would occur as the rule, and not as the excep-tion, when the bones are rigidly fixed. It is caused,I think, by an interference with the blood-supplyof the bone ends by the operative manipulations.This causes the cut ends of the bone to remaininert for a time, and unable to throw out any re-parative callus. But in both cases where I haveobserved it, the delayed union did not cause anyevidence of its presence-that is to say, the functionof the limb was perfect, and I have no doubt thatif the animal had been kept alive long enough(both were killed at a period of six weeks afterthe operation) union would have eventually takenplace.We must admit, I think, that delayed union is a

possible result of operative fixation, but this willleave little or no ill-effect if the fixation has been

so efficient as to last for an indefinite time.

On Indirect Methods of Fixation.It is possible to hold firmly the ends of a broken

bone in good position without directly interferingwith the site of a fracture. I did this by transfixingthe bone as far as possible from its point of divisionand connecting the transfixing rods by outsidemetal bars. Such a method accurately and certainlycarries out what many of the more precise of the

438

non-operative methods aim at-that is to say, thereis a correct alignment of the bones, the muscularforces pulling upon the fracture are counteracted,but the broken ends are not rigidly fixed, and thereis movement permitted in the joints above andbelow.There can be no doubt that the apparatus

which I used gave as perfect results as anyof the direct operative methods. (Fig. 4.) Theanatomical and functional results were uniformlygood, union of the bone was rapid and never

accompanied by any delay or callus excess, whichsometimes goes with direct operative attack. It

which they are applied the bones are accuratelyrestored to position, and there maintained for a

sufficient time for union to take place. Unfor-

tunately, these conditions are often not fulfilled,and the method quite fails then to produce idealresults. Either the bone ends are not properlyreadjusted and there is mal-union, or mobility ispermitted with a_consequent callus excess.

The Trcatment of Comminuted and of OpenFractures.

When there is much fragmentation of the bone atthe site of injury, or when there is an open wound

FIG. 1.

Fir. 2.

FzG. 3.

FIG. L:-.

FiG. l.-Rabbit’s femur. 21 days after plating. Screws have come out from the lower fragment. Malunion with lateral displacement.F1G. 2.-Cat’s femur, 42 days after operation by a steel intramedullary peg. Firm union with some excess of external callus which is

still partly cartilaginous. -FlG. 3.-C#t’s tibia, 42 days after fixation by a long steel plate and split pins. These have been removed and the bone cut open. There

is perfect union. No external callus, visible as such ; a short plug of internal callus and a notable thickening of the dense bone ofthe shaft some distance above and below the fracture.

FlG. 4.-Cat’s tibia, 14 days after operation by the double transfixion apparatus. Early ideal repair. A, Islet of cartilage. r, Internalcallus, present at this stage only in the upper fragment. c, External callus.

is a method by which can be attained a uni-

formly accurate result at any given period, andit affords a good series of specimens showing thestages in callus formation and osseous repair.Further, the method is one which with properapparatus is easily and quickly applied, being atrivial matter which can be done under short gasanaesthesia.

It is a fair inference from these experiments thatmethods of indirect fracture fixation form the idealtreatment of fractures, provided that in any case to

communicating with it, direct operative fixationmay be correspondingly difficult or dangerous. Insuch cases, the method of indirect fixation is

particularly indicated, and I have found that whenthe shaft of the bone has been crushed into smallfragments for a considerable extent (about one-fifthof its length) rapid and solid union takes place withgood anatomical and functional result, but withsome tendency to callus excess. (Fig. 5.)

LÜ’íug Bone as the Origin of Callus.The subject which has for the most part absorbed

439

the attention of workers on experimental fracturesis the method and origin of callus formation. Myobservations on this subject have been largelyinspired by Sir William Macewen’s recent publica-tion on the " Growth of Bone," and I have recordedthem at length in the paper already referred to.The osteoblast is the living bone unit, and for the

most part the osteoblasts are contained in the sub-stance of the dense bone, though they may lie uponits outer surface, beneath the periosteum and inthe medullary canal. Therefore it is that thedense bone itself is the primary factor in all mattersof repair. When it is injured, the osteoblasts arepoured out upon its surface and form the callus ofrepair. The periosteum, apart from osteoblasts

which may adhere to its

deep surface, is nothingbut a limiting membrane,of great practical import-ance, because it limits theamount of callus pouredout and supplies with bloodthis new tissue.These facts are borne out

by various of my experi-ments. When the fractureis surrounded by a metalplate, excluding the peri-osteum, callus formationoccurs between the boneand the plate. It is some-what scanty and union isslow and weak because thecallus gets no periostealblood-supply. In the com-minuted fractures eachsmall particle of bone canbe seen to be the centreof new bone proliferation.New bone is sometimes laiddown by periosteum. Onlyone 9 of my experimentsshowed this. The pheno-menon is certainly excep-tional and probably due tothe osteoblasts which haveremained adherent to thedeep surfaces of the peri-osteum when this is

separated from the bone.

THE CLINICAL PROBLEM.

Turning now to thepractical application ofthese principles to theclinical treatment. of frac-tures we are confronted bytwo important questionswhich to my mind far out-weigh all other considera-tions. The first of these

concerns the selection of the cases requiringoperation, and the second, the best method of

attaining mechanically efficient fixation of thebone. All other matters are either of secondaryimportance or are merely a part of the routinecommon to all major surgical procedures. Thenatural order of these two questions will belirst to ask, in what cases is operation required;and the second to ask, how in each case, an idealoperation may be planned and executed. But as myown work has been so largely concerned with the

3 Reviewed in THE LANCET, March 30th, 1912, p. 874.

Fm. 5.

Cat’s tibia, 28 days after a com-minuted fracture, treated bythe double transfixion appa-ratus. , Separate fragmentsof dense bone. B, Callusmass in which the fragmentsare embedded. (Figs. 1 to 5are from the Bf!’6’A.7o:tfKaof .SiM/-!/.)

elaboration of operative methods I must reversethe above order and consider first the operativeprocedures at our disposal before discussing whichcases require operation.The Attairznaent of mechanically Efficient Fixation.I have already explained the experimental evi-

dence, which has so strongly impressed itself uponmy mind, that the chief necessity of operativefixation (asepsis being assumed) is mechanicalefficiency. By mechanical efficiency I mean a

workmanlike artificial junction of the bones whichwill leave the bone as strong as it was before thefracture, and which will last for an indefinite time.The arguments for its necessity, derived from

experimental evidence and extended to the con-

dition of human fractures, may be summarised asfollows : 1. In order to secure stable equilibrium atthe site of repair. 2. To avoid post-operativesepsis, and to obviate the necessity of a secondoperation for the removal of foreign bodies. 3. Toallow early massage and movement of the partwithout the restraints and restrictions of splintsand bandages. 4. To prevent a bending of the

newly healed bone when it is subjected to the bodyweight. There is only a minimum of callus laiddown with fractures that have been operated upon,and the bone must be reinforced in strength forsome time after the ordinary period of hospitaltreatment. 5. To obviate the disadvantages of

delayed union of the bone, if such should occur.6. To shorten the period of confinement to bed and-retention of the case in the hospital.

It is unnecessary to spend time in elaboratingthe above points ; their experimental basis has beenalready dealt with, and clinical evidence can bestbe given in describing illustrative cases.

0 the Use of Wire.Until quite recently all operations for uniting

bones were performed by silver wire, and it is stilla common thing to speak of " wiring " fractures asthough this represented the routine operation.But it was very soon evident, when operations wereproposed for the attainment of perfect resultsinstead of being merely makeshift devices for deal-ing with bad compound fractures, that " wiring " asit was then done was very unsatisfactory. Nowthat- plating fractures has been introduced and

widely practised "

wiring " has not only been

generally abandoned, but it has almost fallen intocontempt.

It is quite worth while to consider the factorswhich are concerned in the use of wire, to determinewhether it ought to retain any place in our fracturemethods. First, then. as to the material of whichsuture wire is composed. Silver has been used, notonly because it is soft and easily manipulated, butprobably with an old superstitious idea of the valueof one of the precious metals. But it is, in reality,an utterly untrustworthy material. It is a weaksuture even at its best, and its strength variesvery much according to the way in which it is

prepared, so that unless every sample is properlytested there is no reliability to be placed upon it.Again, it has been shown that silver quicklybecomes converted into the sulphide when buriedin the tissues, and this rapidly weakens the wire.Skiagraphy has shown that not only with fractures,but even when silver wire is used as a filigree inthe muscle planes of the abdominal wall, it gene-rally becomes broken up within a short time if it issubject to any tension or movement.4

4 THE LANCET March 30th, 1912.

440

Wire made of aluminium-bronze and of platedcopper is in some ways a good material, but thecopper is a powerful irritant poison in the tissues,which makes me disinclined to use it in either ofthese forms. In experiments where bronze wirehas been used there is always an area of green dis-colouration in the tissues all round it, caused bythe action of the copper. Soft iron wire is farsuperior to silver. It is much stronger than eitherbronze or silver. For example, samples of No. 24(standard wire gauge) of silver, aluminium-bronze,and iron wires had a breaking strain of 31 lb., 44 lb.,and 50lb. respectively, as tested in the engineeringlaboratory. It is, of course, very cheap and can beobtained tin-plated.The second point of importance in using wire in

bone surgery is that the fragments must be

accurately restored to proper position, or at anyrate to a stable equilibrium, before the wire is

tightened. This is often very difficult to do. The

parts are often brought into approximate positionand then the wire placed as tightly as possible, oractually used as a traction material. Then when

FIG. 6.

Forceps for tightening and twisting wire when the bone suturehas to be done in the depths of a wound.

the muscles begin to act, the badly fitted bone endsbecome loose, and there is just that loose surround-ing with wire which I have above shown to be soinimical to fracture repair.

Again, there is a third error commonly made inthe use of wire. It is tightened by being twisted.This always makes a weak place in the wire at thejunction of the last twist with the circular piece,and here the wire often breaks. It is absolutelynecessary that the wire be drawn tight so as toallow no movement whatever, and when this hasbeen done a single turn should be taken withoutrelaxing the tension, and after the long ends havebeen cut off three further turns are taken in theshort ends without any tension at all. This

manipulation has often to be carried out in thedepth of the soft tissues, and it is advisable to have

some mechanical contrivance, such as the forceps Ihave devised, to carry it out. (Fig. 6.) The principleof these wire-tightening forceps is that the wireends are caught in the blades, which open when thehandles are pressed together; and a force, which isfive times as great as the hand tension used, is

applied to the tightening of the wire in exactly theright plane. Then by a single twist of the handlesof the forceps the first twist is made, and theforceps can be disconnected whilst the extra safetytwists are given and the ends cut off and turneddown.

If used under the conditions laid down-i.e.,strong material, accurate reposition of the frag-ments before tightening, and firm tightening beforetwisting, I believe that wire will serve a purpose ina very restricted number of fractures, which cannotbe equalled by any other method. The three casesin which it is especially indicated are fractures ofthe olecranon and patella and very oblique fracturesof long bones where it is difficult to make a com-

plete exposure without serious injury of the softparts.

In the case of the patella it is most importantthat the wire should be applied in the form of asingle circle which surrounds the circumference ofthe disc without any kinking. It is a mistake tomake the suturing in a vertical plane, because theboring of the patella in this is difficult to do

accurately, the wires hold chiefly in the loosecancellous tissue of the bone, and the wires becomesharply kinked when tightened and the fragmentstilted.

On the Usual Methods of Plating Fractures.The common method of operative fixation of

fractures is the screwing of linear steel plates uponthe outer surface of the bone by means of shortscrews which only hold to the dense bone on oneside of the marrow cavity. In spite of the fact thatthe method in the hands of Sir Arbuthnot Lane hasachieved such success that it has become thestandard of operative treatment, I would venture topoint out the several ways in which it falls short ofthe ideal of mechanical efficiency to which I thinkwe ought to aim.

I have already given the reasons derived from

experiments for saying that the screws, however

tightly they are inserted, will become loose withina short time. There is abundant evidence that thisis so, too, in clinical practice. In some cases thescrews come out before any union has occurred anda gross displacement, worse than that which wouldhave taken place without any operation, results. Ihave seen this repeatedly, but especially in cases ofthe upper third of the femur. In other cases thescrews hold long enough for union to occur, butnevertheless eventually become loose in the softtissues and necessitate a further operation for theirremoval. The insecurity of this method of fixationis admitted by its advocates by their practice of

putting up the limb after operation on splints forperiods of from four to eight weeks, so that nostrain shall be placed upon a lightly joined bone.Such an after-treatment subjects the limb to allthe evils of immobilisation that have been so

amply demonstrated by Bardenheuer, Lucas-Championniere, and many others. It risks all thedisability consequent upon adherent tendons andstiff joints.

Consider for a moment the mechanical conditionsof a femur plated in its middle third by a plate4 inches long with three screws on each side of thefracture, each screw being 1/8 inch thick and

441

holding in 1/4 inch thickness of dense bone. Forthe moment let us think of the bone as merelynon-vital material. All the screws are in the sameline, and therefore the bone, 1 inch thick and16 inches long, has to be held by the grip of theplate upon a part of its own substance which is1/4 inch thick, 4 inches long, and 1/8 inch wide.However strong the plate the total strength of theunion cannot be greater than that of the piece ofbone to which the plate is fixed. The actual widthof this piece of bone is only 1/25th of thecircumference of the tubular structure of theshaft, and therefore only 1/25th of the strengthof the bone can be restored by the use of thismethod.Then there is the fact that soon the screws

become loose. This disadvantage it is sought tocounteract by using many screws. But as all theseare in the same line the chief stress must fall uponthose nearest the fracture, as will be seen by theaccompanying diagram. (Fig. 7.) When there is

FM. 7.

Diagram showing how a long linear plate with short screwsbecomes loose. However many screws are placed in thebone, any displacing force acting in the direction of thearrows will fall entirely on the two screws, A and B. next tothe fracture; when these are loose then c and D willsimilarly be displaced.

any force tending to bend the bone in the directionof the arrows the plate, unless very massive, willbend slightly, and all the stress will fall first uponthe screws A and B and then upon c and D andso on.

Therefore, for all these reasons the linear platingof fractures can only be regarded as a verytemporary and insecure union of the bones, whichcan only succeed if (1) rapid vital union occurs,(2) splints are kept rigidly applied until union hastaken place, and (3) that the part be one, such as thelower leg, which can be controlled and immobilisedby splints.One further point of some importance requires

mention, and that is the very great superiority ofthe

" metal-threaded " over the

"

wooden-threaded "

screws. (Fig. 8.) This, I think, was first pointedout by Lambotte, of Antwerp, and has been morerecently insisted upon by various American surgeons,notably by Sherman and Gerster, but neverthelessthe wood screw remains in almost universal use inthis country.The wood screw is intended to bury its thread in

the substance of yielding wood, but it cannot dothis in a dense bone. A metal screw, on the otherhand, must have a female screw thread tapped forits reception, and this is most readily done by somesort of a cutting arrangement at the end of thescrew itself. By this means the screw, instead ofmerely holding by the frictional grip of the very.edge of its thread upon the bone, has its wholethread uniformly embedded in the bone, and its

grip will thereby be enormously increased in

strength. The metal screw holds because it fitsinto a socket made for it, whilst the wood screwholds in dense bone by the sheer pressure of theedge of its thread upon the hard wall of itssocket. Lambotte, by using these metal threaded

screws and by not hesitating to perforate the bone,so as to hold it by both sides, has greatly improvedthe plating method, so as to dispense with the useof the splint in the after-treatment. But even

though this firmer and longer fixation of screwsimproves the method, it does not do away with theobjection that the whole strength of the unioncannot be greater than the thickness of bone

engaged by the single line of screws.

FIG. 8.

A piece of bone into which three screws have been driven.Note the slight grip of the wood" screws as compared withthat of the "metal" screw.

So far I have only referred to the dense structureof the bone shafts. If we consider the structureof the ends of the bone where there is only a verythin shell of dense tissue and all the rest is spongysubstance, it is evident that such parts will affordno hold at all for screws.

(To be coctde.)

CENTRAL MiDwivES BOARD.-A special meetingof the Central Midwives Board was held at Caxton House,Westminster, on Jan. 27th, Sir Francis H. Champneys beingin the chair. A number of midwives were struck off theroll, the following charges amongst others having beenbrought forward: The patient suffering from abdominal painsand a temperature of 104° F.. the midwife did not explainthat the case was one in which the attendance of a regis-tered medical practitioner was required, nor did she hand tothe husband or the nearest relative or friend present theform of sending for medical help, properly filled up andsigned by her, in order that this might be immediatelyforwarded to the medical practitioner, as required byRule E.20 (4). Not carrying to a confinement the appliancesor antiseptics required by Rule E.2 ; continuing in attend-ance upon a patient and being in contact with anotherpatient who was suffering from puerperal fever and not

undergoing disinfection to the satisfaction of the localsupervising authority as required by Rule E.5. Not wearinga clean dress of washable material when attending a patient,as required by Rule E.I. ; neglecting to adopt the antisepticprecautions prescribed by Rules E.3 and 7 ; not keeping theregister of cases, as required by Rule E.23, and medical aidhaving been sought the midwife neglected to send any notifi-cation thereof to the local supervising authority, as requiredby Rule E.21 (1).