01 - history and general principle of fracture treatment

8/10/2019 01 - History and General Principle of Fracture Treatment

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P A R T

I

HISTORY AND GENERAL PRINCIPLES OF

FRACTURE TREATMENT


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M*-

C H A P T E R

1

Historical Review of t eTreat!e"t of Fract#res

a"$ Dislocatio"s

Ramon B. Gustilo, M.D.Joan E. Bechtold, Ph.D.

EVOLUTION OF FRACTURE FIXATION DEVICESDEVELOPMENT OF NTRAMED!LLAR" NA L NG

DEVELOPMENT OF BONE PLATE#DEVELOPMENT OF E$TERNAL F $AT ON

EVOLUTION OF MEDICAL MANAGEMENT OF FRACTURES ANDDISLOCATIONS

Althou%h the methods o& &'actu'e mana%ement ha(echan%ed th'ou%hout medical histo'), the %oal o& *h)si+cians has 'emained constant since the time o& i*+

*oc 'ates- to 'esto'e the *atient to his o*t imal anatomicand &unctional state.

i**oc'ates Fi% /+/0, 1o'n in G'eece in 234 B.5.,ad(anced the &i(e conce*ts o& &'actu'e mana%ement6 antise*sis, 1anda%in%, 'eduction, s*lintin%, and t'ac+

tion6that 7ould su**lement o' 'ein&o'ce the 8iiealin% *o7e's o& natu'e .8 The *u1 lic9s e:*ectations o& the *h)s ician 7e'e minimal 1ecause o& the st'on% &aith in!e$iacatri% "at#ra 8natu'al medicine80. ; 5ases o& malunion 7e'e inte'*'eted as ine(ita1le6natu'e9s 7a)o& handlin% the in


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4 History and General Principles of Fracture Treatment

FIG 1-1.Hippocrates, who laid the foundation for the scientificmethod of medicine, appears to have been particularly inter-ested in fractures and dislocations. (Redrawn from a draw-in by !eter !aul Rubens, in "ettmann #$% A Pictorial His-tory of Medicine. &prin field, I$, 'harles ' homas, 1)*+.

ha(in% 1'ou%ht anothe' seat, and *laced one o' mo'eleathe' *illo7s unde' the a'm, so as to >ee* it a mod+e'ate hei%ht 7hile it is 1ent at a 'i%ht an%le, the 1est

*lan is to *ut 'ound the a'm a 1'oad and so&t s>in, o' 1'oad sha7l, and to han% some %'eat 7ei%ht to it, so asto *'oduce mode'ate e:tension o' othe'7ise, 7hilethe a'm is in the *osition ha(e desc'i1ed, a st'on%man is to ta>e hold o& it at the el1o7 and pull it do7n+7a'd. But the *h)sician standin% e'ect, must *e'&o'mthe *'o*e' mani*ulation, ha(in% the one &oot on some

*'ett) hi%h o1en since the 1e%innin% o& humanit). Asdesc'i1ed 1) Mon'o /; 0, /3 ea'l) methods to sta1i+li e &'actu'ed 1ones include linen s*lints sti&&ened 7ith%um and *laste' 1) the E%)*tians and 1anda%es su&+&used 7ith 'esins, %ums, and 7a:es as 'eco'ded 1) i*+

*oc'ates 4 B.5 .0 and 7ith lime and e%% 7hite as 'e+co'ded 1) the A'a1 *h)sician Rha es. In 0 =; , the ,ir)tEur(pean rep(rt o&t!e u)e (, & p)u" # 1riti)! )ur*&e(n) in Ara#ia (ccurred+ 02 #ut it) pr(pertie) $ere n(te3pl(ited until 0 56 $!en t!e Dutc! )ur&e(n Matt! *)en devi)ed a "et!(d t( c(at and in,u)e c(tt(n #an*


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Historical Review of t e Treat!e"t of Fract#res a"$ Dis locat io"s

da%es 7ith %)*sum. Matth)sen9s method did ha(e thed'a71ac> that *'io' to use the cotton could not 1e+come 7et, 7hich *'ecluded e&&icient sto'a%e o' t'ans+

*o'ta tion such as to the 1at tle&ield0. n the /; 4s theaddition o& 1inde's such as sta'ches, %ums, and de:+t'ins made comme'cial 1anda%e *'e*a'ation &easi1le,althou%h in the !nited #tates it 7as not until a&te' themid+/;24s that comme'cial 1anda%es 7e'e in commonusa%e.3

B'aces and s*lints 'emained o& 'udimenta') desi%n&'om the time o& i**oc'ates until the mid+/ th cen+tu') 7hen Jean+Louis Petit F'ance, /=?30 desi%ned a8&'actu'e 1o:,8 illiam #ha'* En%land, /=3=0 de+si%ned a molded s*lint that is a *'edecesso' o& mode'nmodula' cast 1'ace s)stems, Bennee &o' eithe' a &'actu'ed &emu' o' ti1ia, and Ro1+e't 5hesshe' En%land, / ? 0 desi%ned a dou1le in+clined *lane &o' eithe' &emu' o' ti1ia &'actu'es. /

The *'actical a**lication o& su'%ical inte'nal &i:ation 1e%an onl) in the last 4 to 4 )ea 's , althou%h the'ea'e s*o'adic 'e*o'ts o& the su'%ical im*lantation o& (a'+ious mate'ials th'ou%hout the last se(e'al centu'ies.

'itin%s o& the /3th centu') indicate that the ncasand A tecs ma) ha(e used 8'esinous 7ooden *e%s inthe medulla') canal o& lon% 1ones &o' the t'eatment o& nonunions,8 1ut techniCues and 'esults 7e'e not 'e+co'ded. ? n a simila' conce*t, i(o') *e%s 7e'e used 1)the Ge'mans eine / = 0, ? Bi'che' / 30, andHoeni% /;/ 0 7ith %ood 'esults and %'adual a1so'*+tion o& the i(o') i& in&ection did not de(elo*. ? o+%lund9s 1one *e%s /;/=0 7e'e anothe' ea'l) *'ede+cesso' o& int'amedulla') nailin%. ?

The &i'st 'eco'ded case o& inte'nal &i:ation o& a &'esh&'actu'e is thou%ht to 1e that o& 1'ass ce'cla%e 7i'in%o& the hume'us in /== , althou%h a 'ecent 'e(ie7 o&

*e 't inent li te 'a tu 'e o& the time casts as*e 's ion on7hethe' the o*e'ation actuall) too> *lace. The su'+%eon *u'*o'ted to ha(e *e'&o'med the o*e'ation de+nied an) in(ol(ement, althou%h he did sa) that he hadseen this o*e'ation at the hands o& t7o Toulousse su'+%eons, La*ue 7ith ci 'cum&e'ential st 'a*s a 'ound theti1ia. ?; n / 2 Mal%ai%ne 'e*o'ted a de(ice to achie(e'eduction and sta1ili ation o& a &'actu'ed *atellath'ou%h a &ou'+*'on%ed clam*. ?;

T7o de(ices 7e'e de(elo*ed in the ea'l) /;44s that a'eused toda) in (i 'tuall) thei' o'i%inal &o'm. One is the#teinmann *in. F'it #teinmann 7as a #7iss su'%eon I 7hoin /;4 *u1lished a 'e*o't o& his + to +mm stainlesssteel *in 7ith a sha'* *oint at one end. Th'ee

)ea's &ollo7in% his 'e*o't to the #7iss medical communit), an talian o'tho*edic su'%eon, Alessand'o 5odi+(illa, 7'ote an a'ticle in the same no7n as 8Die&&en+

1ach9s o*e'ation.8 ? eine Ge'man), / = 0 and Ba'+denheu', #ocin, B'uns, and Bi'che' all 'e*o'ted the use

o& i(o') *e%s in t'eatment o& &'actu'es, and Nicholas#enn Mil7au>ee, / 4s0 used 1one and i'on nails inaddition to i(o'), and *e'&o'med animal e:*e'imentson &emo'al nec> &'actu'es in cats. ? Nicola)sen No'+7a), / ;=0 identi&ied int'amedulla') nailin% conce*ts,7ith *a'ticula' attention to the im*o'tance o& t'a(e's+in% the isthmus o& the medulla') canal. ? Lam1otte

Bel%ium, /;4=, 'e*o'ted in /;/ 0 is 'eco%ni ed asalso 1ein% a *ionee' in int'amedulla') &i:ation 1) usin%sc'e7s s*annin% &'om the %'eate' t'ochante' to the

*'o:imal thi 'd o& the medulla') canal to &i: t'ochan+te'ic &'actu'es ? as 7ell as achie(e cla(icula' &i:ation

/;4=0@ he also used 8ca'*ente'9s nails8 &o' metaca'*al

head &'actu'es /;/ 0.?

Bu'%ha'd En%land, /;/20chose >nittin% needles to &i: &emo'al nec> &'actu'es. ?

Lilienthal Ne7 "o'>, /;/40 *e'&o'med int'amedulla')s*lintin% 7ith an aluminum 'od &o' a com*ound &emu' &'actu'e.

Othe's 7ho 7e'e in&luential in the ea'l) decades o& int'amedulla') nailin% 7e'e e) G'o(es En%land,/;/2 to /;/ 0, 7ho used nails o& simila' desi%n tomode'n de(ices and e:*e'imented 7ith 'eso'1a1le ma+te'ials 1ut 7as hinde'ed 1) se*sis@ Lam1otte Bel%ium,/;?20 and Jol) Bel%ium, /; 0, 7ho used Hi'schne'


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History and General Principles of Fracture Treatment

7i'es in the &o'ea'm@ Tennant /;?20, 7ho used *ol+ished *hono%'a*h needles &o' metaca'*al &'actu'e &i:a+tion@ the Rush &amil) &athe' and t7o sons, !nited#tates, /; ;0, 7ho &i'st used #teinmann *ins in ulna' &'actu'es and then de(elo*ed the 8Rush8 *in de+sc'i1ed in /; 30@ and Dic>inson !nited #tates,

/B,?B, ?F

Note that Lam1otte int'oduced the te'mosteos+"t esis and that he 7as a leade' in the de(elo*+ment o& the &ield o& o*e'ati(e &i:ation o& metaca'*aland *halan%eal &'actu'es / and has 1een called the &a+the' o& s)stemic &'actu'e su'%e'). ?;

nt'amedulla') nailin% chan%ed &'om an inte'estin%,&led%lin% t'eatment modalit) to an indis*ensa1le com+

*onent o& e(e') t'auma su'%eon9s a'mamenta'ium &ol+lo7in% Ge'ha'd Hiintsche'9s *ionee'in% 7o'> in Ge'+man) *'io' to and du'in% o'ld a' . is 1asic

*'inci*le 7as that the int'amedulla') nail should *'o+(ide 8elastic im*in%ement8 and the'e1) sta1ilit) in itscontact 7ith the medulla') canal. is desi%ns ha(e in+cluded V+sha*ed, conical, and s*lit c'oss sections, inaddition to the no7+standa'd slotted clo(e'lea& c'osssection. nst'umentation 7as not ne%lected, 7ith se(+e'al e:t'acto's and 'eduction de(ices 1ein% desi%ned

1) Hiintsche' and his associates Fische', Maat , and#toe'. ?

n the ea'l) /;24s the scienti&ic communit)9s 'eac+tion to int'amedulla') t'eatment o& &'actu'es 7as 'e+se'(ed and not unanimousl) *ositi(e. o7e(e', the'e7e'e man) accounts o& int'amedulla') nailin% in theGe'man lite'atu'e. ?9 Bohle' Vienna, /;2 0, a hi%hl)'es*ected t'aumatolo%ist in Eu'o*e, 7as an ea'l) su*+

*o'te' 7ho ad(ocated ca'e&ul case selection. ?

Hiintsche' s*ent the late' )ea's o& o'ld a' ascommande' o& an a'm) hos*ital in Finland nea' the a'c+tic ci'cle. The Finns 7e'e ea'l) *'o*onents o& hismethod, and su'%eons in the !nited #tates, F'ance, andothe' count'ies lea'ned o& Hiintsche'9s de(ices &'om 'e+tu'nin% *'isone's o& 7a'. n #7eden, cases 7e'e *e'+&o'med in Ma'ch o& /;2 1) este'1o'n. ? 9?

The &i'st Ame'ican int'amedulla') nailin% ma) ha(e 1een in #e*tem1e' o& /;2 1) MacAusland in Boston,7ho used a tantalum nail o& simila' desi%n to one he

*'e(iousl) 'emo(ed &'om an Ame'ican ai' &o'ce *ilot7ho 'ecei(ed his int'amedulla') nail in Ge'man). ?

#ho'tl) the'ea&te', a stainless steel diamond+sha*ed nailo& thei' o7n desi%n 7as im*lanted 1) D's. #t'eet,

ansen, and B'e7e'. ? Lottes de(elo*ed a solid+co'ediamond+sha*ed nail in /; /, ? and in the same )ea' #chneide' de(elo*ed a &luted solid nail that 7as sel&+

1'oachin%. P'e1ent nails &ollo7ed soon the'ea&te'. ?

To aid in inse'tion, 1'oaches 7e'e devel(ped in075. # Str %er 6 and ,le3i#le rea"er) # 8iint)c!er/ 65

1e&innin& in 075 $i t! it) ,(undati(n+ t!e Ar#eit)*

%emeinscha&t &u' Oste1s)nthese F'a%enKAssociation &o' the #tud) o& nte'nal Fi:ation AOKA# F0, has e:+

*ounded on the &'actu'e t'eatment *'inci*les *'o*osed 1) Hiintsche' and his de(ices, de(elo*ed a &ull 'an%e o& de(ices, and *'esented man) educational cou'ses. nmo'e 'ecent )ea's, ad(ances in int'amedulla')

use o& inte'loc>in% 1olts to *'o(ide 'otational cont'oland *'e(ent sho'tenin%. Ea'l) e:am*les o& inte'loc>in%int'amedulla') nails include the Li(in%ston +1eam 7ithslots at 1oth ends /; 40 and the Modn) $+sha*ed nail7ith holes th'ou%hout its len%th.8

DE(ELOPMENT OF ,ONE PLATES The &i'st sus*ected use o& 1one *lates 7as du'in%

the Ame'ican 5i(il a' / 3/ to / 3 0, 1ut thei' &i'stsu1stantiated use 7as 1) ansmann in / 3. 2 Lam1ottein /;4; desi%ned a diamond+sha*ed *late that 7asthic>est at the &'actu'e site and ta*e'ed to7a'd eithe' end@ Lane in /;/2 desi%ned a *late 7ith th'ee 'ounde)elet holes a1o(e and 1elo7 the &'actu'e and a scal+lo*ed oute' &o'm to &acilitate contou'in% the *late toune(en 1one su'&aces. The #he'man *late, desi%ned in/;/?, 7as st'on%e' than the Lane *late 1ecause o& itsmo'e st'eamlined sha*e.8 /

Alon% 7ith sha*e 'e&inements, concu''ent im*'o(e+ments in 1one *lates occu''ed 7ith the ad(ent o& st'on%e' and mo'e 1iocom*ati1le metal allo)s.

#lotted *lates to allo7 coa*tation o& &'a%ments 7e'edesi%ned 1) To7nsend and Gil&illan /;2 0, E%%e's

/;2 0, and 5ollison /; 40. 2An ea'l) stud) o& the e&&ect o& com*'ession on &'ac+

tu'e healin% 7as 7'itten 1) E%%e's in /;2;, and heconcluded that muscle cont'action *'o(ided an a**'o+

*'iate le(el o& com*'ession. 2 n the same )ea', Danisde(ised a *late that inco'*o'ated an in+line sc'e7mechanism &o' the su'%eon to *'o(ide a cont'olledamount o& com*'ession. 2 Pe'ha*s due to the di&&icult)in mani*ulatin% the sc'e7 to *'o(ide com*'ession,othe' su'%eons 7e'e not a1le to du*licate Danis9 %ood'esults, and the *late did not 1ecome *o*ula'. 2 Miille' in /;3/ made an in+line com*'ession sc'e7 se*a'ate&'om the *late and 'emotel) accessi1le &o' tu'nin%. 2

Vena1le in /; / 'aised the an%le o& the com*'essin%sc'e7, 1ut this made the const'uct less sta1le. 2 Bo'eauand e'mann /; ?0 desc'i1ed the theo') o& a *latesha*ed simila'l) to a Lane *late, 1ut 7ith a cent'altu'n1uc>le to *'o(ide com*'ession@ the *late, ho7+e(e', did not see e:tensi(e clinical use. 2

Geo'%e Ba%1), 7hile 7o'>in% as a 'esident at theMa)o 5linic /; 3 to /; 0, *e'&o'med )tudie) (n t!e!ealin& (, canine ()te(t("ie) in t!e pre)ence (, c("*pre))i(n/ 9i) plate+ rep(rted in 0752+ inc(rp(rated t!e

& i&d saiso9 aesi%ne1 medulla')9*ins to'9the8 to'e+ 8 nailin% de(ices and techniCues Jia(e centece'i '('u - 1ita'm.


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Historical Review of t e Treatment of Fractures and !islocations "

1asic &eatu'es o& com*'ession *lates cu''entl) in 7ide+s*'ead use. n *a'ticula', his *late int'oduced the as)m+met'icall) 1e(eled slots that *'o(ide com*'ession ascham&e'ed sc'e7s a'e ti%htened. Othe' *lates inco'*o+'atin% these *'inci*les include the Dehnam *late En+

%land, non1e(eled slot0 and one 1) Hondo andMa'umo Ja*an, 1e(eled slots 7ith t7o 1ein% &ansha*ed0. Plates 7ith 1e(eled o1lon% slots a'e the D)+namic 5om*'ession *late AOKA# F0, ?4 !ni(e'sal 5om+

*'ession *late o7medica0, #el& 5om*'ession Plateimme'0, and !slen%hi *late O'tho*aedic ECui*ment

5o'*0.n his 'e(ie7 a'ticle o& com*'ession 1one *latin%,

D'. Ba%1) 2 stated that he *e'sonall) had used his *lateonl) /44 times and &ound that the com*lications and'is>s attendant to o*en *'ocedu'es 7e'e too %'eat to7a''ant its 'outine a**lication.

DE(ELOPMENT OF E)TERNAL FI)ATION Follo7in% Mal%ai%ne9s 8cla7,8 the &i'st *'actical and

accessi1le e:te'nal &i:ato's 7e'e de(elo*ed inde*en+dentl) 1) Pa'>hill Den(e', / ;20 and Lam1otte Bel+%ium, /;4?0. ?; Pa'>hill9s de(ice consisted o& &ou' sc'e7s inse'ted into the co'te: and attached to amechanism ad in /; ? utili in%t'ans&i:ion *ins and an e:te'nal clam* &o' >nee art!r(*desis, 2 in /;2 5ha'nle) de(elo*ed a mo'e *'actical&'ame &o' >nee a'th'odeses that 7as also used as a %en+e'al e:te'nal &i:ation de(ice. ?= Du'in% the same time

*e'iod, a%ne' de(elo*ed a unilateral device ,(r le&len&t!enin&/ 5

In additi(n t( t!e a1o(e unilateral+ #ilateral+ (r

Cuad'ilate'al &'ames, ci'cula' &'ames ha(e 1een de+si%ned. li a'o( in the #o(iet !nion has de(oted )ea'so& his li&e to the stud) o& e:te'nal &i:ation *a'ticula'l)7ith 'e%a'd to 1one len%thenin%0 and 1uilt his o7nhos*ital e:clusi(el) to stud) his ci'cula' &i:ato' 7ithtensioned t'ans&i:ion 7i'es.

E(OLUTION OF MEDICAL MANAGEMENT OF FRACTURES

AND DISLOCATIONS

Medical and milita') histo') a'e o&ten 'elated. The 1at+tle&ield %a(e *h)sicians am*le o**o'tunit) to &ind alte'+nati(e methods o& &'actu'e mana%ement and 7oundhealin%. Du'in% the Na*oleonic 7a's o& the / th cen+tu'), mas to La''e), 7ho *e'&o'med?44 am*utations in a *e'iod o& ?2 hou's a&te' the 1at+tle o& Bo'odino in the Mosco7 cam*ai%n #e*t. 6 3,/ /?0, ?9; mo'talit) 'ates 7e'e si%ni&icantl) 'educed.La''e) 1uilt on some o& the ideas ad(anced 1) theF'ench su'%eon Jose*h DeFault, 7ho 7as the &i'st tode&ine the need &o' su'%ical de1'idement. La''e) alsoad(ocated ea'l) am*utations and immediate su'%e')&o' o*en &'actu'es and de(ised 7hat ma) 1e 'e%a'dedas a *'imiti(e am1ulance se'(ice &o' dealin% 7ith suchconditions. A&te' *a'tici*atin% in mo'e than 34 mano7n that tetanus is caused 1) a7ound, 7e ou%ht not to ha(e an) hesitation in am*u+tatin% immediatel) on the a**ea'ance o& the s)m*toms.

e ma) 1e assu'ed that it is t'aumatic, 1) the natu'e o& the 7ound, the *'o%'ess o& the &i'st s)m*toms, and 1)conside'in% the time o& thei' a**ea'ance, 7hich is&'om the &i&th to &i&teenth da), o' late'.

Am*utations o& the lim1 1ein% made on the &i'st a*+ *ea'ance o& the s)m*toms, all communication 7ith theo'i%inal o& the e(il is cut o&&. This o*e'ation unloads the(essels, and con(ulsi(e motions o& the muscles. These&i'st e&&ects a'e &ollo7ed 1) a %ene'al colla*se, 7hich

*'omotes the e:c'etions and 'e*ose, and 'e+esta1lishesthe eCuili1'ium o& the 1od). /

The ne:t hallma'> date in the e(olution o& &'actu'et'eatment 7as / 3=, the )ea' Jose*h Liste' int'oducedsu'%ical antise*sis 7ith ca'1olic acid. /


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History and General Principles of Fracture Treatment

Du'in% o'ld a' , the *'inci*les o& o*en &'actu'et'eatment &i'st ad(anced 1) a 'u'al Ne1'as>a *h)sician,D'. innette O'', /; 1ecame standa'd th'ou%hout thea'med se'(ices and, e(entuall), all o& medicine- com+

*le te *'ima') de1 'idement, *'ima') 'eduction, com +

*lete immo1ili ation, *'o(ision o& d'aina%e, and in&'e +Cuent d'essin% chan%es.

B) o'ld a' , a**lication o& local sul&anilamide7as added to the 'e%imen. n /;22, *a'ente'al *enicil+lin had 'e*laced the sul&a d'u%s.

o'ld a' 7itnessed othe' si%ni&icant medical ad+(ancements. 5olonel O.P. am*ton /4 o& the !.#. A'm)ad(ocated dela)ed 'i%id inte'nal &i:ation o& &'actu'esand cited the &ollo7in% ad(anta%es- achie(ement o& an+atomic ali%nment@ a(oidance o& 'e*eated mani*ulation@im*'o(ed 7ound ca'e o& the o*en &'actu'es@ &acilitationo& ea'l) eletal t'action o' s*icacast immo1ili ation.

Ame'icans 1e%an to t') ne7 nailin% techniCues inthe /; 4s. Lottes and his.collea%ues /2 *u1lished thei' method o& nailin% &o' ti1ia &'actu'es in /; ?, &ollo7ed

1) Rush9s ? techniCue &o' nailin% o& lon% 1ones in/; 2.

n the ea'l) /;34s, a ne7 conce*t commonl) calledthe 8AO techniCue8 / came into (o%ue and 'e(olution+i ed the mana%ement o& &'actu'es. Ad(anced 1) the As+sociation &o' the #tud) o& the P'o1lems o& nte'nal Fi:+ation A# F0, i ts ad(ocates u'%ed &ull and 'a*id'eco(e') o& the inin% nails &o' the &emu' and ti1ia in unsta1le *os+tu'es caused 1) 1one loss o' se(e'e comminution hassho7ed su*e'io' 'esults. t also 'ele%ates *latin% to dis+

*laced int'a+a'ticula ' and meta*h)seal &'actu'es o& lon% 1ones.

Ad(ances in techniCues and de(ices ha(e 1een *os+si1le than>s to a 1ette' unde'standin% o& 7hen, 7h),and ho7 to ma>e the a**'o*'iate a**lication.

G'aduall) th'ou%h the )ea's, 7ith 1asic and clinicalstudies, it has 1een mandated o' concluded that a'ticu+la' &'actu'es need to 1e 'esto'ed anatomicall) and ea'l)

motion studies conducted in o'de' to *'e(ent the lateseCuelae o& *ost+t'aumatic a'th'itis and


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Historical Review of t e Treatment of Fractures and !islocations 7

*'ima') union and late com*lications o& a(ascula' ne+c'osis o' *ost+t'aumatic a'th'itis in &'actu'es o& 1onesand 0.

n an e'a o& mode'n science and ad(anced technol+o%), *atients e:*ect that thei' &'actu'es 7ill heal &ull),anatomicall), and &unctionall). ndeed, du'in% the *astdecade ad(ances in mana%in% lon%+1one and int'a+a'tic+ula' &'actu'es ha(e 1een t'emendous. The) include the&ollo7in%-

/. Functionall) castin% and 1'acin% 7ith ea'l) 7ei%ht 1ea'in%

?. The AO method o& inte'nal &i:ationKinte'&'a%menta') &i:ation and 'i%id *latin% andea'l) mo1ili ation o& the inin% nails

/. Redisco(e') and im*'o(ement o& e:te'nal &i:ation2. #u'%ical techniCues &o' di&&icult int'a+a'ticula' &'ac

tu'es e.%., aceta1ulum, shoulde' nee le ills, the o'tho*edic and t'auma su'%eon o& toda) isalso an anatomist, *h)siolo%ist, and 1iomechanical en+%inee' 7ho t'anscends the &ields o& medicine and en%i+nee'in% in o'de' to sol(e common *'o1lems.

REFEREN5E#/. Adams F- Hi11ocrates2 T e Ge"#i"e 3or4s of Hi1

1ocrates' Ne7 "o'>, illiam ood 5o, /;?;.?. Ande'son JT- isto') o& the t'eatment o& o*en &'actu'es,

in Gustilo RB ed0- Ma"a5e!e"t of O1e" Fract#res a"$ Co!1licatio"s' Philadel*hia, B #aunde's 5o, /; ?.

+ Austin, RT- T'eatment o& 1'o>en le%s 1e&o'e and a&te' the int'oduction o& %)*sum. I"/#r+ /; @ /2- ;6 ;2. 2.

Ba%1) F - 5om*'ession 1one +*latin%, f ,o"e foi"t S#r5 ,/;==@ ;-3? +3 /.

. Boo>e' AF- isto') o& e:te'nal &i:ation, in Pri"ci1les of E%ter"al Fi%atio"' Baltimo'e, illiams il>ihs, /; .

3. 5allahan DJ, a''is BJ- #ho't histo') o& *laste'+o&+Pa'iscast immo1ili ation. Mi"" Me$ /; 3@ 3;-/; +/;3.

=. 5ha'nle) J- T e Close$ Treat!e"t of Co!!o" Frac

t#res&ed . Edin1u'%h, E # Li(in%stone, /;3/.. E(ans PEL- 5e'cla%e &i:ation o& a &'actu'ed hume'us in/== , &act o' &ictionQCli" Ort o1 /; @ /=2-/ +/2?.

;. Ga''ison F - Histor+ of Me$ici"e ed 2. Philadel*hia, B#aunde's 5o, /;?;.

/4. am*ton OP- Mana%ement o& com*ound &'actu'es inthei' ea'l) *hases. S#r5 O6stet G+"ecol /;23@ 2-==?.

//. ansen #, inCuist R- 5losed int'amedulla') .nailin% o& the &emu'- Huntsche' techniCue 7ith 'eamin%. Cli" Or t o1 /;=;@ / - 3.

/?. Huntsche' G- Practice of I"tra!e$#llar+ Naili"5'#*'in%&ield, ///, 5ha'les 5 Thomas Pu1lishe's, /;3=.

/ + Liste' J- On the antise*tic *'inci*le in the *'actice o& su'%e'). La"cet / 3=@ ?-; .

/2. Lottes JO, ill LJ, He) AJ- 5losed 'eduction, *late &i:ation and medulla') nailin% o& &'actu'es o& 1oth 1ones o& the le%. K ,o"e .oi"t S#r5 7A!8 /; ?@ 2- 3/.

/ . Meals RA, Meuli 5- 5a'*ente'9s nails, *hono%'a*h needles, *iano 7i'es and sa&et) *ins- The histo') o& o*e'ati(e &i:ation o& metaca'*al and *halan%eal &'actu'es.K

Ha"$ S#r5 /; @ /4-/22+/ 4./3. Mon'o JH- The histo') o& *laste'+o&+Pa'is in the t'eat

ment o& &'actu'es. ,r. S#r5 /; @ ? -? =./=. Moone) V, Nic>el VL, a'(e) JP J', et al- 5ast+1'ace

t'eatment &o' &'actu'es o& the distal *a't o& the &emu'.K ,o"e .oi"t S#r5 7A!8 /;=4@ ?-/ 3 .

/ . Miille' ME, All%o7e' M, #chneide' R, et al- Ma"#al of I"ter"al Fi%atio"2 Tec "i9#es Reco!!e"$e$ 6+ t e AO*Gro#1&ed ?. Ne7 "o'>, #*'in%e'+Ve'la%, N" nc,/;=;.

/;. O'' - 5om*ound &'actu'es. A! . S#r5 /; ;@ 23-= .

?4. Pe''en #M, u%%le' A, Russen1e'%e' M, et al- The 'eaction o& co'tical 1one to com*'ession. Acta Ort o1Sta"$ S#11l /;3;@ /? -/;+?;.

?/. Rehde' H- Ma'tin Hi'schne'.KAAM /; ?@ ?2=-/ 4?.??. Romm #- F'it #teinmann and the *in that 1ea's his

name. Plast Reco"str S#r5 /; 2@ =2- 43+ /4.? . Rush LP- Atlas o& Rush *in techniCues. Mississi11i Doc

tor /; @ /-;2.?2. #a'miento A, Latta L, ilioli A, et al- The 'ole o& so&t tis

sues in the sta1ili ation o& ti1ial &'actu'es. Cli" Ort o1/;=2@ /4 -//3.

? . #eli%son D- isto'ical int'oduction in Co"ce1ts i" I"tra!e$#llar+ Naili"5' O'lando, Fla. G'une #t'atton,/; .

?3. #eli%son D, Dude) D- isto'ical int'oduction. 5once*tsin e:te'nal &i:ation. Cli" Ort o1 /; @/ 4-/ +??.

?=. #is> DT- E:te'nal &i:ation6histo'ic 'e(ie7, ad(anta%es,disad(anta%es, com*lications and indication. Cli" Or t o1 /; @ / 4-/ +??.

? . #t'eet D- The e(olution o& int'amedulla') nailin%, in T eScie"ce a"$ Practice of I"tra!e$#llar+ Naili"5' Philadel*hia, Lea Fe1i%e', /; =.

?;. Vidal J- E:te'nal &i:ation6)este'da), toda), and tomo' 'o7. Cli" Ort o1 /; @ / 4-=+/2.

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/. imme'man LM, Veith - Great I$eas i" t e Histor+ of S#r5er+' Baltimo'e, illiams il>ins, /;3/.

01 - history and general principle of fracture treatment

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